Bellevue Post Acute

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dietary needs and preferences were provided for 4 of 5 residents (Residents 3, 4, 5 & 6), reviewed for food preferences. This failure placed residents at risk for dissatisfaction with food, weight loss, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to conduct a thorough investigation for 1 of 4 residents (Resident 1), reviewed for incident investigations. This failure placed residents at risk for repeated incidents, inappropriate corrective actions, and unrecognized abuse/neglect.

Inspectors wroteBased on interview and record review, the facility failed to notify the physician of abnormal vital signs (measurements of the body's most basic functions [temperature, blood pressure]) for 1 of 3 residents (Resident 1), reviewed for quality of care. This failure placed the resident at risk for unrecognized medical complications, unmet care needs and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide appropriate infection surveillance for 5 of 6 months (July 2025, August 2025, September 2025, October 2025 & November 2025), reviewed for infection control. Additionally, the facility failed to ensure proper sanitization of vital sign (measurements of the body's essential functions) equipment were conducted by 1 of 2 staff (Staff Y), reviewed for medical equipment use, and failed to clean insulin (a medication that helps regulate blood sugar levels) pens (device used to inject insulin) prior to administration for 1 of 1 resident (Resident 4), reviewed for insulin administration. These failures placed the residents, visitors, and staff at an increased risk for infection and related complications. [...]

Inspectors wroteBased on interview and record review, the facility failed to designate a qualified staff person to serve as an Infection Preventionist (IP) to oversee the facility's infection prevention and control program. This failure placed the residents, staff, and visitors at risk for unmet infection control issues and lack of oversite of infection control practices.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a homelike environment when residents were served their meals on trays for 1 of 1 dining room (First Floor Dining Room), reviewed for dining observations. This failure placed the residents at risk for a less than homelike environment and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the menu/meal tickets were followed for 3 of 8 residents (Residents 35, 27 & 32), reviewed for food services. This failure placed the residents at risk for unmet nutritional needs, potential negative outcomes and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure foods were handled appropriately in accordance with professional standards of food safety for 1 of 6 Staff (Staff D), 1 of 1 Dry Storage Room, and 2 of 4 Refrigerators (Kitchen Walk-in Refrigerator & First Floor Food Refrigerator), reviewed for food services. The failure to perform hand hygiene, label and discard food items past the use by/best by date, placed the residents at risk for foodborne illness (caused by the ingestion of contaminated food or beverages), cross contamination, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to maintain a Quality Assessment and Assurance (QAA) committee that included the Infection Preventionist (IP), to conduct required Quality Assurance and Performance Improvement (QAPI) and QAA activities. This failure minimized the effectiveness of the interdisciplinary QAA team's ability to identify processes and outcomes related to infection control practices and disease management.

Inspectors wroteBased on interview and record review, the facility failed to consistently follow an established Antibiotic (antimicrobial substance/medication to treat/prevent infections) Stewardship Program (to promote the appropriate use of antibiotics) and complete monthly surveillance for 5 of 6 months (July 2025, August 2025, September 2025, October 2025 & November 2025), reviewed for antibiotic stewardship program. In addition, the facility failed to ensure appropriate antibiotic use were followed for 1 of 4 residents (Resident 3), reviewed for unnecessary medication. These failures placed residents at risk for potential adverse outcomes associated with inappropriate/unnecessary use of antibiotics and an increased risk for multi-drug-resistant organisms (microscopic organisms that are resistant to many antibiotics).

Inspectors wroteBased on interview and record review, the facility failed to ensure Certified Nursing Assistants (CNAs) had the required 12 hours of training, and/or include abuse/neglect, and dementia (memory loss) management training annually for 3 of 6 staff (Staff M, S & T), reviewed for sufficient and competent nurse staffing. This failure placed the residents at risk for unmet care needs and potential negative outcomes.

Inspectors wroteBased on interview and record review, the facility failed to issue a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) before the Medicare (federal health insurance program) coverage ended for 1 of 3 residents (Resident 90), reviewed for beneficiary notification. This failure placed the resident and/or their representative at risk of not being fully informed and losing their right to an appeals process.

Inspectors wroteBased on interview and record review, the facility failed to conduct a thorough investigation for 1 of 1 resident (Resident 45), reviewed for abuse investigations. This failure placed the resident at risk for repeated incidents, unidentified abuse, and inappropriate corrective actions.

Inspectors wroteBased on interview and record review, the facility failed to provide a written transfer/discharge notice as required for 2 of 3 residents (Residents 6 & 64), reviewed for hospitalization. This failure placed the residents at risk for lack of knowledge regarding their protection of resident rights during transfers, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS - an assessment tool) was completed timely for 1 of 1 resident (Resident 9), reviewed for significant change in condition. The failure to complete a SCSA timely placed the resident at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to accurately assess 2 of 16 residents (Residents 9 & 19), reviewed for Minimum Data Set (MDS-an assessment tool). The failure to ensure accurate assessments were coded on the MDS regarding injections and prognosis (an estimate about whether a patient [resident] will recover from an illness) placed the residents at risk for unidentified and/or unmet care needs, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure Level II (or Level 2) Preadmission Screening and Resident Review (PASARR or PASRR - an assessment used to identify people referred to nursing facilities with Serious Mental Illness [SMI], Intellectual Disabilities [ID]; or Related Conditions are not inappropriately placed in nursing homes for long-term care) referral was made for 1 of 5 residents (Resident 19), reviewed for PASRR screening. This failure placed the resident at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to notify the State Pre-admission Screening and Resident Review (PASARR or PASRR-an assessment used to identify people [residents] referred to nursing facilities with Serious Mental Illness [SMI], intellectual disabilities, or related conditions are not inappropriately placed in nursing facilities for long term care) Coordinator after a significant change in status occurred for 1 of 1 resident (Resident 9), reviewed for PASRR screening. This failure placed the resident at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to monitor a resident taking a diuretic (medication used to help remove extra fluid from the body) medication and failed to notify the provider of weight gain for 1 of 5 residents (Resident 5), reviewed for unnecessary medications. This failure placed the resident at risk for unrecognized weight gain, medical complications, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pharmacy services were provided to meet the needs of 1 of 6 residents (Resident 15), reviewed for unnecessary medications. The failure to administer medication in accordance with professional standards of practice placed the resident at risk for negative outcomes and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure Medication Regimen Review (MRR- a comprehensive assessment of resident's medications, performed by a pharmacist [a qualified professional to provide expert advice on medication management, safety, and regulatory compliance]) recommendations were completed accurately and in a timely manner for 2 of 6 residents (Residents 15 & 5), reviewed for unnecessary medications. These failures placed the residents at risk for experiencing adverse side effects, receiving unnecessary medications, medical complications, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure physician's orders with parameters were followed when administering medications for 2 of 5 residents (Residents 5 & 19), reviewed for unnecessary medications. This failure placed the residents at risk for side-effects related to the medications, medical complications, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications and/or biologicals were discarded when expired for 1 of 2 medication carts (Team-One Second Floor Medication Cart), reviewed for medication storage. This failure placed the residents at risk of receiving compromised medications and related complications.

Inspectors wroteBased on interview and record review, the facility failed to provide the required specialized rehabilitative services for 1 of 2 residents (Resident 15), reviewed for rehabilitation services. This failure placed the resident at risk for decline in function, unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure the COVID-19 (a highly transmissible infectious virus that causes respiratory illness and in severe cases can cause difficulty breathing and could result in impairment or death) vaccine was offered to 1 of 5 residents (Resident 5), reviewed for immunizations. The failure to educate and offer the COVID-19 vaccination placed the resident at risk for contracting the COVID-19 virus and related complications.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the survey result binder included the results for 4 of 8 complaint surveys (08/12/2025, 09/16/2025, 10/14/2025 & 12/09/2025) that resulted in citations since the last annual survey. This failure prevented residents, residents' representatives and visitors from exercising their right to review past survey results and the facility's plan of correction.

Inspectors wroteBased on interview and record review, the facility failed to provide written notice of transfer/discharge to the resident and/or their representative and failed to notify the Office of the State Long Term Care Ombudsman (an advocate for residents of nursing homes who protect and promote resident rights under federal and state law and regulations), describing the reason for transfer/discharge for 1 of 2 resident (Resident 2), reviewed for discharges. These failures placed the resident at risk for not having opportunities to make informed decisions about transfer/discharge.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision and accurately assess risk of elopement for 1 of 1 resident (Resident 1), reviewed for accident hazards. This failure placed the resident at risk for elopement, falls, and injury.

Inspectors wroteBased on interview and record review, the facility failed to ensure staff followed and implemented abuse and neglect policies and procedures for the protection of residents during an abuse investigation for 1 of 3 residents (Resident 1), reviewed for abuse allegations. This failure placed the residents at risk for lack of protection from abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure local law enforcement was notified for reasonable suspicion of abuse for 1 of 4 residents (Resident 1), reviewed for abuse. This failure placed the resident at risk for lack of protection from potential abuse and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nurse staffing information postings were posted in prominent locations for 1 of 2 floors (Second Floor), reviewed for Nurse Staffing Information. This failure placed residents and visitors at risk for not being fully informed of current nurse staffing levels and resident census information.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure foods were handled appropriately in accordance with professional standards of food safety for 1 of 1 kitchen, for 4 of 5 staff (Staff O, P, Q & C), and for 2 of 2 floors (First Floor and Second Floor), reviewed for food services. The failure to date and discard food items, perform hand hygiene, use appropriate hair covering and ensure food items were covered during meal delivery placed the residents at risk for food borne illness (caused by the ingestion of contaminated food or beverages), cross contamination, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the survey result binder included the results for 1 of 2 years (2021) recertification and complaint surveys that resulted in citations. In addition, the facility failed to post notice of the availability of survey reports in areas of the facility that are prominent and accessible to the public. These failures prevented residents, residents' representatives and visitors from exercising their right to review past survey results and the facility's plan of corrections.

Inspectors wroteBased on interview and record review, the facility failed to develop a baseline care plan and/or provide a written summary of the baseline care plan to the residents and/or their representatives for 5 of 10 residents (Residents 94, 194, 15, 20 & 5), reviewed for baseline care plan. This failure placed the residents at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and/or implement care plans for 4 of 20 residents (Residents 23, 193, 9 & 29), reviewed for comprehensive care plans. The failure to develop care plans for tilt in space wheelchair (a wheelchair that has reclining function) and Self-Administration of Medications, and the failure to implement dysphagia (difficulty swallowing foods or liquids) care plan placed the residents at risk for unmet care needs, related complications, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the hallway carpet was safe for 1 of 2 floors (First Floor Hallway) and failed to provide adequate supervision for 1 of 1 resident (Resident 29), reviewed for accident/hazards. These failures placed the residents at risk for accidents, injury, and other negative outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure expired medications were disposed timely and drugs were properly labeled and stored in accordance with current accepted professional standards for 2 of 2 medication carts (First Floor Team 1 & Team 2), reviewed for medication storage and labeling. These failures placed the residents at risk for receiving compromised and ineffective medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the facility was managed in a manner that utilized its resources to maintain the residents' highest practicable physical, mental, and psychosocial well-being. The failure to properly maintain the carpet placed the residents at risk for accidents, injuries, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure hand hygiene practices and/or proper use of gloves were followed before, during, and after resident care and passing meal trays for 2 of 6 staff (Staff K & G), failed to implement Enhanced Barrier Precautions (EBP- precaution to protect residents from Multidrug-Resistant Organism [MDRO-a germ that is resistant to medications that treat infections]) for 3 of 3 residents (Residents 37, 193 & 5), and failed to ensure appropriate indwelling catheter (a semi-flexible tube inserted into the bladder to drain urine) care for 1 of 3 residents (Resident 37), reviewed for infection control. These failures placed the residents, visitors, and staff at an increased risk for infection and related complications.

Inspectors wroteBased on interview and record review, the facility failed to inform the resident and/or their resident representative before administering psychotropic (mind-altering) medication for 1 of 5 residents (Resident 5), reviewed for unnecessary medications. This failure placed the resident and/or their representative at risk of not being fully informed of the risks and benefits before making decisions about medications prior to administration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were evaluated, assessed, and obtained a physician order for safe administration of medications for 2 of 3 residents (Residents 193 & 34), reviewed for self-medication administration. The failure to complete a self-administration of medication assessment and obtain a physician's order placed the residents at risk for medication errors, adverse medication interactions, and complications.

Inspectors wroteBased on interview and record review, the facility failed to ensure allegations of abuse was reported to the State Agency as required for 1 of 1 resident (Resident 7), reviewed for abuse allegations. This failure placed the resident at risk for potential unidentified abuse and lack of protection from abuse.

Inspectors wroteBased on interview and record review, the facility failed to identify an abuse allegation and failed to ensure the abuse allegation was thoroughly investigated for 1 of 1 resident (Resident 7), reviewed for abuse investigation. This failure placed the resident at risk for repeated incidents, unidentified abuse, and inappropriate corrective actions.

Inspectors wroteBased on interview and record review, the facility failed to provide written notice of transfer/discharge to the resident and/or their representatives and failed to notify the Office of the State Long Term Care (LTC) Ombudsman (an advocacy group for residents), describing the reason for transfer/discharge for 1 of 1 resident (Resident 25), reviewed for hospitalization. These failures placed the resident at risk for not having opportunities to make informed decisions about transfer/discharge.

Inspectors wroteBased on interview and record review, the facility failed to transmit resident assessment data to the Centers for Medicare & Medicaid Services within the required timeframe for 1 of 3 residents (Resident 30), reviewed for discharge assessments. This failure placed the resident at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to accurately assess 2 of 21 residents (Residents 5 & 40), reviewed for Minimum Data Set (MDS-an assessment tool). The failure to ensure accurate assessments regarding bladder continence and discharge status placed the residents at risk for unidentified and/or unmet care needs, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to review and validate the Preadmission Screening and Resident Reviews (PASARR-an assessment to ensure individuals with Serious Mental Illness [SMI] or Intellectual/Developmental Disabilities [ID/DD] are not inappropriately placed in nursing homes for long term care) had the required Level II referral sent if residents had a positive Level I PASARR, or corrected/updated the resident's PASARR as needed for 1 of 5 residents (Resident 25), reviewed for PASARR. This failure placed the resident at risk for not receiving the care and services appropriate for their needs.

Inspectors wroteBased on interview and record review, the facility failed to conduct care conferences for 2 of 2 residents (Residents 37 & 193), reviewed for care planning. This failure placed the residents and/or their representatives at risk for not having input regarding care goals, unmet needs, and a diminished quality of life. Findings including . Review of the facility's policy titled, Patient [resident] Care Conferences-Social Services Procedures, dated June 2018, showed, After admission, an initial care conference will be scheduled by Social Services with the patient and responsible party (if the patient chooses) to be held within 7 [seven] days. The initial care conference is completed only for the first admission .The initial care conference will be documented on the Patient Care Conference form located in Point Click Care [Electronic Health Record (EHR)]). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 of 3 licensed staff (Staff T) followed professional standards for proper insulin (a hormone that lowers the level of sugar) administration, and ensure medications were not left unattended for 1 of 1 resident (Resident 10), reviewed for medication administration. In addition, the facility failed to ensure blood pressure (BP), and heart rate (HR) were checked prior to blood pressure medication administration for 1 of 5 resident (Resident 25), reviewed for unnecessary medication. These failures placed the residents at risk for unmet care need, adverse effects and potential negative outcomes.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide necessary assistance with nail care and wheelchair transfer for 1 of 3 residents (Resident 20), reviewed for Activities of Daily Living (ADL). This failure placed the resident at risk for decreased self-esteem, decline in mobility and function, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility to provide care and services consistent with professional standards for significant weight gain and use of diuretic medication (that helps to reduce fluid buildup in the body) for 1 of 1 resident (Resident 20), reviewed for quality of care. In addition, the facility failed to implement the bowel management protocol when indicated for 1 of 2 residents (Resident 9), reviewed for bowel management. These failures placed the residents at risk of unmet care needs, medical complications, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure services were consistently provided to increase Range of Motion (ROM) and/or to prevent decrease in ROM for 1 of 1 resident (Resident 145), reviewed for restorative services. This failure placed the resident at risk for a decline in ROM, unmet care needs, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to label/date and properly store nebulizer (a small machine that turns liquid medication into a mist that can be inhaled to treat respiratory conditions) treatment set for 1 of 3 residents (Resident 193), reviewed for respiratory care. This failure placed the resident at risk for respiratory infections and related complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a care plan and interventions to address dementia (a general term for loss of memory, language, problem solving and other thinking abilities that are severe enough to interfere with daily life) care needs for 1 of 1 resident (Resident 25), reviewed for dementia care. This failure placed the resident at risk for having unidentified and/or unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from unnecessary medication for 2 of 5 residents (Residents 20 & 25), reviewed for unnecessary medications. This failure placed the residents at risk for side-effects related to the medications, medical complications, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident was free of unnecessary psychotropic (a drug that affects behavior, mood, thoughts, or perception) medication for 1 of 5 residents (Resident 5), reviewed for unnecessary medications. The failure to ensure licensed pharmacist's monthly Medication Regimen Reviews (MRRs) and physician recommendations were carried out in a timely manner placed the resident at increased risk for receiving medications they no longer needed, adverse side effects, and negative outcomes.

Inspectors wroteBased on interview and record review, the facility failed to ensure Certified Nursing Assistants (CNAs) had the required twelve hours of training, including dementia (memory loss) management training annually for 1 of 5 staff (Staff N). This failure placed the residents at risk for potential negative outcomes and unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure the facility assessment (document describing resident population and needs to determine staff and other resources necessary to competently care for residents) was updated to accurately determine and identify the resources needed for the facility's resident care needs. This failure placed the residents at risk for unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to accurately assess 1 of 2 residents (Resident 1), reviewed for Minimum Data Set (MDS - an assessment tool). The failure to ensure accurate assessments regarding active diagnosis placed the resident at risk for unidentified or unmet care needs, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide a safe environment for 1 of 3 residents (Resident 1), reviewed for accident hazards. The failure to ensure disinfecting wipes were stored properly placed the residents at risk for allergic reaction, injury, and other negative health outcomes.

Inspectors wroteBased on interview and record review, the facility failed to provide showers for 2 of 3 residents (Residents 1 & 2), reviewed for Activities of Daily Living (ADL). This failure placed the residents at risk for poor hygiene, decreased self-esteem, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure 1 of 3 residents (Resident 1) reviewed for pain management was provided pain medications for severe (7 to 10 pain scale) pain. Resident 1, who experienced severe and unrelieved pain during the first 12 hours of their admission when the prescribed pain medication and/or effective alternative to relieve severe pain was not provided. This failure placed the resident at risk for uncontrolled pain and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to notify law enforcement for an allegation of potential abuse for 1 of 1 resident (Resident 1), reviewed for abuse reporting. This failure placed the resident at risk for unidentified abuse, potential ongoing abuse, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide abuse and neglect training for 1 of 1 staff (Staff C), reviewed for required staff training. This failed practice had the potential of not identifying and preventing abuse and/or neglect.

Inspectors wrote[NAME]-[NAME], Glen Based on observation, interview and record review, the facility failed to accurately assess 5 of 15 residents (Residents 15, 12, 680, 129 and 26) reviewed for Minimum Data Set (MDS) assessment. The failure to ensure accurate assessments regarding the use of a walker, dental, diagnoses, vision, and discharge (DC) placed the residents at risk for unidentified or unmet care needs and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure foods stored in the kitchen were labeled/dated when first opened and food products discarded on or before use by date. These failures placed the residents at risk for food borne illness (caused by the ingestion of contaminated food or beverages), and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to inform the resident and/or the resident representative before administering psychotropic (mind altering) medication for 1 of 5 residents (Resident 680) reviewed for unnecessary medications. This failure placed the resident and/or resident representative at risk of not being fully informed of the risks and benefits before making decisions about their medication.

Inspectors wroteBased on interview and record review, the facility failed to ensure bed hold notice was provided at the time of transfer for 1 of 2 residents (Resident 681) reviewed for hospitalization. This failure placed the resident at risk for lack of knowledge regarding the right to hold their bed while in the hospital.

Inspectors wroteBased on interview and record review, the facility failed to ensure baseline care plans were developed within 48 hours of admission to ensure continuity of care and/or to ensure a summary/copy of the baseline care plan was provided to the residents and/or their representatives for 2 of 6 residents (Residents 629 & 129) reviewed for baseline care plan. This failure resulted in the residents not being informed of their initial plan for delivery of care services and placed the residents at risk for unmet care needs.

Inspectors wroteBased on observation, record review, and interview, the facility failed to develop care plans for 1 of 2 residents (Resident 14) reviewed for nutrition, and 2 of 5 residents (Residents 679 & 680) reviewed for unnecessary medications. These failures placed the residents at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure Care Plans (CPs) were maintained, revised, and updated for 1 of 11 residents (Resident 11) whose CPs were reviewed. This failure placed residents at risk for unmet needs and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to meet professional standards of practice to ensure pharmacy Medication Regimen Review (MRR) and physician order parameters were followed for Atenolol (a medication to treat Hypertension [high blood pressure]) for 1 of 5 residents (Resident 12) reviewed for unnecessary medications. Additionally, the facility failed to ensure 1 of 3 licensed staff (Staff G) observed for medication administration follow medication administration practices. These failures placed the resident at risk for potential negative outcomes and possible medication error.

Inspectors wroteBased on interview and record review, the facility failed to ensure a safe discharge for 1 of 3 residents (Resident 26) who chose to leave the facility Against Medical Advice (AMA). This failure placed the resident at increased risk for hospital readmission, infection, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident-centered care and treatment were provided in accordance with professional standards of practice when facility staff failed to follow physician bowel medication orders for 1 of 5 residents (Resident 11) reviewed for unnecessary medications. This failure placed the resident at risk for discomfort or bowel impaction and a diminished quality of care.