Berkley West Healthcare Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the resident's right to be free from financial abuse (illegal or improper use of resident's funds or property) for one of two sampled resident (Resident 1) according to the facility's policy and procedures (P&P) titled, Alleged or Suspected Abuse and Crime Reporting dated 10/2025 evidenced by certified nursing assistant (CNA) 1 taking Resident 1's wallet, $200.00, and credit card and charging $78.70 on the credit card for personal use/gain. This deficient practice had the potential for Resident 1 to feel powerless and unprotected and the potential further financial abuse of residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff implemented its policy and procedures on Health Insurance Portability and Accountability Act (HIPAA- is a U.S. federal law that protects sensitive patient/resident/client health information (PHI) from unauthorized disclosure, ensuring privacy, security, and data integrity while also allowing for health insurance portability and administrative efficiency in healthcare) for one of one resident (Resident 52). This deficient practice violated the privacy and confidentiality rights of Resident 52.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide daily wound treatment per physician's orders for one of one sampled residents (Resident 42) according to Physician's Orders dated 12/24/2025. This deficient practice had the potential to place Resident 42 at risk for worsening of the pressure injury.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of five sampled residents (Resident 40), who had limited range of motion (ROM - the extent of movement of a joint) in the right hand, had a right hand splint applied per the physician's order. This deficient practice placed Resident 5 at increased risk for further decline and contracture formation to the right hand. A review of Resident 40's admission Record indicated the facility admitted the resident on 10/26/2024 and readmitted the resident on 2/6/2025 with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, gait and mobility abnormalities and Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). [...]

Inspectors wroteBased on interview and record review, the facility failed to provide urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) care every shift per the resident's physician order for one of four sampled resident's (Resident 12). This deficient practice had the potential to result in the development of a urinary tract infection (UTI- an infection in any part of the urinary system, the kidneys, bladder or urethra). A review of Resident 12's admission record indicated the facility admitted Resident 12 on 11/28/2025 with diagnoses that included lumbar vertebral fracture (a broken bone in the lower back), urinary retention (inability to completely empty one's bladder) and diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing). [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure insulin (a hormone that regulates blood sugar) for single-patient use (meant for multiple uses for one individual patient/resident) for Resident 34 was ordered and delivered to the facility timely for one of six residents (Resident 34). As a result, on 1/6/2026 at 11:15AM, licensed vocational nurse (LVN) 2, dispensed 2 units (unit of measure) insulin pen (portable medical device used for injecting doses of insulin) that was already in use/circulation and prescribed specifically for Resident 46 and administered/injected Resident 34 with the same insulin therefore decreasing/reducing the intended time and doses of the insulin prescribed for Resident 46.

Inspectors wroteBased on interview and record review, the facility failed to ensure Resident 8's medical records did not contain abbreviations not approved by the facility in accordance with the facility's policy and procedures (P&P - policy explains the rules and presents them in a logical framework while procedures outline the step-by-step implementation of various tasks) titled Charting and Documentation with a revision date of 7/2017. This deficient practice had the potential to result in miscommunication between medical and nursing staff causing delay in providing medical care and services to Resident 8. Findings During a review of Resident 8's admission record (face sheet - a document containing demographic and diagnostic information) indicated Resident 8 was admitted to the facility on [DATE] with the following diagnoses: [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure insulin (a hormone that regulates blood sugar) for single-patient use (meant for multiple uses for one individual patient/resident) for Resident 34 was ordered and delivered to the facility timely for one of six residents (Resident 34). This deficient practice placed both Resident 34 and 46 at high risk for infection and transmission of bloodborne pathogens, including hepatitis B (HBV-a viral infection of the liver), hepatitis C (HCV-a viral infection causing liver inflammation), and human immunodeficiency virus (HIV- a virus that attacks the body's immune system).

Inspectors wroteBased on observation, interview, and record review, the licensed nursing staff failed to follow their own policy and procedure to ensure one of three residents (Resident 1) had an interdisciplinary (IDT)/Bioethics review process to evaluate resident ' s care needs that required informed consent who was known to have fluctuating capacity to understand and make decisions. This deficient practice violated the residents' right to make an informed decision including the use of psychoactive medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure safe and orderly discharge from the facility to home for four of five sampled residents (Resident 1, 2, 4 and 5) by failing to: 1. Properly discharge Resident 1 to home by setting up the home health agency with complete instructions for ongoing care according to physician's order. 2. Complete a discharge plan summary upon Resident 1, 2, 4, 5's discharge to home. 3. Complete an Interdisciplinary Team (IDT - a group of dedicated healthcare professionals who work to bring knowledge together to help residents receive the care they need) meeting with services provided by the Social Services department regarding Resident 1, 2, 4 and 5's discharge planning according to facility's policy and procedure (P&P). [...]

Inspectors wroteBased on interview, and record review, for one of six sampled residents (Resident 1) the facility failed to 1. Monitor the vital signs (VS) which included blood pressure (BP), apical pulse (AP- a pulse point on the chest that gives the most accurate reading of a heart rate), and heart rate (HR-Pulse), according to physician's order for the following medications: a. Amiodarone HCL (Medication to treat/control very rapid and irregular pulse]) 200 milligrams (mg - unit of measurement) oral tablet a day for atrial fibrillation (A-Fib, serious medical condition of the heart: fast and irregular heartbeat) hold for apical pulse <60, Amiodarone dose was held or given with no documented apical pulse on 11/29, 11/30, 12/1, 12/2, 12/3, 12/4, 12/5, 12/6, 12/7, 12/8, and [DATE]. b. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to: 1. Notify Resident 1's physician of the presence of a severe drug-to-drug interaction warning between Amiodarone and Metoprolol Succinate ER on [DATE]. The facility continued to administer amiodarone and metoprolol Succinate ER despite the presence of negative side effects listed in the severe drug to drug warning (bradycardia and hypotension) from 10/24/24 to 12/9/24. 2. Notify Resident 1's physician of the need to hold medication's frequently due to low blood pressure readings or below the parameter ordered between November 2024 and 12/8/24. 3. Notify Resident 1's physician when medications: metoprolol (Medication to treat/control high blood pressure), spironolactone (Medication to treat/control high blood pressure), and Entresto (Medication for heart failure) were administered even below the ordered parameters. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure, one out of 3 sampled residents (Resident 1) were free of significant medication errors (an error in medication administration that may jeopardizes a resident's health and/or safety) by not administering the following medications withhold parameters (conditions for administration indicated in the physician order based on vital sign measurements) a. Metoprolol Succinate (Medication to treat/control high blood pressure) Extended Release (ER) 50 milligrams (mg - unit of measurement) Oral Tab ER 1 tab one time day for hypertension (HTN- high blood pressure) hold for systolic blood pressure (SBP-top number of BP ready) <100 millimeters of mercury (mmHg, unit of pressure) and HR<60, Metoprolol dose administered when BP was below acceptable parameters (SBP<100mmHg) on 11/24/2024, 11/28/2024, and 11/29/2024. b. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain complete and accurate medical record in accordance with accepted professional standards and practices for one out of 3 sampled residents (Resident 1) for the following medications: a. Amiodarone HCL (Medication to treat/control very rapid and irregular pulse]) 200 milligrams (mg - unit of measurement) oral tablet a day for atrial fibrillation (A-Fib, serious medical condition of the heart: fast and irregular heartbeat) hold for apical pulse <60, Amiodarone dose was held or given with no documented apical pulse on 11/29, 11/30, 12/1, 12/2, 12/3, 12/4, 12/5, 12/6, 12/7, 12/8, and 12/9/2024. b. [...]

Inspectors wroteBased on interview and record review, for four of four sampled residents (Residents 28, 144, 147, and 201), the facility failed to ensure: 1. A care plan was developed for psychotropic (any drug that affects brain activities associated with mental processes and behavior) medications and the care plan for impaired renal (kidney) function was specific for Resident 201. 2. A care plan was developed specifically for mouth breathing and oral care for Resident 28. Cross Reference F657 and F677. 3. A care plan was developed when Resident 147 showed signs of high risk of elopement (leaving the facility unsupervised and without staff knowledge). Cross Reference F689 4. A care plan was developed for Resident 144's use of bilateral bed siderails. These failures had the potential to negatively affect the delivery of care and services for (Residents 28, 144, 147, and 201).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: A.The policy and procedure for medication administration was followed for one of three sampled residents (Resident 26). On 11/9/2024 at 9:26 a.m., Licensed Vocational Nurse 2 (LVN 2) was observed crushing Apixaban (anticoagulant used to reduce the risk of stroke and blood clots), lisinopril (can treat high blood pressure and heart failure), Vitamin D (a fat-soluble vitamin that helps the body absorb calcium and perform other important functions) and multivitamin (used to treat or prevent vitamin deficiency due to poor diet, certain illnesses). This deficient practice placed resident at risk for physical and chemical incompatibilities between medications, loss of effectiveness, and worsening of medical conditions. B. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet the needs of residents in the facility by failing to esnure: A. Proper disposal of one open sterile intravenous (IV- inside the vein) administration set sterile intravenous medication tubing (used for delivering fluids or medications though and IV), eight expired sterile collection swabs, seven expired specimen collection tubes, and 10 expired specimen collection kits. B. Medication cart and pill cutter were clean and sanitized at all times. These deficient practices had the potential to compromise the safety and effectiveness of medications and sterile supplies which can result in medication administration error and risk for unsafe, improper medication administration use.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure kitchen staff were competent in safe and effective food preparation and handling practices. By failing to: 1. Ensure [NAME] 1moniotored cooked roast pork for safe cool down process and storage (hot food cooled down within a certain time frame to prevent harmful bacterial growth). 2. Ensure [NAME] 1 knew the concentration strength of the chlorine sanitizer (a substance or product that is used to reduce or eliminate pathogenic agents on surfaces) used for food contact surfaces and did not follow the sanitizer solution procedures and preparation per the facility policy. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the standardized recipes for lunch menu were followed on 11/9/2024 when: 1. Facility failed to follow lunch menu and portion sizes as written for residents on pureed diet. Four residents on pureed diet received ½ cup of pureed Salisbury steak instead of 2/3 of cup per the food portion and serving guide. This deficient practice had the potential to result in decreased nutritional intake and weight loss for Four residents who were on puree diet.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in accordance with professional standards to ensure food service safety. By failing to: 1. Ensure cut watermelon and cantaloupe stored in the reach in refrigerator did not exceed storage periods for ready to eat food. 2. Ensure dietary aide 1 (DA1) adhered to sanitary practices. DA 1 on 11/8/2024 at 6:45 p.m. was observed cleaning the kitchen, leaving the kitchen, returning to the kitchen with the dinner cart with the dishes, putting on a clean apron and proceeded to remove clean and sanitized dishes from the dish machine without washing hands. 3. Ensure DA 1 and DA 2 did not use a kitchen/dish towel to dry the cooking pots, pans, and utensils instead of letting them air dry. 4. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents Advance Directive (ACHD - a legal document indicating resident preference on end-of-life treatment decisions) form was accurately documented in the paper chart and electronic chart for one out of six sampled residents (Resident 147). This deficient practice had the potential to cause conflict with resident's wishes regarding health care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one out of six sampled resident (Resident 144) was free from physical restraint and use of bed siderails by failing to: a. Ensure the use of bilateral (relating to both sides) bed siderails consent was completed per individualized (Resident 144) assessment. b. Obtain a physician's order to use of bilateral bed siderails. These deficient practices had the potential to result in entrapment and injury and residents not being treated with respect and dignity with the use of restraints (bed siderails).

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to document the reason why one of three sampled residents (Resident 41) was discharged from the facility. This deficient practice resulted to incomplete information of reason Resident 41 was transferred to General Acute Care Hospital 1 (GACH 1).

Inspectors wroteBased on interview and record review, the facility failed to complete a notice of bed-hold policy and return form when the resident was transferred to the general acute care hospital (GACH) for one of three sampled residents (Resident 41). This deficient practice had a potential to result in the resident's responsible party being unaware of the bed hold policy and can lead to a transfer of the resident to another skilled nursing facility not of the resident's or responsible party's preference.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS - a federally mandated resident assessment tool) a comprehensive standardized assessment and screening tool) for significant change in status was completed within the required time frame for one of six sampled residents, Resident 41. This deficient practice had the potential to negatively affect the provision of necessary care and services.

Inspectors wroteBased on interview, and record review, the nursing staff failed to revise a care plan for at risk for falls for one of four sampled residents (Resident 24), who sustained a fall and injury after the resident was found on the floor on 12/3/2023 and on 8/9/2024. This deficient practice had the potential to place Resident 24 at increased risk for recurrent falls.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide oral care to two of five sampled residents (Residents 20 and 28). This failure had the potential to result in infection, illness and effect the resident's self-esteem and quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 147) was properly supervised to prevent elopement (leaving the facility unsupervised and without staff knowledge) by failing to: a. Ensure to evaluate and analyze hazard(s) and risk(s) of elopement when Resident 147 verbalized of wanting to leave the facility and made attempt of leaving as she was observed walking out of her room with her two luggage with her multiple times in a day. b. Examine Resident 147 for injury, complete and file an incident report and document relevant information in the resident's medical record when Resident 147 was returned back to the facility per facility's policy and procedure titled, Wandering and Elopement. These deficient practices resulted in Resident 1 eloping on 11/8/2024, walked outside unsupervised and without notifying the staff. [...]

Inspectors wroteBased on observation, interview and record review, the facility staff failed to ensure resident received appropriate treatment and services to prevent urinary tract infections urinary tract infection (UTI- an infection in the bladder/urinary tract) for one of two sampled residents (Resident 144) by failing to ensure Resident 144's indwelling urinary (foley) catheter (a hollow tube inserted into the bladder to drain or collect urine) was placed below the level of the bladder at all times. This deficient practice had the potential to result or resulted in urinary tract infections for the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly assess resident's pain for one of three sampled residents (Resident 196) during a medication pass observation. This deficient practice had the potential to negatively affect the residents' physical comfort and psychosocial well-being and had the potential to increase the pain level and result in an unmanageable pain level.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer medications appropriately to two of four sampled residents, (Residents 26 and 196) observed during the medication pass observation. During medication pass observation, there were four medication errors for Resident 26 and two medication errors for Resident 196 for a total of six medication errors out of 25 opportunities. These medication administration errors resulted to a medication error rate of 24%. Cross Reference:

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a routine dental visit to one of two residents sampled (Resident 28) as per physician's orders dated 9/23/24. This failure had the potential to result in pain, infection, illness and effect the resident's self-esteem and quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 1 of 12 sampled residents (Resident 37) was served the food preferences listed on the lunch meal ticket (physician ordered diet with resident food preferences). By serving Resident 37 who had lactose intolerance (lactose a sugar found in dairy products such as milk) regular milk during lunch, despite lactose being listed as an intolerance on resident's lunch meal ticket/tray card. This Deficient practice had the potential to result in decreased meal satisfaction, decrease caloric intake and experience symptoms associated with lactose intolerance.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff wore appropriate Personal Protective Equipment (PPE- equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses, PPE may include respirators, gloves, overalls, boots, disposable gowns, and goggles) when providing care to one of four sampled residents (Resident 144) who was on enhanced barrier precautions (utilized to prevent the spread of multi-drug resistant organisms) room. This deficient practice had the potential to result in the spread of disease and infection to all 46 residents, visitors, and staffs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that call light (a device with a button or touch pad a resident uses to set off an alarm that flashes/rings to alert the facility staff the resident needs assistance) were within reach for one of six sampled residents (Resident 199). This deficient practice had the potential to result in staff delay in meeting Resident 199's needs for hydration, toileting, and activities of daily living.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff did not use expired N95 Masks during (an infectious disease caused by the SARS-CoV-2 virus) outbreak in the facility. This failure placed the residents/staff/visitors at increased risk of contracting and spreading covid-19.

Inspectors wroteBased on interview and record review, the facility failed to assess for cellulitis (when bacteria enter through a crack in the skin and causes skin to become infected and may appear red, warm, and painful to the touch) in the left lower extremity (left leg) in one of three sampled residents, Resident 1. This deficient practice caused Resident 1 to sign out against medical advice (AMA-when a patient leaves a hospital or facility before the treating physician recommends discharge) and go the general acute care hospital (GACH) where Resident 1 was diagnosed with cellulitis of the lower extremity unspecified laterality, bilateral leg pain and at risk for bacteremia (blood stream infection). [...]

Inspectors wroteBased on interview and record review the facility failed to involve an interdisciplinary team (IDT, is a group of professionals from different disciplines who work together to achieve a common goal for residents), resident and/or resident representative in developing a discharge plan and assist the resident and/or resident representatives in selecting a post-acute care provider for one of three sampled resident, (Resident 1). This deficient practice caused the resident and resident representative to be uninformed regarding the discharge plan and placed Resident 1 at risk potentially going to a facility that does not meet her needs.

Inspectors wroteBased on interview and record review, the facility failed to follow their abuse reporting policy and procedures for one of six sampled residents (Resident 1). This deficient practice resulted in Resident 1 ' s alleged abuse incident not being reported to state licensing/certification office or ombudsman.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure indoor and outdoor visitations for all residents are in placed with no limitations of frequency and length of visits according to federal regulations. This deficient practice violated 33 out of 33 residents ' rights regarding visitation.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's notice of discharge or transfer was provided to the resident and/or resident's representative that included a right to appeal for one of one sampled resident, Resident 1. This had the potential to result in an unsafe discharge and or denying the resident of the right to appeal the discharge.

Inspectors wroteBased on observation, interview and record review, the facility failed to refer and provide podiatry service as ordered by physician for one of four sampled residents, Resident 1. This deficient practice placed the resident at risk of injury and complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one out of one sampled resident (Resident 2) was free from physical restraint by failing to: a. Ensure an individualized assessment was completed for the use of bilateral full bedside rails (barriers attached to the upper and/or lower sides of a bed). b. Ensure a physician ' s order for bilateral full bedside rails was in place. These deficient practices had the potential to result in entrapment (stuck in or trapped), injury, and residents not being treated with respect and dignity.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident received appropriate treatment and services to prevent urinary tract infections (UTI-an infection in any part of your urinary system your kidneys, ureters, bladder, and urethra) for one of one sampled resident (Resident 1) by failing to: 1. Assess Resident 1 who was incontinent (inability to control bowel and bladder function) with bladder and bowel when Resident 1 started showing signs and symptoms of UTI on 1/08/2024. 2. Notify Resident 1 ' s physician timely when Resident 1 started showing signs and symptoms of UTI on 1/08/2024. As a result, Resident 1 was discharged without treatment for a UTI, placing the resident at risk for hospitalization, spread of infection, organ damage, and death.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive care plan (a plan of care that summarizes a resident's health conditions, specific care needs, and current treatments) that met the care/services based on the resident's identified individual needs for one of three sampled residents (Resident 2) by failing to: 1. Develop a comprehensive care plan for Resident 2 ' s personal medication supply kept at Resident 2 ' s bedside. 2. Develop a comprehensive care plan for use of Resident 2 ' s bilateral full bedside rails (a barrier attached to the upper and/or lower sides of a bed). This deficient practice had the potential to delay and affect the quality of care and services received. Cross Reference:

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident received appropriate treatment and services to prevent urinary tract infections (UTI-an infection in any part of your urinary system your kidneys, ureters, bladder, and urethra) for one of one sampled resident (Resident 1) by failing to: 1. Assess Resident 1 who was incontinent (inability to control urine or bowel movements) with bladder and bowel when Resident 1 started showing signs and symptoms of UTI on 1/08/2024. 2. Notify Resident 1 ' s physician timely when Resident 1 started showing signs and symptoms of UTI on 1/08/2024. As a result, Resident 1 was discharged from the facility without reeceiving treatment for a UTI, placing the resident at risk for a spread of infection, organ failure, and death.

Inspectors wroteBased on observation, interview, and record review, facility failed to ensure one of three sampled residents (Resident 2) was free from significant medication errors by failing to ensure Rytary (medication used to treat symptoms of Parkinson's disease and parkinsonism [an umbrella term that refers to brain conditions that cause slowed movements, rigidity [stiffness] and tremors]) was given on time as ordered by the physician. This deficient practice had the potential to lead to a worsening of Parkinsonism symptoms, underdosing and/or overdosing which could result in serios injury, harm, and death. Cross Reference:

Inspectors wroteBased on observation, interview, and record review the facility failed ensure medications were stored as per the facility ' s policy and procedure titled Storage of Medications dated October 2023. By failing to ensure one out of three sampled residents (Resident 2) did not keep a personal supply of Rytary (medication used to treat symptoms of Parkinson's disease and parkinsonism) oral capsule extended release (ER) 23.75-95 milligram (mg) - give 1 capsule (cap) by mouth one time a day for Parkinson ' s at 8:00 a.m., with 145 mg in the bedside table of Resident 2 ' s room. This deficient practice had the potential to lead to medication under and/or overdosing which could result in serious injury, harm, and death. Cross Reference:

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure its telephone system was in good working condition. This deficient practice had the potential to delay the communications for those who need to contact residents in the facility, including doctors and families.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy on Medication Administration for one (1) of three (3) sampled residents (Resident 1) by failing to administer Resident 1 ' s Sinemet (a medication used to treat symptoms of Parkinson ' s disease [a progressive disorder of the central nervous system that affects movement such as muscle stiffness, tremors, spasm, and poor muscle control])on time as scheduled. This deficient practice resulted in a delay for Resident 1 receiving her Sinemet, which might have the negative impact on the management of the resident ' s Parkinson disease.

Inspectors wroteBased on interview and record review, the facility failed to ensure the comprehensive Minimum Data Set (MDS - a comprehensive standardized assessment and screening tool) was completed within the required time frame for four out of seven sample discharged residents (Residents 2, 7, 18 and 31) in accordance with the facility provided MDS 3.0 Resident Assessment (RAI) Manual, dated 10/2019, and the facility's policy and procedures (P&P) titled, Comprehensive Assessments and the Care Delivery Process, revised 10/2022. This deficient practice had a potential to negatively affect the provision of necessary care and services for Residents 2, 7, 18 and 31.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive care plan that met the care/services based on the resident's individual assessed needs for four of 25 sampled residents (Resident 10, 14, 34 and 39) by failing to: 1. Ensure Residents 10 and 14's episodes of behaviors when using psychoactive medications were care planned. 2. Ensure Residents 10, 14 and 34's high risk medications were care planned with black box warning (warning on a medication that represents serious or life-threatening potential side effect associated with the specific medication). 3. To implement care plan for monitoring interventions for Resident 39. These deficient practices had the potential to result negative impact on Residents 10, 14, 34, and 39's health and safety, as well as the quality of care and services received.

Inspectors wroteBased on observation, interview and record review, for five of five sampled residents (Residents 14, 23, 39, 145 and 149), the facility failed to meet professional standards of quality by failing to ensure: 1. Resident 27 did not receive Levalbuterol (a medication that treats lung/airway conditions and makes breathing easier) with an open date past 14 days in accordance with the facility's policy and procedures (P&P) titled, Medication Administration (General), effective date 10/2022, . This deficient practice had the potential to affect the effectiveness of the medication and also inabilityto effectively control lung conditions for Resident 27. 2. Licensed Vocational Nurse 4 (LVN 4) selected appropriate site on a finger to perform blood sugar monitoring for Residents 39, 145 and 149 in accordance with a blood glucose monitoring system user instruction manual used at the facility. [...]

Inspectors wroteBased on interview and record review, for four of six sampled residents (Residents 10, 14, 17 and 39), the facility failed to ensure: A. The attending physician documented in the resident's medical record that an identified drug regimen irregularity has been reviewed and what, if any, action has been taken to address the irregularity for Residents 10 and 17 in accordance with the facility's policy and procedures (P&P) titled, Consultant Pharmacist Reports, reviewed on 10/2022. B. Monthly medication regimen review was completed for Resident 14 and 39 in accordance with the facility's P&P titled, Consultant Pharmacist Reports, reviewed on 10/2022. These deficient practices had the potential to result in adverse medication outcome for potential unnecessary medications for Residents 10, 14, 17 and 39.

Inspectors wroteBased on interview and record review, the facility failed to ensure that three of eight sampled residents' (Resident 10, 14 and 17) psychotropic medication (used to treat mental health disorders) regimens were managed and monitored to promote or maintain the highest practicable mental, physical, and psychosocial well-being of residents by failing to: 1. Ensure Resident 10's psychotropic medication, Lexapro (antidepressant medication), was used to treat a specific, diagnosed and documented condition/ behavioral symptoms manifested. 2. Ensure implementation of monitoring episodes of anxiety for Resident 10's Lexapro use. 3. Ensure implementation of monitoring for any potential adverse effects for Resident 10's Lexapro use. 4. [...]

Inspectors wroteBased on observation, interview and record reviews, the facility failed to: 1. Ensure the removal of discontinued, expired, or medications not approved for resident administration for four out of 12 sampled discharged residents (Resident 153, 43, 37 and 33) from the medication storage room. 2. Ensure expired medications were properly stored and/or discarded per manufacturer's guidelines for four of 12 sampled residents (Resident 19, 25, 20, 27). 3. Ensure Resident 14, and 23's skin treatment medications were properly secured per facility's policy. Those deficient practices have the potential for unsafe use of expired and/or discontinued medications, to result in undetected diversion of medications and to place residents at risk for unintended complications of medications.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure proper sanitation and safe food handling practices in accordance with professional standards for food service safety for 25 of 25 residents who consumed food prepared by the facility kitchen by failing to: 1. Ensure one of two freezers (freezer 2) temperature was being monitored using a temperature log per facility policy. 2. Ensure kitchen and dry storage floor were free from food particles, residue, dirt and or debris. 3. Ensure flour lid container was kept clean. 4. Ensure expired food such as croissant dough, breaded turkey breast and corn were removed from the refrigerator and/or freezer and tortilla was labeled with the used by date when opened. 5. Ensure dented sliced apple can was removed in the storage area room. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow its infection prevention and control protocol to prevent spread of infection by failing to: 1. Ensure the licensed staff properly followed hand hygiene while providing skin care treatment for one of 14 sampled residents (Resident 14). 2. Ensure staff checked the refrigerator temperature and updated the refrigerator temperature log per facility's policy. 3. Ensure two of three sampled residents (Resident 5 and 10) nasal cannulas (NC-a device that delivers extra oxygen through a tube and into your nose) tubing were changed once a week per facility's policy. These deficient practices had the potential to transmit infectious microorganisms and increase the risk of infection for the residents.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the residents and/or responsible party (RP) were informed in advance, of the risks and benefits of psychoactive medication (a drug that changes brain function and results in alterations in perception, mood, consciousness or behavior) for one of five sampled resident (Resident 10) in accordance with the facility's P&P titled, Informed Consent, reviewed on 10/2022, and Psychotropic Medication Use, reviewed on 10/2022. This deficient practice violated Resident 10's right to make an informed decision regarding the use of psychoactive medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide reasonable accommodation to meet the needs and preferences by failing to ensure low air loss mattress (LAL - a mattress designed to prevent and treat pressure wounds) settings were set according toresident's wieght for comfort for three of four sampled residents (Residents 14, 23 and 150) in accordance to the facility's policy and procedures (P&P) titled P&P titled, Accommodation of Needs, dated 10/2022, and facility provided manufacturer's undated P&P, titled, Drive (user guidelines). This deficient practice resulted in Residents 14, 23 and 150 complaining of being uncomfortable and also had the potential to negatively affect the delivery of necessary care and services provided to Residents 14, 23 and 150.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS - a comprehensive standardized assessment and screening tool) for significant change in status was completed within the required time frame for two of 14 sampled residents (Residents 150 and 34) in accordance with the facility's policies and procedures (P&P) titled, Change in a resident's condition or status, revised 10/2022, Resident Assessment Instrument, revised in October 2023, and Resident Assessment Instrument, revised in October 2023. This deficient practice had the potential to negatively affect the provision of necessary care and services for Residents 150 and 34.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the comprehensive Minimum Data Set (MDS - a comprehensive standardized assessment and screening tool) was completed within the required time frame for one of two sampled resident (Resident 23) in accordance with the policy and procedures (P&P) titled, Comprehensive Assessments and the Care Delivery Process, revised 10/2022, and Resident Assessment Instrument, revised 10/2022. This deficient practice had the potential to negatively affect the provision of necessary care and services provided to Resident 23.

Inspectors wroteBased on observation, interview, and record review, the facility failed to refer and provide podiatry service as ordered by physician for one of 14 sampled residents (Resident 17) in accordance with the facility's policy and procedures (P&P) titled, Podiatry/Foot Services: revised on 10/2022. This deficient practice placed the resident at risk of injury and complications.

Inspectors wroteBased on interview and record review, the facility failed to ensure for one of 14 sampled residents (Resident 150) received adequate supervision and assistance based on the residents' individual needs to prevent accidental injuries by failing to ensure Resident 150 was properly assessed and monitored when Resident 150 verbalized that he was choking from his food in accordance with the facility's policy and procedures (P&P) titled, Accidents and Incidents - Investigating and Reporting, revised on 10/2022. This deficient practice had the potential for Resident 150 to aspirate (when something enters the airway or lungs by accident) and cause accidental injury such as shortness of breath (SOB) due to lack of oxygen and even death.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure oxygen nasal cannula (NC - a flexible device used to deliver supplemental oxygen or increased airflow to a patient or person in need of oxygen) tubing was changed every seven days for two of three sampled residents (Residents 5 and 10) in accordance with the the facility's policy and procedures (P&P) titled, Oxygen administration (Mask, Cannula, catheter), reviewed 10/2022. This deficient practice had the potential for Resident 5 and 10 to develop respiratory distress and infection.

Inspectors wroteBased on interview, and record review, the facility failed to provide sufficient staffing to accommodate residents needs and request by not answering the call light timely for three of three sampled residents (Residents 17, 25 and 32) in accordance with the facility's policy and procedures (P&P) titled, Staffing, reviewed on 10/2022, and P&P titled, Call Light Answering, reviewed 10/2022. This deficient practice resulted in residents not receiving needed services timely and efficiently and had the potential to affect the quality of life and treatment given to the residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that staffing information posted was updated with the actual hours on a daily basis on four of four sampled days (10/13/2023, 10/14/2023, 10/15/2023 and 10/16/2023) in accordance to All Facilities Letter (AFL) 21-11 dated 3/17/2021, and the facility's policy and procedures (P&P) titled, Posting Direct Care Daily Staffing Numbers, reviewed on 10/2022. This deficient practice had the potential to prevent residents and visitors from knowing the accurate and final Direct Care Services Hours Per Patient Day (DHPPD - Actual total direct care service) and possibly residents' need to go unmet.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled resident (Resident 10) was adequately monitored for any signs and symptoms of bleeding while using Apixaban (anticoagulant- blood thinner medication that can prevent stroke [when a blood flow to a part of your brain is stopped either by a blockage or rupture of a blood vessel], heart attack [when a blood clot obstruct the heart vessels] and other heart problems) medication. This deficient practice had the potential to place the resident at the risk for hospitalization, even death due to lack of monitoring for side effects including bleeding.