Belmont Terrace

Inspectors wroteBased on interview and record review, the facility failed to ensure that Skilled Nursing Facility (SNF) Advanced Beneficiary Notices (ABN: a notification that provides an estimated cost of continuing services which may no longer be covered by Medicare. Beneficiaries may choose to continue the services but may be financially liable) were provided, as required, for 2 of 2 residents (Residents 18 & 56) reviewed for provision of SNF ABN. This failure placed residents at risk of not having adequate information to make care and financial decisions during their continued stay.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain a homelike environment regarding noise levels for 1 of 4 halls (Mountain View Hall) reviewed for a homelike environment. The failure to ensure appropriate noise levels placed residents at risk for not having a homelike environment, a decreased quality of life, and potential health concerns.

Inspectors wroteBased on interview and record review, the facility failed to offer a bed hold upon transfer to the hospital for 1 of 2 residents (Resident 7 ), and to communicate required/necessary information to the receiving hospital to ensure continuity of care for 2 of 2 residents (Resident 7 & 80) and 4 of 4 discharges reviewed for hospitalization. Failure to offer bed holds placed residents and their representatives at risk of not being informed of their right to, and the cost of holding the resident's bed while hospitalized . The failure to ensure necessary information was communicated to the receiving hospital detracted from continuity of care and placed residents at risk of receiving incoherent, fragmented, or redundant care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure quality of care was provided for insulin administration for 1 of 1 resident (Resident 44), bowel management for 2 of 5 residents (Resident 36 & 85), physical therapy evaluation for 1 of 1 resident (Resident 23) reviewed to Activities of Daily Living (ADLs), oxygen administration for 1 of 1 residents (Resident 85) and edema and weight monitoring for 1 of 1 resident (Resident 80). These failures placed residents at risk of medical complications, unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure restorative nursing programs were provided at the frequency residents were assessed to require, for 6 of 7 residents (Resident 15, 26, 30, 32, 9 & 24) reviewed for restorative services. This failure placed residents at risk for decline in functional mobility, range of motion (ROM), contracture (a permanent tightening or shortening of muscles, tendons, skin, or other tissues that causes joints to become stiff) formation and diminished quality of life.

Inspectors wroteBased on observation, interviews and record review, the facility failed to have sufficient staff to provide and supervise care as evidenced by information provided by 6 resident interviews (Resident 30, 44, 23, 3, 13 & 66), Staff interviews (Staff Q & T) and Resident Council interviews. Additionally, the aid from the Restorative Nursing Program (RNP) was removed from restorative duties to cover direct care staff absences and resident transportation resulting in the RNPs not being completed for residents. The shower aides were also removed from assigned duties to cover direct care staff shortages. The facility had insufficient staff to ensure residents received assistance with Activities of Daily Living (ADL) including showers, restorative services, dining services and basic resident care. [...]

Inspectors wroteBased on interview and record review the facility failed to routinely complete Certified Nursing Assistant's (CNA) annual performance reviews as required for 3 of 5 sampled nursing assistants (Staff I, J, & K) reviewed for performance reviews. This failure placed residents at risk of receiving care from inadequately trained and/or under-qualified care staff, and a diminished quality of life.

Inspectors wroteBased on observation, interview and review of recorded food temperatures, the facility to prepare food in a manner that conserved nutritive value, palatability and that ensured meals served were appetizing and at appropriate temperatures. The facility's failure to follow written recipes for preparation of pureed food, to ensure cold beverages were maintained at or below 40 degrees, and hot food at or greater than 135 degrees during meal service, resulted in residents being served unpalatable food and beverages at unappetizing temperatures. These failures placed the residents at risk for decreased intake, weight loss and dissatisfaction with meals.

Inspectors wroteBased on observation, interview and record review the facility failed to follow and/or implement transmission-based precautions (TBP, infection-prevention measures for known or suspected infections used in addition to Standard Precautions) for 4 of 4 residents (Residents 52, 40, 58, and 17) reviewed for transmission-based precautions. The facility did not ensure staff used appropriate personal protective equipment (PPE) and implemented TBP for symptomatic residents. This failure placed residents and staff at risk for cross-transmission with infectious pathogens.

Inspectors wroteBased on interview and record review the facility failed to ensure residents and/or resident representatives were informed and provided consent before administering psychotropic (medications that alter moods, behaviors, thoughts or perceptions, and affects the brain) medication for 1 of 5 sampled residents (Resident 2) reviewed for right to be informed about treatment decisions. This failure placed residents and/or resident representatives at risk of not being fully informed of the risks and benefits before making decisions about medications and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident assessments accurately reflected the health status and/or care needs for 4 of 20 residents (Residents 43, 80, 7 & 24) whose Minimum Data Sets (MDS, an assessment tool) were reviewed. The failure to ensure active diagnoses, oral assessments, Level II Pre-admission Screening and Resident Review (PASRR) status, and restorative services accurately reflected residents' health status and care provided, placed residents at risk for unidentified and/or unmet care needs.

Inspectors wroteBased on record review and interview, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) was completed and/or reflected accurate mental health diagnosis for 2 of 5 sampled residents (Residents 2 and 7) reviewed for PASRR. This failure placed residents at risk of not receiving mental health services and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement a comprehensive care plan for 5 of 20 sampled residents (36, 2, 80, 7 & 43) reviewed for care plans. The failure to establish care plans that were individualized placed residents at risk for receiving inconsistent and/or inadequate care.

Inspectors wroteBased on interview and record review, the facility failed to provide necessary care and services to ensure that residents received weekly showers for 1 of 2 residents (3) reviewed for activities of daily living (ADLs). This failure placed the residents at risk of poor hygiene and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the daily nurse staffing was consistently posted to include the actual nursing staff hours worked for 3 out of 6 days (02/22/2026, 02/23/2026 and 02/27/2026). This failure caused the facility's staffing information not to be readily available to residents and visitors who may wish to review it.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure written menus were followed, planned menu items were served at the appropriate serving size, substitutions only occurred when necessary and were approved by the Registered Dietician and communicated to the facility residents, and appropriate serving sizes were provided. These failures detracted from residents' ability to determine if they wanted the main meal or the alternative meal when filling out their menus for the week, due to uncertainty if the listed meal would actually be served. This placed residents at risk of receiving food they did not request, therapeutic diet not being followed, and dissatisfaction with meals.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure recommendations of gradual dose reductions were followed for 3 of 4 sampled residents (1, 2, & 3) reviewed for gradual dose reductions. These failures placed residents at risk of taking unnecessary medications, avoidable medication side effects, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a personalized discharge plan based on each residents' identified needs, goals, and preferences and implement it timely for 2 of 3 residents (6 & 8) reviewed for discharge planning. This failure placed residents at risk for delayed discharge, unmet care needs after discharge and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to accurately assess and identify a change in urinary incontinence, ensure a plan for treatment and services to restore as much normal bladder and/or bowel function as possible for 2 of 3 residents (5 & 6) reviewed for urinary incontinence. Failure to identify and assess/determine causative factors of urinary incontinence placed residents at risk for unmet care needs and decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide pain management to adequately control residents pain for 1 of 3 sampled residents (1) when reviewed for pain management. This failure put residents at risk of uncontrolled pain and a diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to repeatedly implement antibiotic protocols to ensure antibiotics were appropriately prescribed for 1 of 3 sampled residents (1), reviewed for antibiotic use. This failure placed residents at risk of development of antibiotic-resistant organisms, adverse side effects, and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure the pneumococcal vaccine (used to prevent pneumonia and sepsis), was provided for 1 of 3 residents (1), reviewed for immunizations. This failure placed the resident at risk of acquiring, transmitting, and/or experiencing potentially avoidable complications from influenza disease.

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 provided for 1 of 3 residents (1), reviewed for immunizations. The failure to provide 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 provide an Advanced Directive (AD, a written instruction of health care directions) for 4 of 5 sampled residents (Residents 59, 28, 43 & 60 ) reviewed for ADs. This failure placed residents at risk for losing their right to have their healthcare preferences and/or decisions honored.

Inspectors wrote<Olympic Hallway> On 11/13/2024 at 11:02 AM, observation of the carpet in the activity room in the Olympic Hallway showed the carpet was worn and heavily soiled. There was a three by four-foot circular stain just inside and to the right of the entrance. Five additional one by one-foot dark brown circular stains with distinct edges were noted on the carpet throughout the room. The stains appeared to be the result of spilled liquids that had dried prior to being cleaned up. On 11/05/2024 at 1:12 PM, Staff C, Resident Care Manager, said the activity room had been previously used as the assist dining room. <Mountainview Hallway> On 11/13/2024 at 11:04 AM, observation of the carpet in front of the first kiosk in the Mountainview hallway showed the carpet had been cut in multiple places and replaced with non-matching carpet (different color and pattern). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure grievances were initiated, logged, investigated, and/or promptly resolved/responded to for 1 of 1 residents (Resident 40) and the Resident Council reviewed for grievances. This failure placed residents at risk for feelings of frustration, powerlessness, and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide a written transfer/discharge notice to the resident and/or their representative for 4 of 4 sampled residents (Residents 18, 40, 16 & 60), reviewed for hospitalization. This failure placed the resident and/or their representative at risk for not having an opportunity to make informed decisions about transfers/discharges.

Inspectors wroteBased on interview and record review, the facility failed to provide a bed hold notice to the resident and/or their representative for 3 of 4 sampled residents (Residents 40, 16 &60), reviewed for hospitalization. This failure placed the resident and/or their representative at risk for not having an opportunity to make informed decisions about bed hold and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set assessment (MDS, an assessment tool) accurately reflected the status for 6 of 25 sampled residents (Residents 53, 10, 21, 56, 176 & 23) reviewed for accuracy of assessments. This failure 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 resident care plans (CPs) were reviewed, revised, and accurately reflected residents' care needs for 7of 35 residents (Residents 62, 176, 376, 67, 23, 28, and 21) whose care plans were reviewed. These failures placed residents at risk for unmet care needs and diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to ensure dependent residents were provided scheduled bathing/showering opportunities for 6 of 8 residents (Residents 43, 19, 64, 176, 67 and 62) reviewed for activities of daily living (ADL's). This failure placed residents at risk of not having their ADL care needs met and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide restorative services at the frequency residents were assessed to require for 6 of 7 residents (Residents 48, 22, 55, 46, 25 and 61) reviewed with restorative nursing programs (RNPs). The failure to provide RNPs at the frequency residents were assessed to require, placed residents at risk for decrease in Range of Motion (ROM), development and/or progression of contractures, increased dependance on staff for care needs and a diminished quality of life.

Inspectors wroteBased on interview, and record review, the facility failed to ensure residents receiving enteral feedings, were administered enteral formula at the physician ordered rate and volume for 1 of 1 resident (Resident 21) reviewed for enteral feeding. The facility also failed to ensure routine resident weights were obtained, reviewed, weight loss trends identified, and nutritional nutritional interventions were timely identified and implemented for 2 of 2 residents (Resident 64 and 21) reviewed for weight loss. Additionally, the facility failed to have a system in place that ensured fluid intake was accurately monitored, documented, and 24-hour intake totals were calculated and evaluated, and labs were monitored for fluid and electrolyte imbalances for 2 of 2 residents (Resident 58 and 10) reviewed with a fluid restrictions. [...]

Inspectors wroteBased on observation, interviews and record review, the facility failed to have sufficient staff to provide and supervise care as evidenced by information provided by 7 resident interviews (Resident 18, 19, 59, 64, 376, 40 & 58), Resident Council interviews (Residents 40 & 59) and Staff interviews (Staff E, BB, CC, DD, EE & H) and as evidenced by failed practices in many identified quality of life and quality of care areas. The facility had insufficient staff to ensure residents received assistance with Activities of Daily Living (ADL) including grooming and showers, assessments, care planning, care plan revision, restorative services, hospice services and infection control in accordance with established clinical standards, and resident needs and preferences. These failures placed residents at risk for unmet care needs, negative outcomes and a diminished quality of life.

Inspectors wroteBased on observation and interview, the facility failed to ensure expired medications and supplies were removed/discarded in 1 of 2 medication storage rooms (Medicare A and Medicare B medication room) reviewed for medication storage and labeling. This failure placed residents at risk of receiving compromised and/or ineffective medications and medical supplies.

Inspectors wroteBased on observation, interview and record review, the facility failed to prepare food in a manner that ensured meals were appetizing, palatable and served at appropriate temperatures for 9 of 15 sampled residents (56, 43, 58, 19, 18, 59, 64, 13 and 126) reviewed for dining. This placed residents at risk for a decreased nutritional intake and dissatisfaction with meals.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents' received therapeutic diets as prescribed by the physician, and/or assessed by the interdisciplinary team for 5 of 23 residents whose meals were observed (Residents 46, 24, 10, 50 and 42), and to provide the correct portion size for 6 of 6 residents (Residents 42, 71, 24, 43 64 and 127) observed with orders for small or large portions. Failure to ensure residents' received physician ordered therapeutic diets and/or portion sizes placed residents at risk for medical complications and/or unmet nutritional needs.

Inspectors wroteBased on interview and record review, the facility failed to seek/ obtain approval from the Resident Council, and to ensure residents were provided a nourishing snack at bedtime, when the time between the dinner and breakfast meals was increased from 14 hours to 15 hours. These failures precluded residents from having input about extending the time between meals beyond 14 hours and placed them at risk for feelings of hunger and inadequate nutrition.

Inspectors wroteBased on interview and record review, the facility failed to have a system in place that ensured effective communication, collaboration, and coordination of care occurred between the facility and the hospice provider for 2 of 2 residents (Resident 64 & 28) reviewed for hospice services. The facility failed to obtain and/or maintain a copy of a resident's current hospice coordinated plan of care, to have documentation in residents' Electronic Health Records (EHR) that showed what hospice disciplines (e.g. registered nurse, chaplain, certified nursing assistant, massage therapist) had visited, when they visited, and what care was provided. These failures detracted from staffs' ability to effectively collaborate, communicate and coordinate care with the hospice provider and placed residents at risk for not receiving necessary care and services and/or unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to perform hand hygiene, follow Personal Protective Equipment (PPE, equipment worn to minimize exposure to a variety of hazards requirements for a resident on Enhanced Barrier Precautions (EBP, an infection control method that involves wearing gowns and gloves during high-contact interactions with residents in nursing homes) orders, failed to prevent cross-contamination for food and PPE carts, and failed to prevent medical equipment from touching the floor for 3 of 25 sampled residents (Resident 7, 21 & 56) and 1 of 3 halls (Med Cart B Hall) reviewed for infection control practices. These failures placed residents at risk of developing and transmitting infections and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide pneumococcal vaccines for 3 of 6 residents (Residents 176, 10 and 21) reviewed for vaccinations. This failure placed the residents at a higher risk for contracting pneumococcal infections, related complications, and a decreased quality of life.

Inspectors wroteBased on observation and interview the facility failed to maintain the emergency fire doors in 1 of 3 main halls (outside room [ROOM NUMBER]) reviewed for maintenance were in working order. This failure placed residents and staff at risk for falls, avoidable injury, and a diminished quality of life.

Inspectors wroteBased on observation and interview, the facility failed to respect and value the residents' private space by not knocking and/or announcing themselves for 3 of 4 sampled residents (Resident 19, 48 & 63) reviewed under resident rights for dignity. This failure placed residents at risk for being treated with lack of dignity and a diminished quality of life.

Inspectors wroteBased on record review and interview, the facility failed to ensure that residents had signed consent prior to psychotropic (group of drugs to treat mental health conditions) medication administration and that residents had the correct risks and benefits provided, for 1 of 5 residents (Resident 21) reviewed for unnecessary medications. This failure placed residents at risk of receiving medication without knowledge of the medication or correct side effects, and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident choices regarding bathing frequency were honored for 2 of 4 residents (Residents 376 and 176) reviewed for choices. The facility's failure to accommodate resident preferences related to frequency and type of bathing placed residents at risk for feelings of un-cleanliness, powerlessness, diminished self-worth, and a decreased quality of life.

Inspectors wroteBased on interview and record review the facility failed to ensure that the Pre-admission Screening and Resident Review (PASRR, a screening tool used to identify mental health needs) was accurate and a referral for Level II PASRR was sent in a timely manner for 2 of 5 sampled residents (Residents 60 and 56) reviewed for PASRR. This failure placed residents at risk for not receiving specialized mental health services, and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 2 of 25 sampled residents (Resident 56 and 126). This failure placed residents at risk for unidentified/ unmet care and safety needs, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure 1 of 3 residents (Resident 176) reviewed for communication, were provided appropriate treatment and services to maintain hearing. The failure to complete Resident 176's earwax removal treatment, resulted in Resident 176 indicating their ears remained clogged with wax and they still had difficulty hearing. This placed the resident at risk for feelings of frustration, diminished self-worth and decreased quality of life.

Inspectors wroteBased on interviews and record review, the facility failed to consistently provide treatments as ordered, and implement timely and appropriate interventions to prevent the worsening of PU (PU/PI, injury to the skin and underlying tissue due to prolonged pressure) for 1 of 3 sampled residents (Resident 64), reviewed for pressure ulcers. This failure may have contributed to worsening/deterioration of the PU to the sacrum (the triangular bone at the base of the spine that connects the lower back to the pelvis). This failure placed residents at risk for skin injuries, PUs/PIs, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to administer parenteral (routes other than the digestive system to give fluids or medication) medication in a manner consistent with professional standards for 1 of 1 sampled residents (Resident 126) reviewed for antibiotics. This failure placed residents at risk for complications, infections, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure orders were followed for 2 of 2 residents (Residents 72 and 10) reviewed for dialysis. This failure put residents at risk for medical complications and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the pharmacist's Medication Regimen Review (MRR) recommendations were acted upon for 1 of 5 residents (Resident 21) reviewed for unnecessary medications. This failure placed residents at risk of decreased effects of medication, medication complications, and a diminished quality of life.

Inspectors wroteBased on on interview and record review, the facility failed to ensure quality of care for 2 of 5 residents (Resident 72 & 56) reviewed for unnecessary medications related to providing ordered medication. This failure placed residents at risk for medical complications and a decreased quality of life. 1) Review of the Electronic Health Record (EHR) showed Resident 10 was admitted to the facility on [DATE]. Resident 10 had a diagnosis of ESRD, required renal dialysis, and had a port (implanted venous access device). Review of the Quarterly Medicare MDS, dated [DATE], showed Resident 10 was cognitively intact. Resident 10 had an order for removing the dressing on Resident 10's port two hours after dialysis on Tuesday, Thursday, and Saturday. Review of the November 2024 administration record showed the dressing was not being removed. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from unnecessary psychotropic (affecting the mind) medications by ensuring Gradual Dose Reductions (GDR) were attempted for 1 of 5 residents (Resident 27) reviewed for unnecessary medications and that GDR recommendations that included laboratory tests were followed up on for 1 of 5 residents (Resident 21) reviewed for unnecessary medications. This failure placed residents at risk for medical complications, receiving unnecessary medications and a diminished quality of life.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents received COVID-19 vaccines that were consented for, for 2 of 7 residents (Residents 10, 21) reviewed for vaccinations. This failure placed residents at risk for a decreased immune response to COVID-19, related complications if infected, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure care plan conferences were held with the resident for 1 of 3 sampled residents (Resident 2) reviewed for participation in care planning. This failure placed residents at risk of not being fully involved and informed of decisions about care and services and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a personalized discharge plan based on each residents' identified needs, goals, and preferences and implement it timely for 1 of 3 residents (Resident 2) reviewed for discharge planning. This failure placed residents at risk for delayed discharge, unmet care needs after discharge and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to accurately assess and determine appropriate treatments for a chronic skin condition for 1 of 3 sampled residents (Resident 1) reviewed for skin conditions, non-pressure. This failure placed all residents at risk for unmet needs, pain and discomfort, declining health, and decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide necessary diabetic nail care and treatment in accordance with professional standards for 1 of 3 sampled residents (Residents 1) reviewed for foot care. This failure placed residents at risk for developing further medical complications, discomfort and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff were compliant with Infection Prevention and Control (IPC) guidelines and standards of practice for 4 of 4 units (Mountain View, [NAME] Mountain, Medicare A and Medicare B) reviewed for IPC procedures when the facility failed to ensure staff followed standards of practice related to donning (placing on) recommended Personal Protective Equipment (PPE) prior to entering a room with resident(s) who were positive for COVID-19 (a highly transmissible respiratory virus) and following recommendations to keep doors closed to rooms with residents on aerosol precautions due to COVID-19, and source control masking. This failure placed all residents, staff and visitors at risk for contracting and potentially spreading COVID-19. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure activities of daily living (ADLs) were provided for dependent residents including toileting for one of three residents (Resident 3) reviewed for ADL care. This failure placed residents at risk of not receiving the care and services needed for which they were unable to perform themselves and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to offer the influenza and pneumococcal vaccine to 2 of 8 sampled residents (Resident 1 and 2). This failure placed residents at risk for developing influenza and pneumonia and medical complications.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents and/or resident representatives were provided education on the risks and benefits including potential side effects of the COVID-19 (a highly infectious respiratory illness caused by a virus) vaccine and ensure documentation of the acceptance or refusal to receive the vaccine was in the medical record for 3 of 8 sampled residents (Residents 1, 2 & 8) reviewed for COVID-19 immunizations. This failure placed residents and resident representatives at risk of not having the opportunity to make an informed decision about the COVID-19 vaccine and the adverse health effects of this communicable disease.

Inspectors wroteBased on interview and record review, the facility failed to consider and act promptly to address concerns raised by residents for 4 of 4 sampled months (June 2023, July 2023, August 2023 & September 2023) reviewed for Resident Council. This failure to ensure resident concerns were considered, acted upon, or a rationale provided when action could not be taken, left residents at risk for unresolved concerns, frustration, a less than homelike environment, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents' care plans (CPs) were reviewed, revised, and accurately reflected residents' care needs for 6 of 22 sample residents (Residents 58, 33, 64, 49, 57, and 36) whose CPs were reviewed. These failures placed residents at risk for unmet care needs and diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide assistance with activities of daily living (ADLs) for 4 of 8 sampled residents (Residents 64, 33, 83 and 58) reviewed for ADLs and choices. Failure to provide assistance with nail care and/or bathing to residents depend on staff for care, placed the residents at risk for unmet needs, poor hygiene, diminished self-image, and decreased quality of life.

Inspectors wroteBased on interview, observation and record review, the facility failed to provide an ongoing program of activities to meet the individual residents' interests and needs for 3 of 5 sampled residents (Residents 9, 69 and 49) reviewed for activities. This failure placed the residents at risk for boredom, isolation, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure respiratory care and services were provided in accordance with Physician's orders and accepted professional standards of practice for 3 of 4 sampled residents (Residents 57, 49 and 58) reviewed for respiratory care when the facility failed to identify and implement maintenance and monitoring orders for resident continuous positive airway pressure/bilevel positive airway pressure machines (CPAP/BIPAP, a form of non-invasive ventilation therapy used to facilitate breathing) and to document the administration of oxygen on resident(s) Medication Administration Records(MAR). This placed residents at risk for unidentified and/or unnecessary oxygen use, respiratory compromise, and other negative health care outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure refrigerator temperatures were maintained within acceptable ranges and/or failed to document refrigerator temperatures for 2 of 3 refrigerators reviewed for food service. These failures placed residents at risk of food-borne illness and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure care and services were provided in a dignified manner which maintained and enhanced quality of life for 2 of 2 sampled residents (Resident 51 & 55) reviewed for dignity. This failure placed residents at risk for feelings of embarrassment, disrespect, decreased self-worth and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident quarterly Minimum Data Sets (MDS, an assessment tool) were completed within 14 days of the assessment reference date (ARD) as required for 1 of 20 (Resident 58) sample residents reviewed for timely assessments. Failure to timely complete resident quarterly assessments, placed residents at risk for a delay in identification of care needs and/or unmet care needs.

Inspectors wroteBased on interview and record review the facility failed to ensure assessments were accurate and reflected the residents' health status for 1 of 20 sampled residents (Resident 33) reviewed for assessments. This failure placed residents at risk for receiving unnecessary medications and/or unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure services provided met professional standards of practice for 3 of 20 sampled residents (Residents 49, 57 and 58) of 20 reviewed. The failure to follow and/or clarify incomplete physician's orders when indicated, and to only sign for those tasks completed, placed residents at risk for medication errors and unmet care needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to consistently assist with the application of a hearing aid for 1 of 2 residents sampled residents (Resident 36) reviewed for communication. This failure placed residents at risk for communication difficulties, frustration, and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide services to prevent decline in range of motion for 1 of 3 sampled residents (Resident 9) reviewed for mobility. This failure placed residents at risk for loss of functional mobility, further decline in range of motion and discomfort.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide nutrition and hydration between meals for 1 of 4 sampled residents (Resident 69) reviewed for nutrition. This failure placed the resident at risk for thirst, hunger, and discomfort.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide individualized non-pharmacological care approaches and/or meaningful activities for 1 of 2 sampled residents (Resident 69) reviewed for dementia. This failure placed residents at risk for unnecessary medications, unrelieved distress, and a diminished quality of life.