Beachside Nursing Center

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to one of three sampled residents (Resident 2). * The facility failed to ensure appropriate notifications were made, an assessment was completed, a care plan was developed, and the resident's unusual behavior was monitored and documented in response to Resident 2's involvement in an allegation of abuse. This failure had the potential to result in ineffective provision of care and negative outcomes for the resident.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to maintain the infection control practices to help prevent the development and transmission of diseases and infections. * The facility failed to ensure an EBP signage and PPE cart were available by Resident 3's entrance door. * The facility failed to ensure the EBP was followed for Resident 3 when LVN 1 and CNA 1 failed to wear a gown during wound care. These failures posed the risk of not preventing the spread of infection in the facility and posed the risk of unsanitary environment.

Inspectors wroteBased on interview and closed medical record review, the facility failed to ensure a care plan was developed to reflect the individual care needs for one of three sampled residents (Resident 1). * The facility failed to develop a care plan to address Resident 1's pacemaker (a small, battery-operated device implanted under the skin, usually near the collarbone, to regulate a slow or irregular heart rhythm using electrical impulses). This failure posed the risk of the resident not receiving the appropriate treatment and services).

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure food safety guidelines related to food storage were followed in the kitchen. * The facility failed to ensure the food items past the use by date were discarded. This failure increased the risk for food borne illness for 56 residents who received food prepared in the facility's kitchen.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the medical record was complete and accurately maintained for two of 15 final sampled residents (Residents 1 and 33) and two of three residents (Residents 78 and 90) reviewed for closed records. * The facility failed to document in the medical record all the observations, assessments, vital signs, interventions, and change in condition, when Resident 78 expired in the facility. In addition, the facility failed to document the names and titles of the facility staff who conducted these observations and assessments and performed the interventions. * The facility failed to ensure the physician's orders for the route of medication administration for Resident 1 were accurate. The medication route was ordered for oral administration instead of via GT. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services for the use psychotropic medications were provided for one of five final sampled residents (Resident 80) reviewed for unnecessary psychotropic medications. * The facility failed to ensure Resident 80 was informed and the informed consent included the indication and manifested behaviors for the use sertraline (antidepressant medication) and Abilify (antipsychotic medication) as ordered by the physician. In addition, the facility failed to ensure the informed consent had the prescriber's signature. These failures had the potential for the Resident 80 to be unaware of the risks and potential side effects associated with the use psychotropic medications.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure privacy was provided for one nonsampled residents (Resident 4) during the medication administration. * The facility failed to ensure Resident 4's privacy was observed when the licensed nurse administered the resident's medications in the hallway. This failure had the potential to negatively affect the dignity of the resident and violate the resident's rights to privacy.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to maintain a safe and homelike environment for one of 15 final sampled residents (Resident 86). * Resident 86's nightstand was not in good repair and safe condition. This failure had the potential to negatively impact on Resident 86's' quality of life and safety.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the comprehensive plan of care were revised to reflect the residents' current care needs and interventions for two of 15 final sampled residents (Residents 17 and 75) reviewed for care plans. * Resident 17's care plan addressing the resident's nutrition was not revised to address Resident 17's significant unplanned weight loss on 1/21/26. In addition, the care plan interventions did not reflect Resident 17's current physician's orders. * The facility failed to ensure Resident 75's care plan addressing the resident's activity was revised to reflect the resident's contact isolation precaution. These failures posed the risk of not providing the resident with individualized and person-centered care.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services status post fall for one of 15 final sampled residents (Resident 82) and dietary services for one non-sampled resident (Resident 40) in accordance to the facility's P&P. * The facility failed to complete the physical assessment, obtain the vital signs and perform the neuro checks post fall incident for Resident 82. In addition, the facility failed to monitor Resident 82's blood pressure and heart rate prior to the administration of sacubitril-valsartan (a medication used to treat chronic heart failure) and complete a fall risk assessment correctly. * The facility failed to provide Magic Cup (a nutritional supplement) to Resident 40 as ordered by the physician. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the appropriate care and services for one of one final sampled residents (Resident 5) reviewed for indwelling urinary catheter (flexible tube inserted into the bladder to continuously drain urine into an external collection bag). * The facility failed to monitor Resident 5's urinary output per the resident's plan of care. This failure had the potential for the resident to develop indwelling urinary catheter related complications.

Inspectors wroteBased on interview, medical record review, facility P&P review, the facility failed to provide the necessary care and services related to weight loss for one of four residents (Resident 17) reviewed for nutrition. * The facility failed to ensure the physician was notified when Resident 17 had a weight loss. In addition, the facility failed to conduct an IDT meeting and carried out an RD recommendation related to Resident 17's weight loss. These failures had the potential for the resident to not receive the necessary care and nutritional interventions and could contribute to resident's further weight loss.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary respiratory care and services for one of one final sampled resident (Resident 86) and two non-sampled residents (Residents 16 and 51) reviewed for the respiratory care. * The facility failed to ensure Resident 86 had a physician's order for the use of oxygen therapy. Furthermore, when Resident 86 had an order for oxygen, Resident 86 was provided with oxygen greater than what was ordered by the physician. In addition, Resident 86's nebulizer mask and tubing were not labeled and stored properly when not in use. * The facility failed to ensure the nebulizer mask and tubing at Resident 16's bedside was labeled and stored in a bag. In addition, the facility failed to ensure the nebulizer mask and tubing at Resident 16's nightstand belonged to the resident. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary pharmaceutical services for one final sampled resident (Resident 7) and one nonsampled resident (Resident 74). * LVN 7 failed to administer Resident 74's probiotic (supplement) as ordered by the physician. * The facility failed to obtain and document Resident 7's blood pressure and heart rate per the physician's ordered parameters for two medications: amlodipine-olmesartan (blood pressure medication) and metoprolol succinate (blood pressure medication). These failures had the potential to negatively affect the residents' well-being.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure for proper storage, labeling, and disposal of the medications for two final sampled residents (Residents 2 and 33), one nonsampled resident (Resident 19) and one of three medication carts (Medication Cart A) observed. * The facility failed to ensure Resident 2's hydrocodone-acetaminophen (a controlled drug used to manage severe pain) and Resident 19's oxycodone (a controlled drug used to manage severe pain) medication bubble packs were properly stored in Medication Cart A. * The facility failed to ensure the accurate labeling of one insulin pen stored in Medication Cart A. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to maintain the infection control practices to help prevent the development and transmission of diseases and infection. The facility failed to ensure Resident 24's wound vacuum machine and the connector tubing were not stored and touching the floor. This failure posed the risk for the resident to develop a wound infection that could negatively affect the resident's health and well-being.

Inspectors wroteBased on interview, medical record review, immunization document review, and facility P&P review, the facility failed to ensure the necessary services related to COVID-19 vaccination was provided for two of five residents (Residents 5 and 7) reviewed for immunizations. * The facility failed to ensure Residents 5 and 7 were provided the education specific to eligibility to receive COVID-19 vaccine. This failure posed the risk for the residents to acquire COVID-19 infection and could negatively affect the residents' health and well-being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to develop and implement the comprehensive person-centered plan of care to reflect the change of condition for one of three sampled residents (Resident 1). * There was no care plan developed for Resident 1's preference to not have any male CNAs provide showers or change the resident when soiled. This failure posed the risk of not providing appropriate, consistent, and individualized care to Resident 1.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the food safety and sanitation guidelines were followed when: * The facility failed to ensure the food items were properly stored and maintained. * The facility failed to ensure the food items were dated and labeled. * The facility failed to ensure the kitchen equipment was maintained in a sanitary condition and/or cleaned properly. These failures had the potential to result in foodborne illnesses for 57 of 59 residents receiving the dietary services in the facility's kitchen.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to two of 15 final sampled residents (Residents 24 and 31). - The physician's order for the resident to be up in the chair during meals was not carried out for Resident 24. - The physician's order was not obtained and the care plan was not developed for the use of the wander guard for Resident 31. These failures had the potential for these residents to not receive the necessary care and services to meet their care needs.

Inspectors wroteBased on observation, interview, medical record review, and the facility P&P review, the facility failed to ensure the appropriate services needed to maintain the acceptable parameters of nutritional status were provided for three of three final sampled resident (Residents 4, 31, and 32) reviewed for weight loss. * The facility failed to ensure the RD's recommendations on 3/14/25, were followed up with the physician and addressed in the Nutrition IDT when Resident 4 had a severe weight loss of 15 lbs in seven days. This failure had the potential for Resident 4 not to receive the necessary intervention to prevent further weight loss. * The facility failed to ensure the RD and IDT analyzed and implemented the necessary interventions to address Resident 32's unplanned severe weight loss of 16 lbs which was equivalent to 8.33% in 21 days. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the GT placement check was performed prior to starting the resident's enteral feeding for one of one final sample resident reviewed for tube feeding (Resident 32). This failure had the potential for the residents to develop complications related to the GT care and management, including tube dislodgement.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary respiratory care and services were provided for two of two sampled residents (final sample resident, Residents 356 and nonsampled resident, Resident 705) reviewed for respiratory care. * The facility failed to ensure the oxygen was administered as ordered by the physician to Resident 356. * The facility failed to ensure the nasal cannula tubing was dated and a storage bag was provided for Resident 705. These failures had the potential for these residents to not receive the appropriate respiratory care or developed respiratory infection which may negatively affect the residents' medical conditions.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 7.41%. * LVN 1 did not administer Resident 34's metformin HCL (medication to lower the blood sugar) with meal or food as ordered. * LVN 1 administered Advil (pain reliver) 200 mg two tablets for Resident 44's pain level of 8 which was not a prescribed pain level for this pain medication. These failures had the potential to negatively impact the residents' health outcomes.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure the proper storage and disposal of the medications. * The facility failed to ensure Medication Cart A was maintained in a clean and sanitary manner. * The facility failed to ensure Medication Cart B was maintained in a clean and sanitary manner and the expired medication in the medication cart was disposed. * The facility failed to dispose of the expired medications in the Medication Storage Room. * The facility failed to store the oral and external medications separately in the Medication Storage Room. These failures had the potential to negatively impact the residents' well-being, for the medications to lose the stability and effectiveness, and medication errors.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the menu was followed as evidenced by: * [NAME] 1 failed to follow the recipe for the egg rolls and cream of rice during the puree preparation. * Residents 7, 706, 707, 756, and 758 (nonsampled residents) were not served a regular textured diet as ordered by the physician. * Resident 706 (nonsampled resident) was not served the appropriate serving portion as ordered by the physician * [NAME] 1 failed to use the correct scoop size to serve rice for Resident 33 (final sample resident). These failures had the potential of not meeting the residents' nutritional needs which could lead to nutritional related health complications.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the medical records were complete and accurately maintained for two of 15 final sampled residents (Residents 4 and 33). * Resident 4's POLST failed to show documentation as to whether Resident 4 had formulated the advanced directive. * The facility failed to ensure Resident 33's peripheral IV catheter care was documented. These failures had the potential for the residents' care needs not being met as their medical information was inaccurate and incomplete.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the hospice and facility staff worked collaboratively together in the plan of care for one of one hospice resident (final sampled resident, Resident 1) as per the hospice contract agreement. This failure had the potential of Residents 1 to not receive hospice care as per the hospice contract agreement and P&P.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the infection control practices were followed as evidenced by: * The OTA failed to perform hand hygiene before and after assisting Resident 4 to the bathroom. * LVN 1 failed to perform hand hygiene before and after taking the resident's blood pressure, during the medication preparation and administration, and in between the medication administration for Residents 3 and 34. * LVN 7 failed to perform hand hygiene after removing her gloves and in between contacts with Resident 24's roommate and Resident 24. These failures posed the risk for the transmission of the communicable diseases to other residents in the facility.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to maintain the kitchen's essential equipment in a clean and safe operating condition when: * The ice machine was not cleaned as per the manufacturer's guidelines for cleaning and sanitizing. * The low temperature dishwasher handles were missing covers and had brown discoloration. * The low temperature dishwasher machine was not operating as per the manufacturer's instructions. * The residents' dining room refrigerator temperature log was not monitored as per the facility's policy. There failures had the potential for the essential equipment to not function in the way it was intended, and exposed the residents to unsafe practices, which could lead to food borne illnesses for the residents.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to treat one of three sampled residents (Resident 2) with dignity when the staff removed her indwelling urinary Foley catheter. * The facility failed to get permission from Resident 2 for multiple staff to be present during the Foley catheter removal. This failure had the potential to negatively affect Resident 2's well-being.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the pharmaceutical services to ensure the medications were administered as ordered for one of three sampled residents (Resident 2). * The facility failed to ensure the medications scheduled for 0900 hours were administered to Resident 2timely. This failure had the potential to negatively affect the resident's health and well-being.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen as evidenced by: * The facility failed to ensure the blenders used for puree preparation were air dried prior to storing. * The facility failed to ensure the cutting boards were kept in a sanitary condition and with cleanable surface. * The facility failed to ensure the kitchen utensils had a smooth cleanable surface and were not worn out. * The facility failed to ensure the sanitary condition of the hood over the stove was maintained. * The facility failed to offer and provide hand hygiene to the residents before and after meals. These failures had the potential to cause foodborne illnesses for the residents in the facility.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 23 final sampled residents (Resident 443) was assessed to self-administer his medications. This failure had the potential for Resident 443 to administer medications inaccurately.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the comprehensive care plan was developed and/or implemented for five of 23 final sampled residents (Residents 21, 29, 37, 344, and 543). * The facility failed to ensure the bilateral floor mats were implemented in accordance with Residents 21 and 37's care plan. * The facility failed to develop a comprehensive person-centered care plan to address the use of CPAP machine for Resident 29. * The facility failed to ensure to follow a plan of care intervention to monitor and document intake and output for Resident 344's use of suprapubic catheter. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to ensure one of 23 final sampled residents (Resident 543) attained and maintained highest practicable physical well being. * The facility failed to ensure Resident 543's blood pressure and pulse rate were assessed and documented as ordered. * The facility failed to address Resident 543's complaints of constipation, notify physician of the change in condition, provide bowel regimen for constipation, and follow the care plan for pain medication and constipation monitoring. These failures had the potential to adversely affect the physical health and create the risk of not providing appropriate and consistent care to the resident.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure three of 23 final sampled residents (Residents 10, 21, and 37) remained free from accident hazards. *The facility failed to implement bilateral floor mats as per the physician's order and as care planned for Resident 37. *The facility failed to ensure the bilateral floor mats were implemented as per the care plan for Resident 21. *The facility failed to continue to monitor and document assessment every shift for 72 hours post fall incident for Resident 10. These failures had the potential to place the residents at risk for serious injury.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary respiratory care for five of 23 final sampled residents (Residents 10, 24, 29, 344, and 543) and one nonsampled resident (Resident 43). * The facility failed to administer oxygen therapy treatment as ordered by the physician for Resident 344. * The facility failed to ensure Resident 43's nebulizer mask was stored properly. * The facility failed to ensure Resident 29's CPAP mask was stored properly. * Resident 24 received continuous oxygen at 3 L/min via nasal cannula without a physician's order. * The facility to administer oxygen therapy as ordered by the physician for Resident 543. * The facility failed to ensure that nebulizer mask and tubing were changed and labeled as per the facility's policy for Resident 10. [...]

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the availability of the prescribed supplements for one nonsampled resident (Resident A). * Resident A had a physician's order for garlic supplement and glucosamine supplement. The licensed nurse was unable to administer the garlic and glucosamine supplements as ordered due to the unavailability of the supplements. This failure posed the risk for inhibiting the therapeutic effects of the supplements and had the potential to negatively affect the resident's health.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the Pharmacy Consultant's recommendations from drug regimen review in August 2023 were acted upon for one of 23 final sampled residents (Resident 9). This failure placed the resident at risk for receiving unnecessary medications, increasing their risk for side effects.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure two of 23 final sampled residents (Residents 10 and 543) were free from the unnecessary psychotropic drugs (any drug that affects brain activity). * The facility failed to ensure Resident 543's episodes of behaviors for the use of duloxetine (medication used to treat depression) and Trazadone (medication used to treat depression and aid with sleep) were consistent with the physician's orders. * The facility failed to provide the non-pharmacological interventions to Resident 10's anxiety to minimize the Xanax and lorazepam use; failed to provide the physician's documentation to extend Resident 10's Xanax and lorazepam medications (psychotropic medications) after 14 days of PRN use; [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 7.41%. Two of two licensed nurses (LVNs 2 and 4) were found to have made errors during the medication administration observations. * Resident 10 had a physician's order to apply 2 grams of 1% Voltaren (pain relief gel); however, the LVN failed to utilize the dosing card to determine the dose of Voltaren administered to Resident 10. * Resident A had a physician's order for Pulmicort inhalation (corticosteroid medication) for hypoxia which was scheduled to be administered at 0900 hours; however, the LVN did not administer Resident A's Pulmicort until approximately 5 hours after the mediation was ordered to be administered. These failures had the potential to negatively affect the residents' health.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the medications were stored and labeled properly two of four medication carts and failed to store resident biologicals and treatment supplies in a safe manner for one of one treatment cart. *The facility failed to ensure two medication carts (Medication Carts A & B) were kept locked when unattended by staff. * The facility failed to ensure medications were not left unattended on top of Medication Cart B. * The facility's treatment cart was observed with several unpackaged gauze pads lying on top of a pair of scissors and Calmoseptine ointment stored inside of a plastic cup. These failures posed the risk of unauthorized persons having access to the medications and had the potential to negatively impact the residents' well-being.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the physician was notified regarding laboratory services were not performed as ordered and abnormal laboratory test results were reported for two of 23 final sampled residents (Residents 344 and 543). * The facility failed to ensure the physician was notified of laboratory test not performed as ordered for Resident 344. * The facility failed to ensure the physician was notified of the abnormal lab results and documented in Resident 543's medical record. These failures had the potential to adversely affect the residents' physical health.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure one of 23 final sampled residents (Resident 343) was provided a prescribed therapeutic diet. This failure posed the risk of Resident 343's nutrition needs not being met.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the rehabilitation services for one of 23 final sampled residents (Resident 345). * The facility failed to ensure Resident 345 was provided RNA services for AROM exercises to bilateral upper and lower extremities as per the physician's orders. This failure had the potential for Resident 345 to decline in the ROM functions and mobility.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the medical records for four of 23 final sampled residents (Residents 10, 31, 344, and 543) were complete and accurate. * The facility failed to ensure the indwelling urinary catheter care was recorded for Resident 344. * Resident 10's physician's order for Pilocarpine 1% ophthalmic solution contained a conflicting administration frequency. * The facility failed to record the edema assessment for Resident 31. * Resident 31's medical record contained a physician's order for another resident (Resident 44). * The facility failed to ensure Resident 543's POLST form was accurate and signed by the physician. * The facility failed to ensure Resident 543's wound treatments were documented in the TAR. [...]

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to implement the infection control practices designed to provide a safe and sanitary environment and prevent the transmission of diseases and infections to all residents; and fail to implement safe and sanitary infection control practices for one of 23 final sampled residents (Resident 393). * The facility failed to ensure the personal items were not on the clean sorting table in the laundry. * The facility failed to ensure Resident 393's urinary drainage bag and urine meter drainage container (used to measure and drain urine when emptying) were not touching the floor. These failures posed the risk for transmission of disease-causing microorganisms.

Inspectors wroteBased on observation, interview, record review, and facility P&P review, the facility failed to ensure the personal privacy was provided during care for one of 23 sampled residents (Resident 543). This failure had the potential to negatively affect the dignity of the resident and violate the resident's rights to privacy.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to accurately complete the MDS assessment for one of 23 final sampled residents (Resident 11). * Resident 11 was a smoker. The facility failed to code Resident 11's use of tobacco in the quarterly MDS dated [DATE]. This failure posed the risk of Resident 11 not receiving the individualized plan of care based on the resident's specific needs.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide and explain a summary of the baseline care plan for one of 23 final sampled residents (Resident 347). This had the potential for inappropriate interventions and care for Resident 347.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 23 final sampled residents (Resident 24) with an existing pressure ulcer received the necessary treatment and services consistent with professional standards of practice. * The Treatment Nurse did not date, time, and initial Resident 24's left heel wound treatment dressing when performed wound care. This failure had the potential for Resident 24 to not receive appropriate care and services to prevent the wound to worsen.

Inspectors wroteBased on observation, interview, medical record review and facility P&P review, the facility failed to ensure the appropriate care and services for the G-tube for one of 23 final sampled residents (Resident 37). * The Treatment Nurse failed to follow the facility's P&P to date, time, and initial the G-tube dressing when performing the dressing changes. This failure had the potential for the resident to not receive the appropriate care and services to prevent infection at the G-tube site.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of two sampled residents (Resident 1) with a history of falls remained free from accidents. * The facility failed to ensure the care plan problem was revised to address Resident 1's fall incident on 8/28/23. Resident 1 had another fall on 8/30/23. This failure put Resident 1 at risk for further falls and serious injuries.