Astoria Healthcare Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a comfortable and safe temperature level for three of three sampled residents (Resident 19, Resident 20, and Resident 21) by failing to ensure the facility temperature was between 71 degrees Fahrenheit ( F, unit of measurement for temperature) to 81 F. This deficient practice had the potential to cause serious medical problems and altered comfort level.

Inspectors wroteBased on interview and record review, the facility failed to protect residents' right to make an informed decision for one of 18 sampled residents (Resident 1), by failing to: 1. Ensure Resident 1's Notice to Beneficiary-Notice for Change of Coverage form (a form completed when residents request change in healthcare coverage) was not obtained from Resident 1 who did not have the capacity to make medical decisions. 2. Ensure Resident 1's Notice of Medicare Non-Coverage (NOMNC- a formal notification that healthcare coverage is ending and notification of appeal rights) form was not obtained from Resident 1 who did not have the capacity to make medical decisions. This deficient practice had the potential to violate Resident 1's right to make an informed decision, negatively affecting Resident 1's well-being.

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) for one of three sampled residents (Resident 1) by failing to accurately reconcile (the formal process of creating the most accurate list of a resident current medications including names, dosages, frequencies, and routes and comparing it against their new medications or medical orders to avoid errors like omissions, duplications, dosing errors, or harmful drug interaction) dabrafenib (medication that blocks the action of an abnormal protein that signals cancer [a disease where the body's cells grow and multiply out of control] cells to multiply and also helps stop the spread of cancer cells) upon Resident 1's readmission on [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Attending Physician (AP) performs the comprehensive visit before allowing the Nurse Practitioner (NP) to visit one of three sampled residents (Resident 1). This failure had the potential to result in an undetected decline in medical, health or psychosocial condition and could lead to a delay in necessary care, treatment and services to Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to maintain accurate and complete medical record for one of three sampled residents (Resident 1) by failing to accurately document time of family notification on 3/16/2026. This failure had the potential to cause confusion in Resident 1's care and the medical records containing inaccurate documentation.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from abuse (deliberately aggressive or violent behavior with the intention to cause harm) for one of seven sampled residents (Resident 1). On 6/1/2026 at approximately 10 a.m., Resident 1 and Resident 2, who were both in the facility's activity room, had a physical (a confrontation or fight involving physical contact or force) and verbal altercation (a noisy argument or disagreement) in which Resident 2 hit the left side of Resident 1's face. This deficient practice denied Resident 1 a safe, harm-free, homelike environment where the resident was not exposed to danger or emotional distress.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement and maintain a system-wide method related to the management and accounting of controlled substances (narcotics- a drug or chemical whose manufacturing, possession, and use are strictly regulated by the government because of its potential for abuse and addiction) affecting two of seven sampled residents (Resident 3 & Resident 4) by failing to document and account for the administration of Resident 3 and Resident 4's controlled substance medications. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who lacked the capacity to understand and make decisions, was not made to sign the Consent to Treat Authorization on 4/7/2026. This deficient practice resulted in the violation of Resident 1's rights.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) received the proper care and services by failing to ensure staff monitored Resident 1's risk for bleeding when on 4/7/2026 Resident 1 was prescribed Lovenox (an injectable medicine, commonly known as a blood thinner [anticoagulant], used to prevent or treat harmful blood clots) injection (the act of putting a liquid-usually medication, vaccines, or vitamins-directly into the body using a needle and syringe). This deficient practice had the potential for Resident 1 to have complications that included bleeding.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure portable oxygen tanks (a sturdy, pressurized metal container, that stores compressed oxygen gas) for one of three sampled residents (Resident 2) were properly stored securely to prevent the oxygen tanks from falling. This deficient practice had the potential for the portable oxygen tanks to fall leading to accidents causing injuries to residents, staff and visitor or cause severe fires.

Inspectors wroteBased on interview and record review, the facility failed to maintain medical records in accordance with acceptable professional standards and practices for one of three sampled residents (Resident 1), when:1. Resident 1 had a fall on 5/5/2026 and the Fall Risk Assessment (a simple check-up by a healthcare provider to see how likely an older adult is to fall) was inaccurate.2. Resident 1's Facility Task titled, Nutrition-Amount Eaten, did not match the Facility provided form titled, Restorative Nursing Assistant (RNA) dining meal percentage. These deficient practices resulted in inaccurate documentation in Resident 1's records.

Inspectors wroteBased on interviews and record review, the facility failed to report the allegation of a resident-to-resident physical abuse (any intentional act causing injury or trauma to another person through bodily contact) to the State Survey Agency (SSA) for one of four sampled residents (Resident 1). On 4/17/2026, an allegation that Resident 2 pulled Resident 1's hair was reported to Registered Nurse (RN) 1, the Director of Nursing (DON), and the Administrator (ADM). The SSA did not receive the report from the Abuse Coordinator for the allegation of abuse. This deficient practice had the potential to result in unidentified abuse and failure to protect other residents from abuse.

Inspectors wroteBased on interview and record review, the facility failed to follow professional standards of nursing practice for one of three sampled residents (Resident 1) by failing to ensure licensed nurses appropriately assessed and monitored Resident 1's medical and psychosocial status ( a person's overall mental, emotional, and social well-being) following the resident's change of condition (COC) on 4/17/2026 related to an alleged physical abuse. This deficient practice had the potential to result in the failure to identify continued or worsening clinical and psychosocial deterioration, thereby placing Resident 1 at risk for adverse health outcomes and compromised safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection control prevention measures for two of three sampled residents (Resident 1 and Resident 2), by: 1. Failing to ensure Resident 1 and Resident 2's soiled linens from an isolation room were placed separately from other residents' soiled linens.2. Failing to ensure Certified Nursing Assistant (CNA) 1 wore gown and gloves when entering Resident 1 and Resident 2's contact isolation room.3. Failing to educate family members on precautions to take when entering a contact precaution isolation room. These deficient practices had the potential to result in transmission of communicable disease and infection to other residents and staff.

Inspectors wroteBased on interview and record review, the facility failed to implement its policy and procedure on infection control for one of seven residents (Resident 1). Resident 1 was diagnosed with having Clostridioides difficile (C.-diff, a highly contagious bacterial infection causing loose stools). The facility failed to expand infection prevention teachings to everyone entering Resident 1's room. This deficient practice increased the risks of exposure to and spread of infection to other residents and facility staff. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow professional standards of nursing practice for one of three sampled residents (Resident 1) by failing to:1. Ensure licensed nurses monitored Resident 1's oxygen saturation (the amount of oxygen circulating in the blood) every shift from 3/14/2026 to 3/19/2026 (five days). 2. Ensure licensed nurse accurately assessed Resident 1's risk for falls following the resident's readmission on [DATE]. These deficient practices had the potential to result in the failure to identify continued or worsening clinical deterioration, thereby placing Resident 1 at risk for adverse health outcomes and compromised safety.

Inspectors wroteBased on interview and record review, the facility failed to ensure the medical record of one of five sampled residents (Resident 1) was maintained in accordance with accepted professional standards and practice, complete, and accurately documented by failing to ensure: 1. Resident 1's Change of Condition (COC) Evaluation indicated the correct date and time the COC happened. Resident 1 had a change of condition (COC) on 3/9/2026, afternoon shift. The COC Evaluation indicated Resident 1's COC occurred on 3/10/2026 during the night shift. 2. Accurate documentation regarding COC notification to Resident 1's Attending Physician (MD) 1 and family member. The COC evaluation indicated on 3/10/2026, Resident 1's Attending Physician (MD) 1 was notified at 9:20 p.m. and the resident's family member was notified at 9:15 p.m. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure three of three sampled residents (Resident 1, Resident 5, and Resident 6) received care consistent with professional standards of practice to prevent pressure ulcers (PU, a localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure, or pressure in combination with shear) by failing to ensure Residents 1, 5, and 6 were turned and repositioned. This deficient practice placed Resident 1, Resident 5, and Resident 6 at risk for the development of pressure ulcers.

Inspectors wroteBased on interview and record review, the facility failed to ensure the medical records of one of three sampled residents (Resident 1) were maintained in accordance with accepted professional standards and practice, complete, and accurately documented by failing to ensure Licensed Vocational Nurse (LVN) 1 documented the level of care provided to Resident 1 while the resident was in the facility. LVN 1 documented the level of care she provided to Resident 1 on 12/13/2025. Resident 1 was discharged to the General Acute Care Hospital (GACH) 1 on 12/10/2025. This deficient practice resulted in incomplete and inaccurate information on Resident 1's medical records and had the potential for delayed medical interventions.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Implement the care plan (a plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial [relating to the interrelation of social factors and individual thought and behavior] and functional needs) for one of four sampled residents (Resident 1) which included interventions related to hemodialysis (a medical treatment that acts as an artificial kidney, filtering waste products and extra fluid from the blood when kidneys are not working well) care that required monitoring of Resident 1's left upper arm arteriovenous fistula (AV fistula or shunt - a surgically created connection between an artery and a vein to provide hemodialysis access where a needle is inserted allowing blood to be drawn, cleaned, and returned to the body) for bleeding upon return to the facility following [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) who returned to the facility after a hemodialysis (a medical treatment that acts as an artificial kidney, filtering waste products and extra fluid from the blood when kidneys are not working well) treatment on [DATE], at approximately 7:10 p.m., received necessary care and monitoring in accordance with professional standards of practice. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two of five sampled staff (Registered Nurse [RN] 1 and Licensed Vocational Nurse [LVN] 1) were competent (a combination of knowledge, skills, abilities, and behaviors that enable an individual to perform a task or role successfully) on dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney or kidneys have failed) care and assessment by:Failing to ensure newly hired staff had orientation (the process of introducing new employees to a company's culture, policies, colleagues, and their specific job role, typically in the first few days or weeks, to help them feel welcome, understand expectations, and integrate effectively into the organization) on dialysis care. Failing to ensure staff were in serviced on dialysis care before providing dialysis care. [...]

Inspectors wroteBased on interview and record review, the facility failed to accurately update the Facility Assessment Tool (an evaluation of the physical environment necessary to meet the needs of the residents) by:Failing to ensure the Facility Assessment indicated the approved facility's name of Skilled Nursing Facility 2 (SNF 2) after a change of ownership on 6/2025. Failing to ensure Facility Assessment was followed, on staff dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) care, training and competency (a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully). Failing to ensure Facility Assessment indicated the type of electronic health information technology used by the facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's Minimum Data Set (MDS - a resident assessment tool), accurately reflected the resident's medical diagnoses for one of four sampled residents (Resident 1). This deficient practice had the potential to delay the provision of necessary care and services to Resident 1 and negatively affect Resident 1's well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement policies and procedures (P&P) for infection control for two of three sampled residents (Resident 1 and Resident 3) when Certified Nursing Assistant (CNA) 1 failed to change their gown after repositioning Resident 1 and before draining Resident 3's urinary catheter (also known as a Foley catheter, device that drains urine from the urinary bladder into a collection bag). This deficient practice had the potential for cross-contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) between Resident 1 and Resident 3.

Inspectors wroteBased on interview and record review, the facility failed to provide nutritional care and services for one of three sampled residents (Resident 4) by failing to ensure Resident 4 was provided with breakfast and lunch on 11/6/2025, 11/7/2025 and 11/11/2025. This failure had the potential for Resident 4 to have a weight loss and potential for delays in the delivery of necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to implement its abuse policy for two of three sampled residents (Resident 1 and Resident 2) by not obtaining dated and signed witness statements (It is a written summary of the evidence of a witness). This deficient practice had the potential to result in inaccurate abuse investigations and had the potential to place Resident 1 and Resident 2 at risk for further abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a person-centered care plan (a tool that ensures residents receive personalized, comprehensive, and goal-oriented care in a nursing home setting) for one of three sampled residents (Resident 4) by failing to develop a care plan to address Resident 4's refusal of feeding assistance. This failure had the potential for Resident 4 to have a weight loss and potential for delays in the delivery of necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) for one of three sampled residents (Residents 4) by failing to follow Resident 4's physician order. This failure had the potential to result in Resident 4 experiencing hypotension (low blood pressure).

Inspectors wroteBased on observation, interview, and record review the facility failed to implement and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections by failing to Ensure Certified Nurse Assistant (CNA) 1 implemented proper use of personal protective equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) for two of four sampled residents (Resident 2 and 4) who are on Coronavirus disease isolation precautions ( infection control intervention designed to reduce transmission of Coronavirus disease [COVID-19-a newly identified respiratory infectious disease] that uses disposable gown, eye protection, mask, and gloves use while in the resident's room and providing resident care). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a thorough investigation was completed following an allegation of financial abuse for one of three sampled residents (Resident 1). This deficient practice had the potential to place Resident 1 at risk for further financial abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 1) received quality of care in accordance with professional standards of practice to meet Resident 1's physical, mental, and/or psychosocial needs (consists of the emotional and social requirements that individuals have to feel safe, supported, and function effectively in their environment), when an interdisciplinary (IDT) meeting did not timely occur after Resident 1's fall on 8/2/2025 and in compliance with the facility's own policy and procedure. This failure had the potential to result in a delay in investigating and determining the causative factors that resulted in Resident 1's fall on 8/2/2025.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medical record of one of two sampled residents (Resident 1) was complete and accurately documented when Resident 1's medical record did not contain a Post-Fall Assessment & Investigation that was required by the facility's own policy and procedure. This failure resulted in an incomplete medical record as the facility's policy and procedure mandates the completion of a Post-Fall Assessment & Investigation after a resident is discovered to have fallen.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident's medical records were updated to show documented evidence that advance directives (a legal document indicating resident preference on end-of-life treatment decisions) were discussed with three of three sampled residents (Residents 94, 17, and 72). These deficient practices violated the resident's rights and/or representative's right to be fully informed of the option to formulate their advanced directives.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, homelike environment for four of six sampled residents (Residents 537, 17, 14, and 107) reviewed during the Environment facility task, by failing to: 1). Ensure the wall clock was set to show the current time of day for Resident 537. This deficient practice had the potential to result in increased confusion, especially to residents with cognitive impairments (deficits in mental functions like memory, thinking, or problem-solving). 2). Ensure Resident 17's broken vertical blind slats were replaced and not left at the bedside while pieces of cardboard were used to prevent light from entering the resident's room. This deficient practice had the potential to negatively affect the residents' psychosocial wellbeing and make the residents feel uncomfortable in their living space. 3). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignity including the right to be free from physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the resident's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) for five (5) of 5 sampled residents (Residents 117, 28, 90, 14, and 102) reviewed for physical restraints care area by: 1. Failing to complete Resident 117's Physical Restraint Assessment form accurately to reflect that the resident was placed on bed pad alarm (a pad with sensors that will alarm when a resident stands up unassisted to help prevent falls by alerting staff) on 3/28/2025. 2. [...]

Inspectors wroted. During a review of Resident 121's Face Sheet, the Face Sheet indicated the facility admitted the resident on 2/18/2021, with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing) with acute (sudden) exacerbation (worsening of the disease), schizophrenia and bipolar disorder. During a review of Resident 121's MDS, dated [DATE], the MDS indicated the resident had clear speech, makes self-understood, and had the ability to understand others. During a review of Resident 121's Physician Order, dated 5/2/2025, the Physician Order indicated Remeron 15 mg by mouth (PO) every hour of sleep (QHS) for depression manifested by poor appetite. During a review of Resident 121's H&P, dated 5/8/2025, the H&P indicated the residents can make needs known but cannot make medical decisions. [...]

Inspectors wroteb. During a review of Resident 121's Face Sheet (admission Record), the Face Sheet indicated the facility admitted the resident on 2/18/2021 with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing) with acute (sudden) exacerbation (worsening of the disease), schizophrenia (a mental illness that is characterized by disturbances in thought), and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs). During a review of Resident 121's Minimum Data Set (MDS-a resident assessment tool), dated 2/25/2025, the MDS indicated the resident had clear speech, makes self-understood, and had the ability to understand others. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the comprehensive care plan (CP - a plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs) was revised for one of five sampled residents (Resident 26) reviewed during the Infection Control task and two of two sampled residents (Resident 153 and 289) reviewed for pressure ulcer/injury (localized damage to the skin and/or underlying tissue usually over a bony prominence) by failing to: 1. Review and revise the CP for Resident 26's precaution status (levels of infection control practices used in healthcare to minimize the spread of infections). 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide care in accordance with professional standards for two (2) of 2 sampled residents (Residents 107 and 12) reviewed for insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) use by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) insulin administration sites. This deficient practice had the potential for adverse effect (unwanted, unintended result) of the same site subcutaneous administration of insulin such as excessive bruising, lipodystrophy (abnormal distribution of fat), and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin).

Inspectors wrotec. During a review of Resident 117's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated the facility admitted the resident on 3/28/2025, with diagnoses including history of falling and osteoporosis. During a review of Resident 117's MDS, dated [DATE], the MDS indicated Resident 117 had severely impaired cognition (mental action or process of acquiring knowledge and understanding). The MDS further indicated Resident 117 required supervision or touching assistance with eating and oral hygiene; substantial/maximal assistance with upper toileting hygiene, bathing, and lower body dressing; partial/moderate assistance from staff with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident receives necessary respiratory care and services in accordance with professional standards of practice for four of four sampled residents (Resident 175, 61, 94, and 291) reviewed during Respiratory care area, by failing to: 1. Store the Bilevel Positive Airway Pressure (BiPAP-a non-invasive ventilation therapy that uses a machine to deliver two different levels of air pressure to the patient during breathing) mask free in a manner that is free from contamination for Resident 175. 2. Store the nebulizer (a medical device that converts liquid medication into a fine mist that can be inhaled through the lungs) in a clear plastic bag, labeled with the resident's name and the date it was last changed for Resident 175. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) for eight of 24 sampled residents (Residents 3, 62, 291, 95, 130, 440, 19, and 96) by: 1. Failing to ensure medication was administered as per physician order. Licensed Vocational Nurse (LVN) 1 administered 100 milligrams (mg - metric unit of measurement, used for medication dosage and/or amount) of docusate sodium (medication used to treat constipation [bowel movements are infrequent, and the stool is hard and difficult to pass]) to Resident 3 and the physician order was 250 mg. 2. Failing to ensure expired medication was not administered. LVN 2 administered expired docusate, dated 4/2025, to Resident 62 on 5/6/2025. 3. [...]

Inspectors wrote2. During a review of Resident 107's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated the facility originally admitted the resident on 3/23/2020 and readmitted in the facility on 7/26/2024, with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) following cerebral infarct (stroke, loss of blood flow to a part of the brain) affecting right dominant side, diabetes mellitus (DM 2-a disorder characterized by difficulty in blood sugar control and poor wound healing), and gastrostomy status (GT - a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe provision of pharmaceutical services for three of four sampled medication storage (two medication carts in Station B and the medication room in Station A) by: 1. Failing to ensure medications were labeled inside the medication room. Medication room in Station A had two unlabeled meropenem (medication used to treat infection) vials (a small, usually cylindrical container, typically made of glass or plastic, designed to hold medicine), in the Intravenous (IV - within the vein) Cart. 2. Failing to ensure the medication cart does not contain expired medication. Station B medication cart had psyllium (medication used to treat constipation [infrequent or difficult bowel movements]) with an expiration date of 9/2024. 3. Failing to ensure the medication cart does not contain expired medication. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare foods in a form designed to meet individual needs when puree mixed vegetables was too sticky and did not pass the spoon tilt test (a test used to determine the stickiness of the food and the ability of the food to hold together) for residents on puree diet (foods that are smooth with pudding like consistency)/International Dysphagia Diet Initiative (IDDSI-a framework for categorizing food textures and drink thickness level four (4). This deficient practice had the potential to result in difficulty in swallowing, chewing, decreased food intake and nutrient intake to 21 of 21 residents on a puree diet, resulting in unintended weight loss and aspiration (when something other than air gets into your airways).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen by failing to: 1. Dispose of tomato soup dated 5/2/2025. 2. Dispose of stewed prunes dated 3/2/2025. 3. Label one box mixed grapes, oranges, apple, and one carrot with an expired date and opened date 4. Label one Tutta [NAME] - Grated Parmesan Style Cheese, five (5) pounds (lbs.- a unit of measurement), received on 4/29/2025 with an opened date. 5. Ensure sliced cheeses were not mixed with avocadoes and grapes in one clear plastic bin. 6. Label one bin of purple cabbage with received date and expired date. 7. Label leafy lettuce with a received date and expired date. 8. Label the expiration date accurately on the unopened frozen pepperoni. 9. Label the opened sliced deli meat, roast beef with an expired date and opened date. 10. [...]

Inspectors wroteg. During a review of Resident 175's admission Record, the admission Record indicated the facility admitted the resident on 4/14/2025 with diagnoses including acute respiratory failure (a condition where the respiratory system can't effectively exchange oxygen and carbon dioxide, leading to a buildup of carbon dioxide and a deficiency of oxygen in the blood), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), and congestive heart failure (CHF- a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). During a review of Resident 175's History and Physical (H&P), dated 4/14/2025, the H&P indicated the resident has the capacity to understand and make decisions. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide sufficient space for storage of equipment to provide adequate space for rehabilitative services provided in the Physical Therapy (PT, a rehabilitation profession that restores, maintains, and promotes optimal physical function) gym. This deficient practice had the potential to minimize the usable treatment space of the PT gym and create a cluttered, unhomelike environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain one of three freezers (Freezer that stores milk) reviewed during Kitchen Task and maintain mechanical, electrical, and patient care equipment in safe operating condition for two (2) of 2 sample residents (Residents 65 and 107) reviewed under the Environmental Task, by failing to: 1. Ensure the light bulb was in working order in the freezer that stores milk. This deficient practice had the potential to result in poor visibility and sanitation concerns. 2. Ensure the base of Resident 65's bed controller (device used to change the height and angle of the bed) cord did not have exposed wires. 3. Ensure the wall sockets at the head of Resident 107's bed did not have a crack and were in disrepair. (Cross Reference F584). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care in a manner that maintained a resident's dignity for one (1) of 1 sampled resident (Resident 115) reviewed for dignity by failing to ensure Certified Nursing Assistant (CNA) 3 was not standing over the resident while assisting the resident during mealtime. This deficient practice had the potential to negatively affect the residents' psychosocial wellbeing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident and/or responsible party (RP) was informed in advance, of the risks and benefits of psychoactive medication (a drug that changes brain function and results in alterations in perception, mood, consciousness or behavior ) for one of one sampled resident (Resident 121) reviewed for informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) by failing to ensure Resident 121's Remeron (also known as mirtazapine, a medication used to treat depression [a mood disorder that causes a persistent feeling of sadness and loss of interest]). This deficient practice violated the resident's right to make informed decisions regarding the use of psychoactive medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medication self-administration was clinically appropriate and failed to honor the resident's right to self-administer medications for one of three sampled residents (Resident 96) reviewed under the Accidents care area by failing to perform a medication self-administration assessment when staff had knowledge that the resident kept medication at the bedside for self-administration. This deficient practice violated the residents' right to self-administer medications and had potential for the residents to experience adverse effects (an undesired effect of a drug or other type of treatment) of the medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide reasonable accommodation of resident needs and preferences by failing to ensure the call light (an alerting device for nurses or other nursing personnel to assist a patient when in need) was connected to the wall plug for one (1) of 1 sampled resident (Resident 107) reviewed under the Environment task. This deficient practice had the potential to result in the delay of care and services and possible injury to residents when they are unable to call for assistance.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a baseline care plan (the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care) for: 1. One of four sampled residents (Resident 291) reviewed for respiratory care (helping people breathe easier when they have trouble with their lungs or airways) by failing to develop and implement a baseline care plan on oxygen therapy (a treatment that provides extra oxygen to breathe in). 2. One of one sampled resident (Resident 289) reviewed for anticoagulant (a substance that is used to prevent and treat blood clots in blood vessels and the heart) use by failing to develop and implement a baseline care plan on the use of anticoagulant (Pradaxa). [...]

Inspectors wroteBased on interview and record review, the facility failed to follow up and schedule the resident's orthopedic (broad based medical and surgical specialty dedicated to the prevention, diagnosis, and treatment of diseases and injuries of the musculoskeletal system) appointment for Resident 112. This deficient practice had the potential to result in a delay of care and treatment for Resident 112.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident received care consistent with professional standards of practice to prevent pressure ulcers/injury (the breakdown of skin integrity due to pressure) for two of two sampled residents (Residents 153 and 289) reviewed for pressure injury by failing to ensure the low air loss mattress (LALM, a special kind of mattress designed to help prevent and treat skin problems like pressure sores [bedsores]) was set according to the residents' weight. These deficient practices had the potential for development and worsening of pressure ulcers/injuries to residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 121) received appropriate Restorative Nursing Aide program (RNA, nursing aide program that help residents to maintain their function and joint mobility) services to prevent a decline in range of motion (ROM, full movement potential of a joint) by failing to provide Resident 121 with active assisted range of motion (AAROM, movement at a given joint with a person's own effort and assistance from an external force or another person) exercises to the left upper extremity (UE, shoulder, elbow, wrist, hand) during the 5/7/2025 RNA session, as ordered by a physician and according to Resident 121's care plan. This deficient practice had the potential for a decline in mobility, ROM, and overall functioning in Resident 121.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the staff providing care and services to the resident who has a feeding tube (are soft plastic tubes through which liquid nutrition travels through the gastrointestinal tract [the series of organs that food and liquids pass through as they are digested, absorbed, and leave the body as feces]) are aware of, competent in, and utilize facility protocols regarding feeding tube nutrition and care for two of four sampled residents (Residents 53 and 107 ) reviewed for tube feeding by failing to ensure: 1. Resident 53's gastrostomy tube (g-tube, a feeding tube inserted through the abdomen into the stomach) Glucerna 1.2 (brand of formula feeding) was labeled with the time it was hung, and the water flush bag via pump had the time it was hung with its rate of infusion. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure staff competency (a combination of knowledge, skills, abilities, and behaviors that enable an individual to perform a task or role successfully) were performed annually (yearly) for one of six sampled staff (Certified Nursing Assistant [CNA] 1). This failure had the potential to affect the care necessary to provide nursing care and related services to meet resident needs safely.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five percent (% - one per one hundred), two medication errors out of 31 total opportunities contributed to an overall medication error rate of 6.45% affecting two of five sampled residents (Resident's 3 and 62), observed for medication administration by: 1. Failing to ensure Licensed Vocational Nurse (LVN) 1 administered docusate sodium (medication used to treat constipation [bowel movements are infrequent, and the stool is hard and difficult to pass]) 250 milligram (mg - metric unit of measurement, used for medication dosage and/or amount) to Resident 3 as per physician order. LVN 1 administered 100 mg on 5/6/2025. 2. Failing to ensure LVN 2 checked the docusate sodium 250 mg expiration date before medication administration to Resident 62. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a computed tomography scan (CT scan, medical imaging technique to create detailed cross-sectional images of the body) to one of 38 sampled residents (Resident 128) in a timely manner when a CT scan ordered on 9/9/2024 was not completed until 10/21/2024. This deficient practice had the potential to cause a delay in identification of diseases and delayed follow up orthopedic (medical specialty involving muscles and bones) care for Resident 128.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure kitchen staff were routinely trained and evaluated for competency skills when one of one staff (Cook 1) was unable to verbalize and prepare puree mixed vegetables in a consistency that passed all established testing guidelines including spoon-tilt test (a test used to determine the stickiness of the food and the ability of the food to hold together) for residents on puree diet (foods that are smooth with pudding like consistency)/International Dysphagia Diet Initiative (IDDSI-a framework for categorizing food textures and drink thickness level four (4). These deficient practices resulted in an improper puree consistency which was too thick and did not pass the spoon-tilt test, which had the potential to place the residents at risk for aspiration (when something other than air gets into your airways). [...]

Inspectors wroteBased on interview and record review, the facility failed to provide Occupational Therapy (OT, rehabilitative profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) treatments five times a week according to resident's OT plan of treatment and care plan for one of six sampled residents (Resident 128). This deficient practice had the potential for Resident 128 to not meet OT treatment goals and have a decline in function.

Inspectors wrote2. During a review of Resident 128's Face Sheet (FS), the FS indicated Resident 128 admitted to the facility on [DATE] with diagnoses including, but not limited to, muscle wasting and atrophy (weakening, shrinking, and loss of muscle) and right humeral neck fracture (broken bone of upper arm). During a review of Resident 128's Physician's History and Physical Examination (H&P) dated 8/10/2024, the H&P indicated Resident 128 had the capacity to understand and make decisions. During a review of Resident 128's Minimum Data Set (MDS, resident assessment tool) dated 2/10/2025, the MDS indicated Resident 128 had moderate cognitive impairments (mental processes involved in gaining knowledge and comprehension, includes thinking, knowing, remembering, judging, problem-solving). [...]

Inspectors wroteBased on interview and record review, the facility failed to implement the policy for antibiotic (medication used to treat infection) stewardship (efforts in doctors' offices, hospitals, long-term care facilities, and other health care settings to ensure that antibiotics are used only when necessary and appropriate, means prescribing the right drug at the right dose at the right time for the right duration) for one of three sampled residents (Resident 42) by failing to ensure Resident 42's Antibiotic Log (record that involves the systematic collection, analysis, and interpretation of data related to infections within a healthcare setting) antibiotics use was accurately filled up on 4/2025. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a person-centered care plan for one of three sampled residents (Resident 1) by failing to ensure Resident 1's bed alarm (a pad with sensors that will alarm when a resident stands up unassisted to help prevent falls by alerting staff) was functioning as indicated in Resident 1's Care Plan for fall. This failure had the potential for Resident 1 to fall and placed Resident 1 at risk for injury. Cross reference F689.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policy on fall prevention for one of three sampled residents (Resident 1) who had a history of fall and had an incident of fall on 4/23/2025 while admitted at the facility by: 1. Failing to ensure Resident 1's bed alarm (a pad with sensors that will alarm when a resident stands up unassisted to help prevent falls by alerting staff) was turned on and functioning. 2. Failing to accurately assess Resident 1's Fall Risk Assessment after incident of fall on 4/23/2025. These failures can potentially place Resident 1 at risk for further injury, fall, and accidents. Cross reference F656.

Inspectors wroteBased on interview and record review, the facility failed to report injury of unknown origin within 24 hours to the State Survey Agency (SSA- the agency that inspects long-term care facilities for the purposes of survey and certification) and the Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities), as per its policies and procedures on abuse for one of three sampled residents (Resident 1). This deficient practice had the potential to place Resident 1 at risk for an unidentified abuse while under the care of the facility.

Inspectors wroteBased on interview and record review, the facility failed to maintain accurate and complete medical records for one of three sampled residents (Resident 1). This failure had the potential to cause confusion in care and the medical records containing inaccurate documentation

Inspectors wroteBased on observation, interview and record review, facility failed to maintain privacy of confidential information when Licensed Vocational Nurse 2 (LVN 2) left electronic health record (EHR- a digital version of a patient's paper chart) opened, unattended and out of view for one of three sampled residents (Resident 1). This deficient practice violated Resident 1 ' s right to privacy and confidentiality of their medical records.

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

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care that was consistent with professional standards of care for one of three residents (Resident 2) when humidifier bottle (a medical device used to humidify oxygen which in turn increases the moisture) was observed with no water. This deficient practice had the potential for Resident 2 to be uncomfortable and a risk for bleeding due to the nasal passage and throat becoming dried out due to the use of pure oxygen.

Inspectors wroted. A review of Resident 46's Face Sheet indicated the facility admitted the resident on 10/6/2023, with diagnoses including anxiety (feelings of fear, dread, and uneasiness that may occur as a reaction to stress), congestive heart failure (a long-term condition that happens when the heart cannot pump blood well enough to give the body a normal supply), and chronic obstructive pulmonary disease (COPD, a chronic inflammatory lung disease that causes obstructed airflow from the lungs). A review of Resident 46's History and Physical, dated 10/13/2023, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 46's MDS dated [DATE], indicated the resident had impaired vision and cognition. The MDS indicated the resident required substantial to partial assistance in mobility. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a safe, clean, and homelike environment to three out of six sampled residents (Resident 61, 7, and 135) investigated during review of environment facility task by failing to: 1. Ensure Resident 61's bed controls did not have exposed wires. The deficient practice placed the resident at risk for injuries such as electrical shock. 2. Maintain Resident 7 and Resident 135's bolsters (a long, thick pillow or cushion that can be cylindrical in shape or rectangular, with a cover that can be cleaned) in good condition. This deficient practice had the potential to make the residents feel uncomfortable, at risk for accidents, and can negatively affect the residents' quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents were treated with respect and dignity including the right to be free from physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the resident's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) to five out of five sampled residents (Residents 40, 46, 127, 31, 28, and 7) investigated during review of physical restraints care area by failing to: 1. Ensure Resident 40, 31, and 68's bed was not placed against the wall without obtaining an informed consent from the resident or the resident's representative. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. To develop and implement a care plan on the use of a restraint (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the resident's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body), placement of bed against the wall to two out of seven sampled residents (Resident 46, 127, 31, and 68) investigated during review of restraints care area. This deficient practice had the potential for the residents to not receive the proper and necessary care related to use of restraints. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure licensed nurses provide care in accordance with professional standards to three of three sampled residents (Resident 40, 18 and 124) investigated during review of insulin (a hormone that lowers the level of blood sugar in the blood) use by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) insulin (a drug used to control the amount of sugar in the blood) injection sites. The deficient practices had the potential for adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin such as lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (a rare disease that occurs when a protein called amyloid builds up in organs). Cross-reference to F760.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services and treatments to maintain joint range of motion (ROM, full movement potential of a joint) for two of six sampled residents (Residents 28 and 92) by failing to: 1. Follow physician's orders for a Restorative Nursing program (RNA, nursing aide program that help residents to maintain their function and joint mobility) treatments to apply left knee extension (straighten knee) splint (rigid material or apparatus used to support and immobilize a broken bone or impaired joint) for maximum of three to four hours for Resident 28. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents' environment remains as free of accident hazards as is possible and residents receive adequate supervision to prevent accidents by failing to: 1. Ensure two single-use vitamin A&D ointment (a medication to treat or prevent dry, rough, itchy skin) packets were not left unattended and readily available in the residents' shared room for two of two sampled residents (Resident 2 and 48) observed during the screening process. 2. Ensure the Oxygen in Use, sign was placed outside of the resident room entrance door while on oxygen therapy for one (1) out of two (2) sampled residents (Resident 68). These deficient practices had the potential to place residents at risk for hazard or injury and at risk for obtaining topical medication without staff knowledge resulting in accidental ingestion.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide appropriate treatment and services to prevent complications of enteral feeding (EF - a form of nutrition that is delivered into the digestive system as a liquid) for three of three sampled residents (Residents 63,110, and 106) investigated during review of tube feeding (a medical device that delivers liquid nutrition directly into the stomach through a tube placed in the abdominal wall) care area by: 1. Failing to label Residents 63's water flush bag with the rate of administration and the date and time the water flush was administered. 2. Failing to label Resident 110's EF bag with the date and time the EF was administered. 3. Failing to change Resident 106's water flush bag every 24 hours. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who need respiratory care are provided care consistent with professional standards of practice for two of six sampled residents (Resident 28 and 38) investigated during review of respiratory care area by failing to: a. Ensure Resident 38 was administered as needed (PRN, when necessary) oxygen (O2) per physician orders, oxygen was documented when administered, and oxygen was monitored while in use. b. Ensure Resident 28's oxygen tubing was undated, not touching the floor, and did not have condensation inside the tubing while connected to the resident. These deficient practices had the potential to place residents at risk for respiratory distress.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Physicians Order for Life Sustaining Treatment (POLST, a form designed to improve patient care by creating a portable medical order form that records patients treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency) were dated by the physician for three of nine sampled residents (Residents 164, 39, and 14) investigated during the Initial Pool process. This deficient practice had the potential for delay of necessary services, poor continuity of care and follow-up on the resident's status. Findings 1.a. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement the recommendations for one of one resident (Resident 28)'s Medication Regimen Review (MRR - a pharmacist's thorough evaluation of a resident's medication routine and recommendations). This deficient practice could result in Resident 28 receiving unnecessary anti-anxiety (medication for feeling of fear and worry) medication.

Inspectors wrote3. A review of Resident 424's Face Sheet (admission Record) indicated the facility admitted the resident on 4/22/2024 with diagnoses that included Alzheimer's disease (a type of dementia [general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life]), encounter for palliative care (specialized medical care for people living with a serious illness), anxiety disorder, unspecified dementia with agitation, and bipolar disorder (a mental health disorder that causes extreme mood swings). A review of Resident 424's Minimum Data Set (MDS - an assessment and screening tool) dated 4/28/2024, indicated the resident usually was able to understand others and usually was able to make herself understood. The MDS further indicated the resident was dependent on staff for bathing; required substantial assistance with dressing; [...]

Inspectors wroteBased on interview and record review the facility failed to ensure residents are free of any significant medication errors to three out of three sampled residents (Residents 40 18), and 104) investigated during review of insulin use by failing to rotate (a method to ensure repeated injections are not administered in the same area) insulin (a medication that regulates sugar in the blood) injections sites. The deficient practices had the potential for adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin such as lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (a rare disease that occurs when a protein called amyloid builds up in organs).

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure kitchen staff were routinely trained and evaluated for competency skills as followed: a. Staff failed to verbalize proper storage of food. b. Staff failed to verbalize and follow the manufacturer's guidelines of cleaner chlorine test paper (a type of test strip) when checking the chlorine (a chemical used to disinfect dishes) sanitizer concentration. These failures had a potential to result to cross-contamination (a transfer of bacteria from one object to another), unsanitized dishware and bacterial growth to food that could lead to foodborne illness (an illness caused by contaminated food and beverages) in 167 of 173 medically compromised residents who received food and ice from the kitchen.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow the menu of and did not meet nutritional needs of 79 of 173 residents on regular texture (diet with no texture restriction) and 22 of 38 residents on soft mechanical finely chopped diet (diet consisted of food that are chopped half inches ([in] a unit of measurement) or less and restrict food that are difficult to chew or swallow) by: a. Not following portion sizes for oven fried chicken based on facility spreadsheet. b. Not following menu for dessert for finely chopped diet. These deficient practices had the potential to cause difficulty in eating, chewing, and swallowing to the residents and decrease food intake resulting to unintended (not done on purpose) weight loss or increased food intake resulting to unintended weight gain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare food by methods that conserved flavor when puree chicken did not taste like chicken. This deficient practice had a potential to cause unplanned weight loss, a consequence of poor food intake 21 of 173 facility residents on puree diet (a diet with smooth, pudding like consistency foods) getting food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to distribute and serve food in accordance with professional standards for food service safety for one of two sampled residents investigated during a complaint investigation (Resident 146) when Resident 146 was not provided clean dishware during meal service. The facility also failed to ensure safe and sanitary food storage and food preparation practices in the kitchen and when: A. 1. Hygiene a. Staff were wearing jewelries during food handling and preparation. 2. Proper food storage a. Unlabeled food for expiration date in the walk-in refrigerator and in the kitchen. b. Uncovered fruit plates and key lime pie inside the walk-in refrigerator. c. One (1) dented can was stored in the dry storage area along with the undented cans. d. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose garbage and refuse properly by not completely covering two (2) of four (4) black dumpster (a large trash container designed to be emptied into a truck) for unknown amount of time. This deficient practice had a potential to attract flies, insects, cats, and other animals to the dumpster area placing 167 of 173 facility residents getting food from the kitchen cross-contamination (a transfer of harmful bacteria from one place to another).

Inspectors wroteb. A review of Resident 424's Face Sheet (admission Record) indicated the facility admitted the resident on 4/22/2024 with diagnoses that included Alzheimer's disease (a type of dementia [general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life]), encounter for palliative care (specialized medical care for people living with a serious illness), anxiety disorder, unspecified dementia with agitation, and bipolar disorder (a mental health disorder that causes extreme mood swings). A review of Resident 424's Minimum Data Set (MDS - an assessment and care screening tool) dated 4/28/2024, indicated the resident usually was able to understand others and usually was able to make herself understood. The MDS further indicated the resident was dependent on staff for bathing; [...]

Inspectors wrote10. A review of Resident 28's Face Sheet indicated the facility admitted Resident 28 on 11/2/2023 with diagnoses including, but not limited to, acute (present) and chronic (long-term) respiratory failure (a condition where you don't have enough oxygen in the tissues in your body or when you have too much carbon dioxide in your blood), dependence on supplemental oxygen, and chronic obstructive pulmonary disease (COPD - a condition involving constriction of the airways and difficulty or discomfort in breathing). [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to monitor proper temperatures of the resident's refrigerator and freezer from 4/10/2024 to 5/15/2024 in Stations one (1), two (2) and three (3). This deficient practice had the potential to result in danger zone temperatures (a range of temperature in which food-borne bacteria could grow) that could lead to foodborne illness (illness caused by food contaminated with bacteria, viruses, parasites, or toxins) in 167 of 173 medically compromised residents who stored food in the resident's refrigerator and freezer.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care in a manner that maintained or enhanced a resident's dignity and respect in full recognition of their individuality for one of two sampled residents investigated under the dignity care area (Resident 80) when Resident 80's urinary catheter bag (device used to collect urine drained from the bladder via a urinary catheter [a tube inserted into the bladder through the urethra (duct that lets urine leave the bladder and body) to allow urine to drain]) was not covered with a privacy bag (also known as a dignity bag - device used to cover the contents or a urinary catheter bag). This deficient practice had the potential to negatively affect the resident's psychosocial wellbeing and loss of dignity.

Inspectors wroteBased on interview and record review, the facility failed to provide the Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN, a written notification to the resident or responsible party of the potential liability charges for services not covered when the resident was discharged from Medicare Part A services with benefit days remaining) in a timely manner for one of three sampled residents (Resident 425) investigated during review of the Beneficiary Notification task. This deficient practice had the potential to result in residents or responsible parties not being able to exercise their rights to make decisions regarding their care and their right to file an appeal.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure privacy for one of four sampled residents (Resident 159). This deficient practice had the potential to cause Resident 159 embarrassment and distress due to a lack of privacy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to update Resident 28's Restorative Nursing Restorative Nursing Aide program (RNA, nursing aide program that help residents to maintain their function and joint mobility) Care Plan to reflect the current RNA orders. This deficient practice had the potential for Resident 28 to receive incorrect services and minimize the facility's ability to review the effectiveness of the RNA program.

Inspectors wroteBased on interview and record review, the facility failed to provide necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one of two sampled residents investigated during a complaint (Resident 146), 10 of 10 resident council group attendees investigated under the resident council task, and for one of three sampled residents investigated under the activities of daily living care area (Resident 92) when the facility failed to: a. Temporarily move Resident 146 out of the room after his roommate (Resident 325) expired. b. Offer the resident council group attendees and Resident 92 to eat their meals in the dining room. These deficient practices resulted in or had the potential to: a. Resident 146 experiencing feelings of increased stressed and anxiety. b. Negatively affect residents' psychosocial wellbeing. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice and the resident's choices to one out of three residents (Resident 172) investigated during review of closed record by failing to: 1. Ensure the admission orders address the resident's code status (refers to the level of medical interventions a resident wish to have started if their heart or breathing stops) Resident 172 had a previous code status of Do Not Resuscitate (DNR, refers to a medical order issued by a physician that directs healthcare providers not to administer CPR in the vent of cardiac or respiratory arrest)/Do Not Intubate (DNI) from General Acute Care Hospital 1 (GACH 1). 2. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure residents receive treatment and services to maintain vision to one out of four sampled resident (Resident 18) investigated during review of communication/sensory care area for vision by failing to schedule an optometrist/ophthalmologist (eye care specialist) appointment Resident 18. This deficient practice had the potential to result in worsening of the resident's vision that could negatively affect their daily activities and overall well-being.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents who were incontinent (lacks voluntary control over urination) of bladder (organ in the pelvis that stores urine) received appropriate treatment and services to prevent urinary tract infections (UTI, common infections that happen when bacteria infect the urinary tract) for two out of four sampled residents (Resident 80 and 146) reviewed under the urinary catheter (a tube that is inserted into the bladder, allowing urine to drain) care area by failing to keep Resident 80 and Resident 146's urinary catheter tubing from coiling and allowing the contents to flow freely into the urinary catheter bag (container that connects to a urinary catheter and collects urine). This deficient practice had the increased potential for residents to obtain a UTI.

Inspectors wroteBased on interview, and record review, the facility failed to ensure that a resident who was receiving dialysis (clinical purification of blood as a substitute for the normal function of the kidney) treatment received services consistent with professional standards of practice for one (1) out 1 sampled resident (Resident 162) investigated during review of dialysis care area by failing to complete the post dialysis assessment on 5/11/2024 per facility policy. This deficient practice placed the resident at risk for developing complications related to renal disease such swelling, high blood pressure and shortness of breath.

Inspectors wroteBased on interview and record review, the facility failed to provide medically-related social services (services provided by the facility's staff to assist residents in attaining or maintaining their mental and psychosocial health) to maintain the highest practicable psychosocial well-being for one of two sampled residents reviewed during a complaint investigation (Resident 146) when the social services department did not provide follow-up visits to Resident 146 after his roommate (Resident 325) expired. This deficient practice had the potential for the resident's stress and anxiety to increase. Cross-reference to F675.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that an unlabeled, and unpackaged medication pill was labeled or disposed of in medication room [ROOM NUMBER]. This deficient practice had the potential for an unknown medication to be administered to a resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe provision of pharmaceutical services by failing to ensure two unlabeled cephalexin (an antibiotic [medication used to treat bacterial infections in different parts of the body]) capsules were not stored and readily available for use in Medication Cart #2 for one of three medication carts (Medication Cart #2) inspected during review of the Medication Storage and Labeling task. This deficient practice had the potential to result in medication being administered to the wrong resident possibly resulting in allergic reactions and the loss of resident medication.

Inspectors wroteBased on observation, interview, and record review the facility failed meet resident's (Resident 17) food preferences when there were missing items on the resident's tray. This deficient practice had the potential to cause frustrations and decrease food intake resulting to unintended (not done on purpose) weight loss.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents had the right to receive mail for 10 of 10 resident council group interview attendees investigated under the resident council task by failing to ensure residents receive mail on Saturdays. This deficient practice violated the residents' right to receive mail on Saturdays and had the potential to negatively affect the resident's psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote the resident rights to examine the results of the most recent survey (a survey to determine compliance with state and federal regulations) of the facility by failing to post survey results in a place that is prominent and accessible (a place where individuals wishing to examine survey results do not have to ask to see them) to residents, family members, and legal representatives of residents. This deficient practice had the potential for residents' and their representative not having access to examine the most recent survey results.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the assessment entries on the Minimum Data Set (MDS- an assessment and care screening tool) related to bowel and bladder were accurately documented for one of four residents (Resident 164) investigated during review of urinary catheter care area by failing to ensure the assessment did not indicate the resident had an indwelling catheter (a flexible tube placed in the bladder to drain urine). This deficient practice had the potential to negatively affect Resident 164's plan of care and delivery of necessary care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident received care consistent with professional standards of practice to prevent pressure ulcer (PU-a localized injury to the skin and or underlying tissue usually over a bone prominence as a result of pressure or pressure in combination with shear [occur between the internal body structures and skin tissues typically moving in opposite directions and may lead to deep tissue injury]) for one of three sampled residents (Resident 1) by: 1. Failing to accurately monitor and ensure Resident 1's skin was assessed for pressure ulcer. 2. Failing to ensure there were appropriate number of linens between Resident 1 and the air pressure redistribution mattress (APM - [air mattress] a mattress composed of inflatable air cushions that is used to relieve pressure on the body parts) per manufacturer's guidelines. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to observed infection control measures for two of three sampled residents (Resident 1 and Resident 2) by failing to ensure oxygen tubing was not touching the floor. This deficient practice resulted in contamination (the process of making something dirty) of the residents' care equipment and placed the residents at risk for infection.

Inspectors wroteBased on interview and record review, the facility failed to prevent physical and verbal abuse for two of three sampled residents (Resident 1 and Resident 2). On 12/3/2023 at around 7 p.m. Resident 2 bumped his wheelchair into Resident 1 ' s wheelchair, subsequently Resident 1 and Resident 2 got into an exchange of verbal profanity against each other and punched each other ' s face with close fist several times. This deficient practice resulted in Resident 1 and Resident 2 being subjected to physical and verbal abuse by one another while under the care of the facility. Resident 1 sustained redness to the left check and Resident 2 had swelling to the left cheek (inflammation) needing cold compress (chilled or frozen object, often a piece of cloth to relieve pain / swelling). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate records of administration of all controlled drugs (prescription medications that are designated by law and whose manufacture, possession and use is regulated by the government) for one of three sampled residents (Resident 3). On 11/27/2023, Licensed Vocational Nurse 3 (LVN 3) did not document the administration of hydrocodone/acetaminophen (Norco, a combination opioid [work in the brain to produce a variety of effects, including pain relief]). This deficient practice resulted in inaccurate reconciliation of the controlled medication and placed the facility at potential for inability to readily identify loss and drug diversion (illegal distribution of abuse of prescription drugs or their use of unintended purposes) of a controlled medication.

Inspectors wroteBased on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices for one of one sampled resident (Resident 3) by, failing to maintain documentation of the follow-up notes for Resident 3, subsequent to their transfer to the general acute care hospital (GACH). This deficient practice had the potential to result in gaps in the Resident 3's medical history and could lead to delays or errors in providing appropriate medical care.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement interventions as indicated in residents' individualized care plans, for two out of two sampled residents investigated under the care area of care planning as evidenced by: 1. Resident 46's fall care plan indicated to provide floor mattress and set bed in low position to reduce and minimize potential injuries from falls and was observed not being implemented. This deficient practice placed the resident at risk for serious injuries in the event of a fall incident. 2. Resident 46's activity care plan indicated to provide 1:1 or group activities that meets his needs and interests as was not implemented. This deficient practice has the potential to result in resident feeling isolated and depressed. 3. Resident 14's activities of daily living (ADL) care plan indicated to provide basic needs. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all residents have a right to a dignified existence by failing to ensure a resident (Resident 225) had a privacy bag over the urinary drainage bag (bag used to collect urine) for one of one resident reviewed under the care area of dignity. This deficient practice had the potential to affect Resident 225 right to a dignified existence.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident's advance directives (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) were readily accessible in the physical chart for one of three sampled residents (Resident 84). This deficient practice had the potential to delay emergency treatment or the potential to force emergency, life-sustaining procedures against the resident's personal preferences.

Inspectors wroteBased on observation and interview, the facility failed to provide maintenance services to maintain a safe and homelike environment for two of two sampled residents (Residents 23 and 65) by failing to seal the gap around the pipe connecting to the toilet for Resident 23 and 65's room. This deficient practice had the potential for Residents 23 and 65 to be exposed to pest infestation and an unsafe environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one out of one sampled resident (Resident 14) was provided care and services to maintain good grooming and personal hygiene. This deficient practice resulted in Resident 14 having long and unkept fingernails that had the potential to result in a negative impact on the resident`s self-esteem and self-worth.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide on-going activities that incorporate the resident's interests based on the comprehensive assessment for one out of one sampled resident (Resident 46). This deficient practice had the potential to affect the Resident 46`s sense of self-worth and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of four sampled residents (Residents 9 and 101) received treatment and care in accordance with professional standards of practice by: 1. Failing to ensure current doctor orders were in place for treatment of gangrenous toes (a condition in which body tissue dies from not getting enough blood) for Resident 101. 2. Failing to ensure blood sugar monitoring was completed on 09/13/2021 for Resident 9. These deficient practices had the potential to result in a delay of healing for Resident 101's gangrenous toes, and placed Resident 9 at risk for undetected hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar) that can result in nausea and vomiting, blurred vision, lightheadedness, or shakiness that can lead to falls and injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the low air loss mattress (LALM, a pressure-relieving mattress used to prevent and treat pressure ulcers [a wound that occurs as a result of prolonged pressure on a specific area of the body]) was properly set between 120-150 pounds (lbs - unit of measurement) based on the resident's weight for one of four sampled residents (Resident 44). This deficient practice placed Resident 44 at risk for skin breakdown and development of pressure ulcers.

Inspectors wrotec. A review of the Face Sheet (admission record) indicated Resident 46 was admitted to the facility on [DATE], with diagnoses that included history of falling and dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). A review of the Minimum Data Set (MDS - a comprehensive assessment and care screening tool) dated 08/10/2021, indicated that Resident 46`s cognitive skills (cognition refers to conscious mental activities, and include thinking, reasoning, understanding, learning, and remembering) for daily decision-making are severely impaired. The MDS also indicated that the resident requires extensive assistance on staff for dressing, toilet use, personal hygiene, and bathing. [...]

Inspectors wroteBased on interview and record review, the facility failed to document the pain assessment for one out of one sampled resident (Resident 92) to ensure the resident received effective pain management. This deficient practice had the potential for the resident to endure and suffer from unrelieved pain.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Narcotic and Hypnotic Record (accountability record of controlled medications that are considered to have strong potential for abuse) coincided with the number of doses in the bubble pack (blister pack, medication package with compartments of single doses), and failed to ensure the licensed nurse documented the administration of controlled medication on the Narcotic and Hypnotic Record for Resident 231. These deficient practices resulted in inaccurate reconciliation of the controlled medication (hydrocodone-acetaminophen [Norco] - narcotic) and placed the facility at potential for inability to readily identify loss and drug diversion (illegal distribution of abuse of prescription drugs or their use of unintended purposes) of controlled medication for Resident 231.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure to indicate a duration or to limit an as needed (PRN) physician's order for the psychotropic medication (medication that affects behavior, mood, thoughts, or perception) Lorazepam (medication to relieve anxiety) to 14 days for one out of seven sampled residents reviewed addressing unnecessary meds (Resident 87). 2. Failed to document specific indication for the use of Klonopin (medication used to treat anxiety and panic disorders) for one out of seven sampled residents reviewed addressing unnecessary meds (Resident 84). These deficient practices had the potential to place the residents at risk for adverse side effects (any unexpected or dangerous reaction to a drug) associated with the use of psychotropic medications and inconsistent monitoring of behaviors.

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Remove and discard three expired insulin (a hormone that lowers the level of glucose in the blood) vials. 2. Store two opened Basaglar Insulin Pen (long acting insulin that helps to control blood sugar levels) in room temperature according to the manufacturer's guidelines. 3. Label two opened Humulin Insulin (short acting insulin that helps to control blood sugar levels) vials with open date. These deficient practices had the potential to compromise the effectiveness of insulin if stored outside the required temperature range and had the potential for the resident potentially receiving an out-of-date insulin that may affect the residents' health conditions.

Inspectors wroteBased on interview and record review, the facility's licensed nurses failed to maintain accurate Medication Administration Record (MAR) for one out of three sampled residents (Resident 26). The licensed nurses failed to document when they held (not administer) Resident 26's hydralazine (a medication to lower blood pressure). This deficient practice had a potential for creating confusion to staff and placed the resident at risk for not receiving appropriate care.

Inspectors wroted. A review of Resident 52's Face Sheet (admission record) indicated the resident was admitted into the facility on 4/29/2021 with diagnoses that included chronic kidney disease stage 3 (moderate kidney [organs involved in filtering wastes and excess fluids from the blood] damage), diabetes mellitus type 2 (a chronic condition that affects the way the body processes blood sugar), and dementia (group of symptoms affecting memory, language, problem-solving, and other thinking abilities). A review of Resident 52's Minimum Data Set (MDS - a standardized assessment and screening tool), dated 8/6/2021, indicated the resident had the ability to sometimes make self understood and had the ability to sometimes understand others. [...]