Bridgeview Post Acute

Inspectors wroteBased on the interview and record review, the facility failed to ensure it treated residents in a dignified manner for one of eight residents (Resident 1) sampled for resident rights when: Certified Nursing Assistant (CNA) A entered Resident 1's room without explaining the purpose for being there and pulled Resident 1's pajama bottoms down without asking permission to see if he needed his brief (adult diaper) changed and was unaware that Resident 1 did not wear briefs. This upset and embarrassed Resident 1, who complained to staff about the care he received from CNA A, and Resident 1's family member (FM) expressed she was dissatisfied with the care her husband had received. FindingsA review of the facility's Dignity policy and procedures, dated 10/2025, indicated on Line 9, Staff inform and orient resident to their environment. Procedures are explained before they are performed. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to protect one of three sampled residents (Resident 1) from neglect when nursing staff failed to recognize and appropriately respond to slurred speech, facial drooping, and right sided arm weakness, which represented of a significant change in condition. The facility failed to ensure timely assessment, provider notification (the physician), and medical intervention. This failure resulted in delayed recognition and treatment of Resident 1's brain bleed, contributing to a permanent and preventable decline in functional abilities, including decreased use and strength of the right arm and loss of independence in performing personal tasks. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the physician and resident representative for one of three sampled residents (Resident 1), when Resident 1 experienced a significant change in condition. This failure resulted in delayed timely treatment, during which Resident 1 experienced a preventable decline in functional status, losing strength in the right arm and becoming unable to independently perform personal care tasks.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the physician's orders for psychiatric evaluation and treatment were implemented and incorporated into the care plan for two of the three residents (Residents 1 and 2). This failure resulted in Resident 1 and 2 not receiving mental health evaluation and had the potential for both residents not to reach their highest practicable level of mental and psychosocial well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety when: Several kitchenware stacked wet, and few kitchenware had oily substances and stored in the clean and ready-to-use areasTwo cooking pans were not well maintainedOne kitchen staff verbalized the process of the manual dishwashing with 3-compartment sink incorrectlyThe arrangement of the food stored in the walk-in refrigerator was not in a food safety mannerOne kitchen staff did not have hair restraint to cover the facial hairResidents' food in residents' food refrigerator found did not store and label properly These failures had the potential to cause food contamination which could cause illness to the medically vulnerable residents who consumed food from the kitchen and resident refrigerator in the facility. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care in a manner and in an environment that promoted maintenance of quality of life for 9 out of 33 sampled residents (Resident 30, Resident 33, Resident 50, Resident 73, Resident 102, Resident 117, Resident 122, Resident 124, Resident 132) when:Staff spoke a non-English language in resident rooms during resident care when English was the residents' primary language. Resident 73 was not able to use eating utensils to eat his meal and had to use his hands. These practices had the potential for residents to not have their right for dignity, respect, and negatively impact on residents' physical, mental, and psychosocial wellbeing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication administration error rate did not exceed 5% for 2 of 34 sampled residents (Resident 66 and Resident 89).1. For Resident 89, a licensed nurse administered canagliflozin (medication used to treat diabetes) not in accordance with Manufacturer's Specifications.2. For Resident 66, a license nurse administered two medications, spironolactone (used to help remove extra body fluid and swelling) and megace (a type of hormonal medication that increases appetite), not in accordance with Physician Orders, resulting in two sperate medication errors. As a result of this failure, 3 errors were identified of 25 opportunities during the observation of medication administration; the facility medication error rate was 12%.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the menu was followed for the therapeutic diet (a modification of a regular diet, tailored to fit the nutritional needs of a particular person - may be part of a treatment or medical condition and usually prescribed by a physician) during the lunch meals on 1/6/26 and 1/7/26 when:A. [...]

Inspectors wroteBased on observation, interview and record review, the facility was failed to ensure the two dietary staff had proper skill to prepare the appropriate texture for Soft and Bite Size (SBS) texture (chopped or cut into pieces size no larger than 1.5 centimeter(cm) by 1.5cm) and Mince and Moist (MM) texture (soft and moist (with all excess fluid drained), size no larger than 4 millimeters (mm) by 15 mm), food items. This deficient practice had the potential to increase risk for the residents with swallowing and/or chewing difficulties to choke and/or aspirate (a condition in which food, liquids, saliva, or vomit is breathed into the airway). There were 31 residents on sb size texture diets and seven residents on mm texture diets, out of the census of 117.

Inspectors wroteBased on Interview and Record Review, the facility failed to ensure that 1 of 34 sampled residents (Resident 8) were free of Unnecessary Medication, when Resident 8 had inaccurate diagnoses indications for receiving divalproex sodium, a psychotropic medication. This failure resulted in Resident 8 continuing to receive unnecessary psychotropic medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary care related to activities of daily living (ADL) to maintain good personal hygiene when one of three sampled residents (Resident 26) fingernails were long, untrimmed, jagged, and had dirt and food under and on top of the nails. This failure had the potential for self-injury and infection due to unkept nails.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its enteral tube (delivers liquid food, medication, and fluids directly into the digestive system (stomach or intestines) when a person can't eat or swallow safely) medication administration policy when staff did not flush enteral feeding tubing with purified or distilled water as required. Instead, staff used tap water to flush the tubing. This deficient practice had the potential to introduce contaminants and place immunocompromised residents at risk for infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the risk and benefits of bed rails ( bed canes - safety device placed on the side of the bed used to help people with mobility issues move) for two of five sampled residents (Resident 10, Resident 14), when Resident 10 and 14 were using bed rails and did not have a bed safety assessment completed. This failure had the potential to put residents at risk for entrapment, accidents, and injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that their emergency drug kits (E-kit) had accurate or complete record keeping, when 1 of 4 antibiotic tablets was found to be unaccounted for. This failure had the potential for medications to be potentially lost or diverted without documentation.

Inspectors wroteBased on interview and record review, the facility failed to ensure that Pharmacy staff were conducting accurate Medication Regimen Reviews for 1 of 34 sampled residents, when Resident 8 was found to have unnecessary medication prescribed for an incorrect diagnosis for 3 months. This failure had the potential to harm residents when medications were not monitored by pharmacy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that medications were stored at the correct temperatures. This failure had the potential for medications to not be therapeutically effective.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to ensure two of seven sampled residents (Resident 13, and Resident 65) medical records contained accurate documentation when their Physician Orders for Life-Sustaining Treatment (POLST - a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end-of life) inaccurately indicated that Resident 13 and Resident 65 had advance directives (a written instruction, such as a living will or durable power of attorney for health care, recognized under State law, relating to the provision of health care when the individual is incapacitated [inability to make decisions]). These failures had the potential to result in delays or inaccuracies in Resident 13, and Resident 65's wishes being carried out if they were incapacitated.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a plan of care for safety and supervision for one of three sampled residents (Resident 4), when Restorative Nursing Assistant (RNA) H left Resident 4 alone outside on a patio for 30 minutes, where Resident 4 fell and sustained a subdural hematoma (bleeding between the brain and its lining). This deficient practice resulted in Resident 4 experiencing a major head injury, emergency care at hospital, and a significant decline in their quality of life. Resident 4 was transferred to the hospital on [DATE] after he fell. Resident 4 returned to the facility on [DATE], with Hospice services (specialized end of life care). Resident 4 passed away at the facility on [DATE], 13 days following the fall. Refer to F609, F679 and F726. [...]

Inspectors wroteBased on interview and records review, the facility failed to report a major injury for one of three sampled residents (Resident 4), when Restorative Nursing Assistant H (RNA H) left Resident 4 alone outside on a patio for 30 minutes, where Resident 4 fell and sustained a subdural hematoma (bleeding between the brain and its lining) This failure resulted in delaying an investigation into a major injury, and had the potential for other incidents not to be reported. FindingsDuring a review of the Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.19.1, page J-26, dated [DATE]. The CMS document defined Major Injury as Including bone fractures, joint dislocations, closed head injuries with altered consciousness, subdural hematoma. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to honor an activity preference that was developed in the activity care plan for one of three residents (Resident 1). This failure had the potential for Resident 1's mental and psychosocial needs not to be met.

Inspectors wroteBased on interview, and record review, the facility failed to ensure that direct care staff had competencies necessary to care for one out of three sampled residents (Resident 4) when Restorative Nursing Assistant H (RNA H) left Resident 4 alone on a patio for 30 minutes, where Resident 4 fell and sustained a major head injury. This deficient practice resulted in Resident 4 experiencing a major head injury, admission to an acute care hospital, a decline in condition, and eventually death. This failure also had the potential for incompetent staff to care for other residents. FindingsDuring a review of records titled Restorative Nursing Assistant (RNA) Job Description, indicated that RNA H signed the document on 8/26/25, indicating they understood the duties and responsibilities outlined. [...]

Inspectors wroteBased on interview and record review, the facility failed to report an abuse allegation for one of five sampled residents (Resident 4) when Resident 4 informed staff that they had been slapped in the face by another resident on 6/20/25. This failure had the potential to result in psychosocial and emotional harm for Resident 4 and had the potential to place all the residents at risk for undetected/unreported elder neglect or abuse.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two of three sampled residents (Resident 1 and Resident 2) were free from accidents and hazards when: a) post fall evaluations did not determine the reason for the falls. b) residents care plan interventions were not reevaluated for effectiveness. c) new interventions were not developed prevent further falls and injuries. d) direct care staff did not know how to identify high risk fall residents and find their fall plan of care. This resulted in multiple repeated resident falls and had the potential for all residents to be at risk for fall/injuries.

Inspectors wroteBased on interview, record review, and observation, the facility failed to meet this requirement when construction materials were improperly stored in the room of three residents (Residents 2, 3 and 4). This had the potential for accidents and hazards and created an environment that residents did not find home like.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food safety and sanitation requirements were met in accordance with professional standards for food service safety when: 1. Food was not properly stored, labeled and dated, with expired food items present in kitchen refrigerator/freezers. 2. Kitchen and food service equipment was not in sanitary condition; 3. The kitchen environment was not in sanitary condition; 4. Resident food was not stored or labeled per policy and procedure (P&P) in the resident refrigerator/freezer, and the refrigerator was visibly dirty inside. These failures created the potential risk for exposure to food- and waterborne illnesses in a medically vulnerable population of 105 residents who receive food stored and prepared in the facility.

Inspectors wrote3. A review of the facility's policy titled Resident Rights and Dignity revised February 2021, indicated Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Policy Interpretation and Implementation 11. Staff promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. A review of Resident 101's admission Record dated 5/28/24, indicated Resident 101 was admitted to the facility on [DATE] with diagnoses that included stroke (blood flow to the brain is blocked and some brain cells die causing disabilities), muscle weakness, difficulty in walking, and major depressive disorder. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure allegations of abuse for three out of five sampled residents (Residents 22, 35, and 40) were investigated and residents were protected during this process when: 1. Certified Nurse Assistant (CNA) M did not report suspicions of abuse when CNA M noticed Resident 22 showed fear during care. 2. CNA J did not report an allegation made by Resident 40 that the Housekeeper (HSK) A instructed Resident 40 to clean her own toilet. 3. When facility staff did not report an allegation of staff to resident physical abuse, when CNA E held down Resident 35. This placed all residents at risk for staff to resident abuse and had the potential for physical and psychosocial harm.

Inspectors wroteThe facility failed to provide medically related Social Services, that met the needs of the residents, for four out of 22 sampled residents (Residents 35, 87, 90, and 98) when: 1. Social Service care plans (a document that described resident goals and the interventions [instruction, actions, education, and care required] that facility staff would utilize to assist in residents reaching their goals) were not updated quarterly (every 3 months) or as needed for Residents 87 and 90. 2. Care conference meeting (meeting held quarterly to discuss care, needs, and goals, that included the resident, social services, nursing, activities director and the dietary department) notes did not reflect a discharge plan or discharge planning needs for Resident 90. 3. Social Services did not assist Resident 90 with financial documents when requested. 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications and medication supplies were stored and labeled in accordance with currently accepted professional principles when: 1. Two loose pills were found in the drawer of medication cart 2. 2. Six medications that were being dispensed were opened and not dated. 3. Four Foley drainage bags (A bag that collects urine which comes from the bladder through a catheter tube) in a storage room ready for use were expired. 4. Pro-Stat concentrated liquid protein medical food was being dispensed but had expired. These failures had the potential for medication misuse, medication ineffectiveness, and potential exposure to harmful pathogens (bacteria, viruses, fungi) from expired supplies for residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to prepare and serve food that maintained an appetizing flavor, texture, appearance, and at a palatable (pleasant taste) temperature when 5 of 22 sampled residents (Residents 11, 35, 77, 84, 215) when: 1. Resident 77 stated the food was overcooked and could not even cut it. 2. Resident 84 stated the pork was undercooked, and he had to throw it away. 3. Resident 11's ice cream was served melted. 4. Resident 35's food was served cold, ice cream was served melted, and biscuits were served burnt. 5. Resident 215's pizza was served burnt. These failures resulted in meals to be served overcooked, undercooked, cold, unpleasant, and not meet the resident food preference, which had the potential for residents to decrease meal intakes and have weight loss issues. Findings 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of 22 (Resident 35 and 40) residents were free from abuse and the potential for ongoing abuse when: 1. Certified Nursing Assistant (CNA) E grabbed and held Resident 35's arm when attempting to do personal cares and CNA E continued to be assigned to Resident 35's room after the incident. 2. Housekeeper (HSK) A made Resident 40 clean her own toilet that had feces on it. HSK A continued to be assigned to clean Resident 40's room. This failure caused emotional distress and mental anguish for Resident 35 and Resident 40.

Inspectors wroteBased on interview and record review the facility failed to report suspicions and allegations of abuse for three out of five sampled residents (Residents 22, 35, and 40) when: 1. Certified Nurse Assistant (CNA) M did not report suspicions of abuse when CNA M noticed Resident 22 showed fear during care. 2. CNA J did not report an allegation made by Resident 40 that the Housekeeper (HSK) A instructed Resident 40 to clean her own toilet. 3. Facility staff did not report an allegation of staff to resident physical abuse, when CNA E held down Resident 35. The failure to report abuse suspicions and allegations had the potential for residents' to be at risk for staff to resident abuse and had the potential to cause psychosocial harm and negatively impact the resident's overall wellbeing.

Inspectors wroteBased on interview, and record review, the facility failed to ensure accurate and complete documentation for one of three closed records reviewed when Resident 112 was transferred to an acute care hospital and the facility did not document the date and time of their transfer, where they transferred to, how they were transported, or the disposition of their personal effects and medications. This failure had the potential to negatively impact Resident 112's continuity of care and had the potential risk of them receiving inadequate care or services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 23 (Resident 101) residents had non-skid footwear on to prevent falls as per his care plan. The facility's lack of safety intervention for Resident 101 had the potential for injury related to unwitnessed falls.

Inspectors wroteBased on interview and record review, the facility failed to provide appropriate care for two out of three sampled residents (Residents 87 and 214) with a gastrostomy tube (g-tube, a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) when: 1. Licensed Nurses (LN) did not follow Resident 87's Physician orders regarding g-tube feeding (Physician prescribed liquid nutrition [formula/feedings] amounts, hydration (free water provided for hydration), water flushes (water flushes aide in keeping the g-tube unclogged and maintained), and inaccurately documented intake amounts. 2. For Resident 87, LNs provided g-tube care without a Physician's order and did not document the care that was provided. 3. Resident 214 received an excessive amount of fluids. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure physician progress notes (doctor's note about resident progress, care, and medical issues) were complete, signed and dated at each visit for for two of four sampled residents (Resident 34, and 98). This failure had the potential to negatively affect communication between disciplines and to result in inappropriate care and service for the residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure nursing staff demonstrated appropriate skill sets that were required to care for *** out of 22 sampled residents when: 1. Licensed Nurses (LN) did not reassess, notify the Physician, or follow up on Resident 98's potentially infected right eye. 2. LNs and Certified Nurse Assistants (CNA) did not report suspicions or allegations of abuse for Residents 22, 35, and 40. (Refer to F609) 3. LN did not adequately monitor gastrostomy tube (g-tube, a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) feedings (liquid hydrations provided through the g-tube) and provided care without a Physician's order. (Refer to F693) 4. LNs did not thoroughly check meal trays to ensure residents received the appropriate food. [...]

Inspectors wroteBased on observation, interview, and record review, one of 22 sampled residents (Resident 61) failed to be free of unnecessary psychotropic medications when Resident 61 had a routine Ativan (anti-anxiety medication) order of 0.5 milligrams (mg - a unit of measure) and a pro re nata (PRN - as needed) order for Ativan 0.5 mg. The PRN Ativan order was available for five months without an order end date despite Consulting Pharmacist (CPH) recommendations to discontinue the PRN order or limit the order to 14 days per Centers for Medicare and Medicaid Services (CMS - a federal entity that works to improve the quality of healthcare) regulations. Psychotropic medications affect brain activities associated with mental processes and behaviors and include anti-psychotic, anti-depressant, anti-anxiety and hypnotic (sedating) medications. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the facility's policy and procedure (P&P) on dental services was followed for one of 22 sampled residents (Resident 35). This failure had the potential to result in Resident 1's weight loss due to difficulty eating.

Inspectors wroteBased on observation, interview, and record review, the facility failed to honor food preferences for five out of 22 sampled residents (Residents 46, 90, 100, 104, and 106) when: 1. Resident 46 received eggs for breakfast. 2. Resident 90 received rice with meals. 3. Resident 100 received tomatoes with a salad. 4. Resident 106 received eggs for breakfast and a tuna fish sandwich for lunch. 5. Resident 104 received carrots, peas, and corn with meals. This failure had the potential to negatively impact psychosocial health and cause weight loss.

Inspectors wroteBased on interview and record review the facility failed to ensure one of four sampled residents (Resident 1) received respiratory care when a physician ordered Bilevel Positive Airway Pressure (BiPAP-a device that helps breathing) was not implemented for 14 days. This resulted in an emergent transfer to hospital for treatment for severe respiratory failure (not enough oxygen) for five days.

Inspectors wroteBased on interview and record review the facility failed to ensure enough nursing staff had the appropriate competencies and skills to implement a respiratory plan of care for one of four sampled resident (Resident 1). This failure resulted in a decline in Resident 1 ' s respiratory and metabolic status (a condition where the decline of the lung function negatively affects the functioning of the rest of the body) resulting in emergent transfer to a hospital for treatment. Refer to F695.

Inspectors wroteBased on interview and record review the facility failed to ensure that one of four residents (Resident 1) was educated, informed and allowed to make her own medical decisions before administering a psychotropic (alters mood and behavior). This failure resulted in Resident 1 to receive an unnecessary medication and had the potential for adverse effects such as sedation, dry mouth, weakness, headaches, dizziness, nausea and being unable to sleep. Refer to F758.

Inspectors wroteBased on interview and record review the facility failed to create an accurate comprehensive admission assessment for one four sampled residents (Resident 1) when a physician ordered treatment for a Bilevel Positive Airway Pressure (BiPAP-a device to help breathing) was not identified. This resulted in a decline in Resident 1 ' s respiratory and metabolic status (a condition where the decline of the lung function negatively affects the functioning of the rest of the body) requiring a transfer to a hospital for emergent treatment.

Inspectors wroteBased on interview and record review the facility failed to create a baseline care plan that included a respiratory treatment for one four sampled residents (Resident 1) when she did not receive her physician ordered Bilevel Positive Airway Pressure (BiPAP-a device that helps breathing). This resulted in a decline in Resident 1 ' s respiratory and metabolic status (a condition where the decline of the lung function negatively affects the functioning of the rest of the body) requiring a transfer to a hospital for emergent treatment.

Inspectors wroteBased on interview and record review, the facility failed to ensure that one of four residents (Resident 1) was free of an unnecessary psychotropic medication (drug prescribed to affect the mind, emotions, or behavior) when she was prescribed Lexapro (medication used to treat depression and anxiety) was administered without clinical indication. This failure resulted in Resident 1 to receive an unnecessary medication and put her at risk for adverse side effects such as sedation, dry mouth, weakness, headaches, dizziness, nausea and being unable to sleep. Refer to F552.

Inspectors wroteBased on interview and record review the facility failed to ensure the Medical Director (MD) supervised the development and implementation of a plan of care for one of four sampled residents (Resident 1) when: 1. Upon admission orders for BiPAP (device to help breathing) were not implemented. Refer to F 695 2.a. Informed consent was not obtained before administering a psychotropic (alters mood behavior) medication. Refer to F 552 b. An unnecessary psychotropic was prescribed without clinical justification. Refer to F 758 This failure resulted in respiratory failure that required emergent hospitalization and an unnecessary psychotropic medication to be administered without clinical justification.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one resident (Resident 48) who entered the facility without a pressure ulcer (PU), did not develop a pressure sore and that the resident received necessary care and services to promote healing, when Resident 48 was at a risk for PU's upon admit and routine skin assessments did not identify the pressure ulcer at an early stage. Resident 48's PU was identified on 4/7/23 at stage 3 (full thickness tissue loss without muscle, tendon, or bone visible). Resident 48's PU was not evaluated and treated by a wound care physician for 40 days and progressed to a stage 4 PU (a pressure injury that extended through the skin to muscle, tendon, or bone) on 5/18/23. [...]

Inspectors wroteBased on observation, interview, facility document and Policy and Procedure review, the facility failed to ensure acceptable parameters of nutritional status were maintained for one of 21 sampled residents (Resident 48) when: 1. A Change of Condition (COC) assessment was not completed, and the Physician was not notified of Resident 48's severe weight loss of 12.8 pounds (lbs.), 7.7 % between 1/6/23 and 2/5/23, 15 lbs., 9% between 1/6/23 and 2/7/23, and 17.2 lbs., 10.2% between 8/20/22 and 2/7/23, 2. Weekly weights were not completed as ordered on 1/26/23 for Resident 48, and 3. Interventions to mitigate the severe weight loss of 12.8 pound (lbs.), 7.7 % between 1/6/23 and 2/5/23, 15 lbs., 9% between 1/6/23 and 2/7/23, and 17.2 lbs., 10.2% between 8/20/22 and 2/7/23 for Residents 48 were not implemented in a timely manner. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure food safety and sanitation guidelines were followed when: 1. The ice machine was not in sanitary condition, 2. Time Temperature Control for Safety Foods (TCS) (food that requires time and temperature to limit the growth of illness causing bacteria) were not handled safely, 3. Food was not stored safely, 4. Food preparation equipment was not cleaned or air dried, 5. Nonfood contact surfaces were not clean, and 6. One food preparation sink and one steamer did not have an air gap. These failures had the potential to cause food borne illnesses in a medically vulnerable population of 99 who received food prepared in the kitchen.

Inspectors wroteBased on interview and record review, the facility failed to ensure an effective Quality Assessment and performance Improvement (QAPI) plan was in place for identifying and responding to resident care concerns with a good faith effort, by implementing, monitoring, and evaluating action plans for weight loss, pressure ulcers, staffing and competency, and abuse. This failure had the potential to affect how the facility ensures care and services are delivered meet accepted standards of quality, identify problems and opportunities for improvement, and ensure progress toward correction or improvement was achieved and sustained.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one of six sampled residents, (Resident 303) received communication in a language that she could understand and verbalize needs in order to make informed care choices and decisions, when the resident only spoke Spanish and no interpreter services were used in the facility. This failure had the potential for the resident's needs and preferences not being met and the potential for complications of health status related to recent heart valve replacement and diabetes.

Inspectors wroteBased on interview and record review the facility failed to ensure resident complaints were acted upon timely and implement plans of action to correct the identified issues. This failure resulted in ongoing unresolved complaints.

Inspectors wroteBased on observation and interview, the facility failed to ensure the right to personal privacy for all residents who showered when there was no system for communicating when a shower was or was not in use without opening the door. This failure had the potential to cause distress for the residents and threaten their health and well-being.

Inspectors wroteBased on observation and interview, the facility failed to provide a clean, safe, comfortable and homelike environment for ten of ten sampled residents (Residents 10, 17, 21, 24, 29, 33, 51, 58, 300, and 302) when: 1. The walls were in disrepair in room [ROOM NUMBER]. 2. A screen was protruding from the window in room six. 3. Vertical blinds were broken in room [ROOM NUMBER]. 4. Screens were in disrepair with holes in rooms 24, 30, 32, 34, and 35. 5. A picture was not hung on the wall and a piece of furniture not assembled for Resident 24. This failure had the potential to allow pests to enter through the open windows and to create a visually unpleasant environment, both of which could have negatively impacted the residents' health and well-being.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure direct care and administrative staff reported allegations of staff to resident abuse to the mandated agencies for three of three sampled residents (Resident 63, 74 and 86). This had the potential to put all residents at risk for abuse from staff at the facility.

Inspectors wroteBased on interview and record review the facility failed to ensure allegations of staff to resident abuse were investigated and residents were protected during this process for three of three residents (Residents 63, 74 and 86). This put all residents at risk for staff to resident abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that six of six sampled residents (Residents 23, 29, 32, 33, 64, and 302), received assistance with activities of daily living to attain or maintain their independence when: 1. Routine grooming activities were not completed for Resident 32 and Resident 64. 2. Routine and scheduled showers were not completed for Residents 23, 29, 33 and 302. These failures had the potential to result in the residents feeling depressed with poor self-esteem, and had the potential to contribute to skin breakdown, infection, and negatively impact their ability to attain or maintain their highest practicable level of well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide sufficient staff to meet the individual care needs for 14 out of 20 sampled residents (Residents 63, 26, 10, 15, 250, 33, 29, 23, 302, 32, 64, 68, 57 and room [ROOM NUMBER]) when: 1. Insufficient nursing staff to answer call lights to provide care to dependent residents. This resulted in residents to feel angry and neglected. 2. Showers and nail care were not provided. This had the potential for changes in resident skin conditions not to be identified and to feel undignified. 3. Certified Nursing Assistants (CNAs) performing Activities of Daily Living (ADL,resident care) during meal tray delivery. This resulted in residents to feel frustrated, hungry and food was cold.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that Certified Nursing Aides (CNAs) are able to demonstrate competency in skills to follow the residents plan of care to meet their needs. This failure resulted in dependent residents not to receive nursing interventions to ensure their plan of care was implemented.

Inspectors wroteBased on interview and record review the facility failed to ensure performance reviews for four out of six Certified Nursing Assistants (CNA A, B ,C and D) were completed every 12 months. This had the potential for direct care staff not to provide quality of care and meet the needs of the residents.

Inspectors wroteBased on observation, interview, and facility policy and procedure review, the facility failed to ensure the menu was followed when: 1. The procedure to puree foods was not followed for eight of eight residents, 2. Correct portion sizes were not followed and 3. Gravy was not added per the menu. This failure had the potential to not meet the resident's nutritional needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide 1 of 6 Residents (Resident 150) the right to be treated with dignity and respect when his clothes were visibly soiled. This failure led to the lack of self-esteem, frustration, and loss of dignity for Resident 150.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the physician was informed of a change of condition for one of 21 sampled residents (Resident 48). This failure had the potential for Resident 48 to have a delay in care and treatment.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive and person-centered Care Plan for one of three sampled residents (Resident 8) when there was nothing included for depression. This failure had the potential for Resident 8's needs to go unmet which could have negatively impacted their health and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary care and services and devices to maintain or improve hearing difficulty, for one of one resident reviewed for communication-sensory (Resident 3). This failure had the potential for Resident 3 to not effectively communicate and express her needs, which potentially negatively affected her well-being and quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure two residents out of six sampled residents (Resident 302 and 303) were treated for pain in a timely manner by not identifying and reporting a new onset of pain. This failure resulted in altered mood, and the potential to cause a decline in health status and overall quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to accommodate seven out of out of 20 residents (Residents 10, 20, 24, 35, 36, 64, and 82) with preferred food preferences when dietary staff did not update or serve the dietary preferences the residents requested or tried to obtain an alternate. This failure created the potential for a lack of the variety in foods and flavors needed to encourage meal intakes, enhance resident's quality of life, and had the potential to contribute to weight loss.

Inspectors wroteBased on observation, interview and facility policy and procedure review, the facility failed to ensure the policy titled, Foods Brought by Family/Visitors' dated 3/2022, was implemented. These failures posed the risk of resident food brought to the facility from the outside not being handled in a safe manner which posed the risk of food borne illnesses.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three trash bin lids were tight fitting when one of three lids had a hole. This had the potential for an unsafe environment for the residents and visitors due to possible pest infestation and spread of diseases in the facility.