Brookside Care Center

Inspectors wroteBased on interview and record review, the facility failed to ensure that one of three resident's (Resident 1) drug regimen (a detailed plan for taking medication) was free from unnecessary drugs, failed to obtain informed consent (ICO -process where a doctor explains a mind-altering medication, its risks, and benefits, alternatives, ensuring the patient or legal guardian agrees freely before treatment) for the use psychotropic medication (mind altering drugs) prior to Resident 1 starting the medications, failed to monitor for adverse side effects (ASE -harmful, negative, unintended reactions caused by medication treatment) of multiple psychotropic medications with black box warnings (BBW -life threatening risks), and failed to assess, intervene, and transfer Resident 1 to an acute care setting (hospital) until the evening of 8/13/26 when a family member/responsible party (RP) insisted [...]

Inspectors wroteBased on interview and record review the facility failed to ensure the informed consent (ICO -when a resident or their legally authorized representative must agree, authorize, or be given the right to decline to take a prescribed mind-altering medication after being fully informed about its purpose, potential benefits, risks, and alternatives) for psychotropic medications (mind altering drugs that affect brain activities associated with mental processes, mood and behavior include the categories: antipsychotics, antidepressants, anti-anxiety, and hypnotics to sleep) included the risks, side effects, the benefits and/or the Black Box Warnings (BBW -the most serious type of warning the U.S. Food and Drug Administration can require on a medication label) for two of three sampled residents (Resident 1 and Resident 2). [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure safe and secure order communication among providers when medication orders were communicated via a text messaging system involving nursing staff's personal smart phone (a mobile phone that performs many of the functions of a computer, typically having a touchscreen and internet access) and the physician for one of three sampled residents (Resident 1) based on regulatory requirements on Protected Health Information (or PHI, any information in the medical record that can be used to identify an individual in the course of providing a health care services). This failure could violate residents' health information privacy and confidentiality.

Inspectors wroteBased on interview and record review, facility failed to ensure accurate documentation of resident's medical records for one of three sampled residents (Resident 2) when Resident 2's nurse's progress notes were not being recorded consistently documenting the monitoring of Resident 2's condition for a medication error which occurred on 7/17/26. This failure placed Resident 2 at risk of potential harm and unnoticed side effects from the medication error.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who resided at the facility since 2013 and was transferred to a General Acute Care Hospital (GACH) in 4/2026, was readmitted to the facility after Resident 1 was cleared by the GACH to return to the facility on 6/4/2026. This deficient practice resulted in Resident 1 remaining at the GACH after Resident 1 was deemed appropriate for discharge back to the facility resulting in Resident 1's temporary loss of residence and had the potential for negative psychosocial outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement person centered interventions to ensure the safety of one of three sampled residents (Resident 1) who was an elopement (when a resident leaves the facility or a safe area without authorization) risk when Resident 1 removed her wanderguard (a device that alerts the staff when a resident at risk of elopement approaches a monitored exit door), eloped from the facility on 7/4/26, and upon return to the facility did not have interventions in place to prevent another elopement. This failure had the potential to contribute to another elopement from the facility that could have caused Resident 1 injury or harm.

Inspectors wroteBased on interview, and record review, the facility failed to report an allegation of physical abuse immediately to the Department for 2 of 3 sampled residents (Resident 2 and Resident 3), when a resident-to-resident altercation involving Resident 2 and Resident 3 occurred on 6/16/26. This failure resulted in a delay in the Department's investigation of a physical abuse allegation and decreased the facility's potential to protect residents from physical and psychosocial harm.

Inspectors wroteBased on interview, and record review, the facility failed to provide routine and emergency drugs and biologicals for 1 of 3 sampled residents (Resident 1), when Resident 1 was prescribed Nitroglycerin (medicine to relieve chest pain) by her cardiologist (heart doctor) on 2/25/26, and it was not communicated to the facility's doctor until 3 days later. This failure resulted in a delay in ordering and having Resident 1's medication available. There was also a potential for a delayed medication administration that could result in unrelieved chest pain for Resident 1.

Inspectors wroteBased on interview and record review the facility failed to ensure one of four sampled residents (Resident 1) remained free from abuse (willful infliction of injury, and/or intimidation resulting in physical harm, pain or mental anguish) when Resident 2 hit Resident 1 with his cane. This failure caused Resident 1 to feel threatened and fearful for his safety while residing in the facility and had the potential to result in emotional distress and ongoing fear.

Inspectors wroteBased on interview and record review the facility failed to follow their discharge planning policy for one of four sampled Residents (Resident 1) when Resident 1's electronic health record (EHR) did not contain documentation of Resident 1's discharge goals and needs. This deficient practice had the potential to delay Resident 1's discharge and to not involve him in the planning process.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure activities of daily living (ADL, personal care tasks which include bathing, dressing, eating, and transferring in and out of bed) were provided to maintain proper hygiene for two of four sampled residents (Resident 1 and Resident 4) when: 1. Resident 1 and Resident 4's fingernails were untrimmed and soiled; and, 2. Resident 1 did not receive his scheduled shower. These failures had the potential for Resident 1 and Resident 4 to sustain injury and/or infection related to having long, unclean fingernails and had the potential to cause psychosocial distress due to the lack of hygiene.

Inspectors wroteBased on interview, and record review, the facility failed to hold a residents' monthly resident council meeting for a census of 88 residentswhen, the resident council meeting was not held for the months of February 2026 and March 2026. This failure resulted in not honoring the residents' rights to meet for the resident council meeting and had the potential for residents' not to have their grievances or other concerns being heard and resolved.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe environment for 5 of 26 sampled residents (Resident 17, Resident 44, Resident 54, Resident 63, and Resident 90) when:1. Resident 54's cabinet and closet were not in good repair and the sliding door was not functional as a door; and2. Resident 17, Resident 44, Resident 63, and Resident 90's sliding door was not functional as a door. These cumulative failures resulted in Resident 17, Resident 44, Resident 54, Resident 63, and Resident 90 a lack of a homelike environment and had the potential to negatively impact Resident 17, Resident 44, Resident 54, Resident 63, and Resident 90's psychosocial well-being.1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop, implement, and update comprehensive care plans (a dynamic, individualized, and multidisciplinary document outlining a resident's medical, functional, and psychosocial needs) for 5 of 26 sampled residents when:1. Resident 95's Enhanced Barrier Precautions (EBP, an infection control strategy used primarily to prevent the spread of multidrug-resistant organisms [MDROs, superbugs/bacteria that have developed resistance to multiple classes of antibiotics, making the infections harder to treat]) care plan intervention was not implemented;2. The care plan was not initiated for resident 62's oxygen therapy;3. Resident 111's low air loss mattress (LAL mattress, a specialized medical mattress designed to prevent and heal bedsores) intervention was not initiated; and4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement an adequate activities program for 4 of 26 sampled residents (Resident 5, Resident 49, Resident 69, and Resident 85) when:1. Resident 5's initial activity review was not completed,2. Resident 69 was not provided one-to-one activities,3. Resident 85 was not provided opportunities to attend group activities; and,4. Resident 49 did not receive his one to one activities services and there were no accessible activities offered for his visual impairment,These cumulative failures had the potential to negatively impact the psychosocial well-being for Resident 5, Resident 49, Resident 69, and Resident 85.

Inspectors wroteBased on observation, interview, and record reviews, the facility failed to provide food storage and preparation, as well as maintain kitchen equipment and food contact surfaces in accordance with professional standards for food safety for 85 residents when:1. A dietary staff was observed not wearing her hairnet properly while walking in the kitchen;2. Food preparation areas, and equipment were not kept clean per food safety standards;3. The rack above the stove was observed to be dusty;4. Three wet containers were observed stacked on top of each other in the clean area;5. An open container of yogurt stored in the walk-in refrigerator was observed without proper labeling; 6. The inside of the Walk-in freezer was observed with heavy frost built up; 7. The cleaning log for the ice machine was not consistently signed;8. The chute/slide inside the ice machine was observed visibly discolored; [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure safe infection prevention and control practices with resident census of 88 when:1. Resident 62's oxygen tubing was not properly kept when not in use.2. Enhanced Barrier Precautions (or EBP, an infection control measure designed to prevent the spread of infection) were not implemented for Resident 95. 3. Shared glucometer (a device that measures blood sugar) was not cleaned and sanitized based on standards of practice and manufacturer specifications for Resident 4, Resident 39 and Resident 50.4. Nursing staff handled the pills with bare hands during medication administration for Resident 13 and Resident 93.5. [...]

Inspectors wroteBased on interview and record review, the facility failed to inform and document an informed consent (a signed document requires healthcare providers to disclose risks, benefits, alternatives to ensure patients make educated decisions about their care or medication use) for use of trazodone (a mind altering medication used for sleep or depression) in 1 out of 5 residents (Resident 50) reviewed for unnecessary drug use. This failure could violate Resident 50's right to be aware of consequences (risks versus benefits) of using a mind-altering drug that could contribute to unwanted adverse effects.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide reasonable accommodation of resident needs for 1 of 26 sampled residents (Resident 85) when, Resident 85 was not provided with a wheelchair. This failure had the potential for Resident 85 to be at risk for emotional distress, feelings of isolation, and at risk for falls.

Inspectors wroteBased on interview and record review, the facility failed to ensure 1 of 26 sampled residents (Resident 68), remained free from abuse (verbal, mental, sexual, or physical abuse) when, Resident 95 hit Resident 68 on his head on 5/4/26. This failure caused Resident 68 to feel sad and fearful for his safety while residing in the facility and had the potential to result in emotional distress and ongoing fear.

Inspectors wroteBased on interview and record review, the facility failed to ensure that an as needed (PRN) psychotropic medication (any drug that affects brain activities associated with mental processes and behavior) was limited to 14 days for 1 of 26 sampled residents (Resident 12), when Resident's 12's PRN psychotropic medication did not have a stop date. This failure placed Resident 12 at risk of being chemically restrained (the use of any drug for discipline or that makes it more convenient for staff to care for a resident) due to ongoing psychotropic medication use without proper evaluation by the physician.

Inspectors wroteBased on interview and record review the facility failed to ensure an allegation of physical abuse was reported in a timely manner, within 2 hours to the department for 2 of 26 sampled residents when Resident 95 hit Resident 68 on 5/4/26 and it was not reported to the required entities until 5/5/26. This failure led to the delayed immediate protection of Resident 68 and delayed abuse investigation process. This failure had the potential to put Resident 68's psychosocial, physical health and safety at risk.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident assessments accurately reflected a resident's status for 2 out of 26 sampled residents (Resident 49 and Resident 29) when: Resident 49's quarterly Minimum Data Set (MDS - a standardized, federally mandated clinical assessment tool used to evaluate the health, functional capabilities, and care needs of all residents in nursing homes) assessment was not accurate, and The facility did not accurately document Resident 29's diagnosis in the electronic medical record and MDS database. These failures had the potential to negatively affect the care and services provided to Resident 49 and Resident 29, due to the inaccurate assessment of their strengths, needs, diagnosis, and health status and the of risk of not treating the residents accordingly based on resident's medical needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate care and services to promote healing and for the prevention of a pressure injury (a localized injury to the skin and/or underlying tissue because of prolonged pressure) for 4 of 8 sampled residents (Resident 105, 111, 64, and 4), when:Low-air loss mattress (LAL mattress, a mattress designed to prevent and treat pressure wounds that uses a continuous, gentle flow of air through a surface of tiny holes to reduce pressure helping to prevent and treat skin breakdown and pressure wounds) pump was not correctly adjusted according to the weight of Resident 105, Resident 64, and Resident 4. This deficient practice had the potential to delay wound healing and placed Resident 105, Resident 111, Resident 64, and Resident 4 at increased risk for developing pressure injury and/or skin breakdown. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate intake and output was recorded in the electronic health record (EHR) for one of 26 sampled residents (Resident 2) with an indwelling urinary catheter (a hollow tube inserted into the bladder to drain or collect urine). This failure had the potential to lead to late detection of fluid status abnormalities which could adversely affect Resident 2's health status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respiratory care provided was consistent with professional standards of practice for 1 of 16 sampled residents receiving respiratory treatment (Resident 29), when Resident 29's oxygen tubing was not dated and labeled to indicate when it was last changed. This failure had the potential to result in a negative impact on Resident 29's health and safety including risks for ineffective oxygen therapy, and respiratory distress.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the Emergency IV Kit (or IV-Ekit, a sealed container storing emergency intravenous [into the vein, or IV] medication and supplies) in the [NAME] station medication room was replaced in timely manner and communicated to the provider pharmacy after it was opened and used with census of 88 residents. This failed practice could contribute to unsafe medical care when IV medications were not available in a timely manner.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure safe medication administration practices when medication error rate was more than 5% (% or percentage- number or ratio that expressed as a fraction of 100) with the census of 88 residents. Medication administration observations were conducted over multiple days, at varied times, in random locations throughout the facility. The facility had a total of six errors out of 31 opportunities which resulted in a facility wide medication error rate of 19.35 % in five out of 16 residents (Resident 69, Resident 12, Resident 7, Resident 50, Resident 13) during medication administration observation as follows:1. Resident 69 was given a medication labeled as Senna-Plus (a combination of Senna and Docusate; a stool softer plus stimulant laxative) when the doctor's order was for Senna (stimulant laxative) only.2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of sixteen resident's (Resident 69) were free from medication errors when Resident 69's once-monthly drug called Ibandronate for osteoporosis (also called Boniva, a drug used to treat and prevent osteoporosis, a bone disease that weakens bones by decreasing bone mass and caused bone fracture) was administered more than once a month against manufacturer specification. This failed practice could compromise the safety of Resident 69 with over-exposure to a long-acting drug (drug that stays in the body for a long time) with adverse effects and outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure safe medication storage practices in the medication room and medication carts with resident census of 88 when: 1. The refrigerator in the medication room (a room that stores medications given to residents) at [NAME] Long station was heavily frosted where insulin and vaccines were stored. 2. The medication cart (a wheeled cart that stores medications given to residents on daily basis) in [NAME] Long station contained medications not dated upon opening. 3. The medication cart at East station contained medications not labeled with open date upon opening. These failures could result in unsafe medication storage and the risk of residents receiving ineffective or contaminated products.

Inspectors wroteBased on interview and record review, the facility failed to provide adequate physical therapy services to 1 of 26 sampled residents (Resident 49) when, Resident 49 who was visually impaired, was provided therapy services with a white cane (a tool used by people who are blind or visually impaired to scan the environment in front of them) instead of being provided an appropriate mobility device of a walking stick (a mobility tool used to help with balance and walking). This failure had the potential for Resident 49 not to attain, maintain, or restore his highest practicable level of physical function and well-being. This failure also presented an increased risk for falls for Resident 49.

Inspectors wroteBased on interview, and record review, the facility failed to implement an effective immunization program to offer, obtain informed consent and provide education to a resident or resident representative (RP) about the influenza (or flu, is a contagious viral infection of the respiratory system that can range from mild to severe, causing symptoms like fever, cough, sore throat, muscle aches, and fatigue) vaccine and pneumococcal (a serious bacterial infection that can cause respiratory illness) vaccine for three out of five sampled residents when:1. Resident 64, Resident 46, and Resident 96 were not offered the Influenza vaccine during the 2025- 2026 flu season; and,2. Resident 64 was not offered a Pneumonia vaccine. [...]

Inspectors wroteBased on interview, and record review, the facility failed to provide the COVID-19 vaccine, for one of five sampled residents (Resident 64), when there was no documentation in Resident 64's medical record that the COVID-19 vaccine was offered to the resident and the vaccine history (including previous administered COVID- 19 vaccines) was not obtained for Resident 64. This deficient practice placed Resident 64 at risk to be infected with the COVID-19 virus that could lead to severe illness, hospitalization, and/or death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a functioning call light system (system/device used by residents to call staff for assistance) was in place for 1 of 26 sampled residents (Resident 63) when Resident 63's call light was not working. This failure had the potential to result in Resident 63 being unable to call staff for help when needed and the resident's needs not being met.

Inspectors wroteBased on interview and record review the facility failed to arrange transportation to and from the office of an ophthalmologist (specialist in the treatment of vision) in the provision of an eye examination for 1 of 11 sampled Residents (Resident 1). This failure led Resident 1 to miss his initial ophthalmologist appointment and the potential for delayed treatment for Resident 1 could have resulted in a decline in health and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 out of 11 sampled residents (Resident 1) received proper foot treatment and care, when Resident 1 was not seen by a podiatrist (a specialist physician and surgeon who diagnoses and treats conditions affecting the foot, ankle, and lower leg) to prevent complications from his long and thickened toenails and nail avulsions (detachment of toenail from the bed) to some of his toenails. This failure had the potential for Resident 1 to sustain skin injury and/or to acquire an infection and not achieve his highest practicable well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed provide adequate supervision for one of seven sampled residents (Resident 1) when Resident 1 eloped from the facility through the non functioning alarmed front door and was missing from the facility for approximately 20 minutes and eventually located at a corner gas station. This failure to provide adequate supervision placed Resident 1 at risk for injury and psychosocial distress.

Inspectors wroteBased an observation, interview, and record review, the facility failed to ensure a resident's right to a quiet environment was maintained for one of three sampled residents (Resident 1) when Resident 1 could not get rest due to continuous noise from Resident 1's roommate from 2/26/26 through 3/4/26. This failure resulted in Resident 1's having sleepless nights that led to migraines (extreme headaches) and emotional and psychological distress.

Inspectors wroteBased on interviews and record reviews, the facility failed to protect, secure, and maintain personal belongings for one of three sampled residents (Resident 1) when Resident 1's black safe box (that contained valuables and collectibles) was not accounted for when Resident 1's belongings were transferred from another facility three days from admission. This failure resulted in Resident 1's black safe box missing and had caused her emotional distress for losing her valuables and collectibles.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) who was dependent on staff to carry out activities of daily living (ADLs, tasks of everyday life including eating, dressing, grooming, bathing, showering, and using the bathroom) received services to maintain personal hygiene, when Resident 1 was not provided with showers or bed baths as scheduled from 2/1/26 through 2/28/26. This failure had the potential to cause discomfort, skin impairment, infection, and a decline in emotional and psychological well-being.

Inspectors wroteBased on interviews and record reviews, the facility failed to provide needed care and treatment to two out of three sampled residents (Resident 1 and Resident 2) when:1. Resident 1 missed 2 scheduled appointments for a follow up order with the cardiologist within 2 weeks from discharge from the acute hospital and the follow up order was not transcribed into Resident 1's electronic file, and 2. Resident 2's attending physician was not notified of Resident 2's 3 consecutive days of poor intake either meal refusals or 0 to 25% consumed. These failures had the potential for Resident 1 not to receive required care in a timely manner and the potential for delayed treatment for Resident 2 that could lead to weight loss and could possibly result in a decline in health and well-being.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to implement measures to prevent the development and/or worsening of pressure ulcers/injuries (PU/PI, areas of damaged skin caused by staying in one position for too long, usually over an area on the body where a bone is close to the skin's surface) when:1. Resident 1's low air loss (LAL) mattress (a mattress designed to prevent and treat pressure ulcers/injuries in patients with limited mobility which uses an air-filled bladders that inflate/deflate to relieve pressure, combined with tiny holes that blow air to keep skin cool, dry, and moisture free) was not plugged to an emergency outlet when the power in her room was off; and,2. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure a resident was free from misappropriation of property for one of four sampled residents (Resident 1), when two facility staff members had accepted money from Resident 1 to buy food. This failure had placed the resident at risk for financial hardship which could eventually affect the psychosocial well-being of Resident 1.

Inspectors wroteBased on interview and record review the facility failed to implement effective interventions to keep two residents (Resident 1 and Resident 2), in a sample of eleven, who had a prior altercation in the facility's dining room on 1/1/26, apart to prevent further incidents. As a result, on 1/5/26 Resident 1 and Resident 2 were in the facility's dining room again when they got into a physical altercation and Resident 1 was transferred to the hospital due to his injuries and ultimately a different facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure Resident 1's rights to return to the facility were honored following a transfer to the emergency room due to a resident-to-resident altercation where Resident 1 was the victim when:1. Resident 1 was inappropriately discharged from the facility following an emergency room visit and admitted to a sister facility (a closely related, often co-owned or affiliated, location-frequently in senior living, healthcare, or industrial sectors-that share ownership, management, or services) on 1/6/26;2. Resident 1's reason for discharge did not meet the requirements which would allow for a facility-initiated discharge to occur; and3. Resident 1 was not provided with a bed hold notice and the facilities bed hold policy was not followed. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a notice of transfer/discharge to Resident 1 and the State Long-Term Care Ombudsman office (acts as an independent advocate for residents, protecting their health, safety, welfare, and rights) when, Resident 1 was transferred to the emergency room due to injuries as a result of a resident-to-resident altercation that occurred on 1/5/26 where Resident 1 was the victim and Resident 1 was then discharge from the facility while Resident 1 remained in the emergency room. Resident 1 was admitted to a sister facility (a closely related, often co-owned or affiliated, location-frequently in senior living, healthcare, or industrial sectors-that share ownership, management, or services) after being discharged from the emergency room on 1/6/26. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure an allegation of employee-to-resident physical abuse was reported by the facility for one of three sampled residents (Resident 1) when on 11/17/25, the facility failed to report Resident 1's allegation of physical abuse by a Licensed Nurse to the state agency. This failure resulted in a delayed abuse investigation and had the potential to affect Resident 1's physical and psychosocial well-being.

Inspectors wroteBased on interview and record review the facility failed to ensure an allegation of employee-to-resident physical abuse was thoroughly investigated by the facility in a timely manner when on 11/17/25, the facility did not fully investigate an allegation of abuse to Resident 1. This failure resulted in a delayed facility abuse investigation and had the potential to affect Resident 1's physical and psychosocial well-being.

Inspectors wroteBased on interview, and record review, the facility failed to protect one of four sampled residents (Resident 1) from misappropriation (the unauthorized use of funds or other property for purposes other than that for which intended) of property and personal belongings, when Resident 1's cell phone went missing while he was hospitalized .This failure caused Resident 1 emotional distress and had the potential for loss and theft for other residents' property while residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to implement its written abuse policies and procedures when staff did not follow the required steps for responding to and reporting a documented allegation of resident-to-resident abuse after Resident 1 reported that Resident 2 threw objects, including cups and utensils, toward Resident 1. This failure left Resident 1 and Resident 2 without required protective interventions and placed them at risk for psychosocial harm. [...]

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of resident-to-resident abuse incident to the Department within the required timeframe when Resident 1 reported that Resident 2 was throwing objects, including cups and utensils toward Resident 1. This failure left Resident 1 and Resident 2 without required protective interventions and placed them at risk for psychosocial (internal cognitive aspects of a person's life and how they interact with those around them) harm. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) was provided with an environment free from accident hazards when certified nursing assistant (CNA) 1 provided care to Resident 1 alone, but based on Resident 1's assessed needs required two staff members, and Resident 1 had an air mattress (a mattress that works by using air chambers that redistribute pressure, improve blood flow, and reduce friction for residents with limited mobility) placed on his bed without a physician's order or monitors in place to ensure the correct settings were maintained. These failures resulted in Resident 1 falling from his bed and sustaining a broken bone in his right big toe on 9/25/25.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide respiratory care (the diagnosis, treatment, and management of residents with breathing or other cardiopulmonary (heart and lung) disorders) consistent with professional standards of practice for two of two sampled residents (Resident 1 and Resident 2) with a tracheostomy (an opening surgically created through the neck into the trachea (windpipe) to allow air to fill the lungs) when: 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a clean and sanitary kitchen environment when:1. Spoiled grapes were available for resident consumption; and,2. Water from a floor sink (a drain in the floor that dirty water flows into) overflowed into the walk-in refrigerator; and,3. The resident refrigerator/freezer was not clean, contained outdated items, contained staff lunch bags and undated food containers, and was not monitored for temperature. 1. During an interview with Resident 4, on 8/5/25, at 2:22 PM, Resident 4 stated when she had asked for fresh fruit, she had been given a bag of 'rotten grapes'.During a concurrent observation and interview, on 8/6/25, at 11 AM, with the Dietary Manager (DM), in the walk-in refrigerator, three bags of grapes were observed to be in a box dated 7/14/25. [...]

Inspectors wroteBased on observation and interview the facility failed to ensure outside garbage bins were kept covered. This failure could have been a contributing factor in the facility harboring pests (cockroaches, flies, ants) with the potential to negatively impact the health and well-being of residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the kitchen oven was in good working order when the right oven door was hanging open and could not be closed. This failure had the potential to delay meal service and have hot foods not maintained at a safe food temperature (Hot food should be kept at 140 degrees Fahrenheit ( F - unit of measurement) or above to avoid rapid bacteria (germs) growth, which could negatively affect the health of 87 residents who received food from the kitchen. During an observation on 8/6/25, at 11:40 AM, in the kitchen, the right-side door of a double oven was hanging open and the right-side door of the oven was not attached to the oven. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were administered within professional standards of practice, to one resident (Resident 4) in a sample of four, when Resident 4's medications were left at her bedside. This failure had the potential for Resident 4 not taking her medications and/or another resident taking Resident 4's medication, negatively impacting the resident's health and well-being.

Inspectors wroteBased on observation and interview, the facility failed to ensure one of four sampled residents (Resident 4) received food that was safe and at an appetizing temperature when Resident 4's lunch meal on 8/7/25 was served cold and Resident 4's cold drink was served warm. This failure had the potential for Resident 4 to not obtain her nutritional requirements due to unpalatable food, negatively affecting Resident 4's health and well-being.

Inspectors wroteBased on interview, and record review, the facility failed to ensure they had the capability to provide a specific respiratory care need prior to admitting one of three sampled residents (Resident 1) with a tracheostomy (a surgical procedure that creates an opening in the trachea (windpipe) to allow air to enter the lungs) when, the facility was not able provide cool aerosol mist (provides humidity to the airway to prevent airway secretions from drying out because a tracheostomy bypasses the natural humidifying and warming functions of the nose and mouth, potentially leading to dry, thick secretions that can obstruct the airway) to Resident 1 upon admission and readmission to the facility. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents' rights to be treated with dignity were honored for 1 of 3 sampled residents (Resident 1) when Resident 1 was not offered to wear her own clothing. This failure had the potential to negatively impact Resident 1's psychosocial well-being.

Inspectors wroteBased on interview, and record review, the facility failed to document and investigate the grievances for one resident (Resident 1) with a facility census of 98, regarding her care concerns. This failure had the potential for Resident 1's care concerns to not be honored and addressed timely.

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) received treatment and care in accordance with professional standards of practice when:1. There was no follow up for Resident 1's appointment with a neurology specialist (specialty doctor who specialized in diagnosing and treating diseases and disorders of brain, spinal cord, nerves, and muscles); and,2. A care plan was not initiated for Resident 1's diagnosis of polyneuropathy (a general term for peripheral nerves system disorders that impact nerve function in multiple areas of the body. Symptoms can include pain, a pins-and-needles sensation, numbness, and weakness). These failures had the potential to result in a worsening nerve condition and/or other serious medical complications including a delay in care without proper interventions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were available for administration for 1 of the 3 sampled residents (Resident 1), when anxiety medication was not available for Resident 1. This failure had the potential to negatively impact Resident 1's health and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to distribute and serve food in accordance with professional standards for food safety for 1 of the 3 sampled residents (Resident 1) when:1. The lunch tray did not contain a dietary ticket/identifier; and,2. The drink on the tray did not match the tray ticket. These failures had the potential to place Resident 1 health at risk for consuming the wrong diet.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one out of three residents (Resident 1) who were at risk for wandering/elopement received adequate supervision to prevent an elopement (when a resident leaves the facility without supervision) from occurring, when Resident 1 eloped from the facility for the third time on 5/23/25 (Resident 1 had previously eloped from facility on 5/15/25 and 5/20/25). This failure led to Resident 1's elopement on 05/23/25 resulting in a four-day absence, and subsequent hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe and hazard free environment when one of two resident lift devices (a resident lift device used by caregivers to safely transfer residents) wheels were not locked. This failure placed a resident census of 93 and staff at risk for injury.

Inspectors wroteBased on interview, and record review, the facility failed to provide a copy of written Notice of Transfer/ Discharge to the appropriate parties for one of one sampled resident (Resident 1), when the Long Term Care (LTC) Ombudsman (a patient rights advocate) was not notified in writing of Resident 1's transfer to the acute care hospital on 1/9/25. This failure resulted in the State LTC Ombudsman not being informed of Resident 1's transfer and removed the opportunity for the State LTC Ombudsman to advocate on Resident 1's behalf.

Inspectors wroteBased on observation, interview, and record review, the facility failed to re-admit one of one sampled resident (Resident 1), when Resident 1 was transferred to an acute care hospital on 1/9/25 and was ready to return to the facility on 1/13/25. This failure resulted in a violation of Resident 1's right to return to the facility and had the potential to cause psychosocial harm due to not being able to return to the facility.

Inspectors wrote2. During a review of Resident 48's clinical record titled, admission RECORD, indicated Resident 48's diagnosis included hearing loss. During a concurrent observation and interview on 1/28/25, at 8:39 AM, with LN 8, Resident 48 was in her room and there was a whiteboard (writing board) on her nightstand approximately three feet from her bed and not within reaching distance. There was no whiteboard marker in the room. LN 8 stated Resident 48 was deaf (unable to hear) and mute (unable to speak); however, Resident 48 pointed at objects and wrote on her whiteboard in order to make her needs known. LN 8 stated he thought Resident 48 had a marker at her bedside and left the room and retrieved a whiteboard marker. Resident 48 wrote a sentence on the white board, but the handwriting was not discernable. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an ongoing activity program that was resident centered for 2 of 27 sampled residents (Resident 23 and Resident 54) when: 1. Person-centered activities were not provided for Resident 23 while on contact precautions (set of steps to prevent the spread of illnesses that can be transmitted by direct or indirect contact) isolation; and, 2. Person-centered activities were not provided for Resident 54 who preferred to remain in his room. These failures had the potential to negatively impact Resident 23's and Resident 54's physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from accidents and hazards when: 1. One of two sampled residents (Resident 43) who were at risk for elopement (leave the facility or a safe area without the facility's knowledge and supervision), did not have an effective plan of care was in place to protect Resident 43 from elopement, 2. The facility did not ensure the lint traps were clean in 2 out of 2 dryers; and, 3. The facility did not ensure 1 of 27 sampled residents (Resident 45)'s sliding door was operational. These failures could have resulted in injury such as falls, burns, or inability to exit a room.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure direct care staffing information was posted as required for a census of 92. This failure prevented the residents and visitors from viewing the hours and number of direct care staff providing care to the residents of the facility daily.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and distributed in accordance with professional standards for food service safety for 85 out of a census of 92 residents who ate facility prepared meals when: 1. Several containers of spices had lids left open, 2. Expired food item was not removed from the dry storage area, 3. Kitchen staff did not wear gloves while preparing ready to eat food, 4. Kitchen staff did not perform hand hygiene when moving from dirty to clean surfaces, 5. Appropriate measuring utensil was not used during food distribution; and, 6. Chopping boards were not color-coded to indicate different food items for a specific color. These failures placed residents at risk for foodborne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and effective infection prevention practices with a resident census of 92 when: 1. The facility's policy on Enhanced Barriers Precaution (or EBT, an infection control measures used to prevent the spread of disease and required the caregivers wear gowns and gloves during high-contact care activities) and use of protective gown (Protective gear worn to reduce exposure of germs to resident and prevents the spread) was not followed in one out of six residents (Resident 76) observed for medication administration during a high contact ( involves significant physical contact) resident care activity when the Feeding Tube (or FT, also known as enteral nutrition, where a tube was inserted into the stomach to provide nourishment, fluids or medications to a patients unable to take by mouth) was accessed to [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 2 of 27 sampled residents (Resident 66 and Resident 87) were provided a home-like environment when: 1. Resident 66's bed mattress had tears in the plastic barrier and the bed sloped to the left side; and, 2. Resident 87's bathroom had stool and urine on the toilet seat, toilet paper on the bathroom floor, and a non-operational soap dispenser in the bathroom. These failures led to an uncomfortable sleeping environment for Resident 66 and Resident 87's bathroom was not clean enough to utilize.

Inspectors wroteBased on observation, interview, and record review, the facility failed to report an allegation of stolen property when Resident 40 reported his suspicion that 2 facility staff members had stolen his money. These failures resulted in a delay of the state survey agency investigating the allegations of abuse, which had the potential to put residents' psychosocial and physical health and safety at risk.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 of 27 sampled residents' (Resident 48) assessment was completed accurately to identify her hearing and speech disability. This failure could have resulted in Resident 48 not receiving the needed services and communication aids to effectively make her needs known and could have resulted in a decrease in quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe cleaning and sanitization of shared glucometer (a device used to measure blood sugar) in-between resident care on one out of six residents (Resident 30) observed for medication administration based on the facility's policy and manufacturer specifications. This failure had potential to spread infection among residents and compromise resident's well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide quality care for 1 of 27 residents (Resident 56) when Resident 56's physician orders for cardiology (medical specialty that focuses on the heart), urology (medical specialty that focuses on urinary tract or organs that produce urine), psychiatry consults, and neurology (medical specialty that focuses on conditions of the brain, spine and nerves) referral were not addressed. These failures could contribute to health concerns not being addressed and could lead to adverse events for Resident 56.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of seven residents (Resident 76) was provided with appropriate care and services with enteral feeding (also referred to as G-Tube feeding-gastrostomy tube feeding, the delivery of food and nutrients through a feeding tube directly into the stomach or part of the intestines) when: 1. The enteral feeding formula container did not have a stop time and a re-start time labeled on the bottle; and, 2. The water flush bag was not labeled with Resident 76's name, room number, date, time started and stopped, the administration rate, and initials of the nurse. These failures had the potential for Resident 76 to not receive adequate enteral nutrition and proper hydration and to not receive the correct water flush bag.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and timely medication acquisition, handling, use, and disposition (destruction of unused medications) with a resident census of 92 when: 1. Non-controlled prescription medication (medications prescribed by a doctor and not an opioid) destruction logs were either not signed or not co-signed by licensed nurses in the destruction medication binder in one of two nurse's stations (East nurse station); and, 2. Resident 45's and Resident 83's prescribed medications were not available and not refilled (process of obtaining additional medication) in a timely manner leading to missed doses. These failed practices led to the residents not receiving prescribed medications as a result of unavailability and delay in the refill process, and potential for medication diversion.

Inspectors wrote3. Review of Resident 56's electronic medical record titled, admission RECORD, indicated, Resident 56 was admitted to the facility during February of 2022, with a diagnoses including but not limited to post-traumatic stress disorder (PTSD, when a person's past experience cause emotional problems on their daily life), anxiety disorder (excessive fear or worry about a specific situation), major depressive disorder (affects how you feel, think and behave and can lead to a variety of emotional and physical problems), and insomnia (inability to sleep) among others. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe medication administration practices when the medication error rate was more than 5% (% or percentage- number or ratio that expressed as a fraction of 100) with a resident census of 92. Medication administration observations were conducted over multiple days, at varied times, in random locations throughout the facility. The facility had a total of five errors out of 35 opportunities which resulted in a facility wide medication error rate of 14.29% in 3 out of 6 residents (Resident 17, Resident 5, and Resident 76) were observed for medication administration. These failures may result in unsafe medications use affecting residents' health and well-being.

Inspectors wroteBased on interview, and record review, the facility failed to maintain accurate medical records for 2 of 27 sampled residents in accordance with accepted professional standards and practices when Protected Health Information (PHI - any information that can be used to identify a person and is related to their health including any information about a person's physical or mental health, treatment, and payment for healthcare) of another resident was found in Resident 40's and Resident 43's Electronic Medical Record. These failures had the potential to violate the safeguarding of residents' health information, privacy, and confidentiality.

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of three sampled residents' (Resident 2) personal funds were protected when the facility filled out documentation to receive Resident 2's Social Security without Resident 2's knowledge and consent. This failure had the risk of financial insecurity and psychosocial harm to Resident 2.

Inspectors wroteBased on interview, and record review, the facility failed to safeguard and take reasonable care of one discharged resident's (Resident 1) personal property when Resident 1's personal property was given to Family Member (FM) 1 without Resident 1's knowledge, and without requiring FM 1 to sign for the property on Resident 1's inventory sheet (a list used to track what personal items come in and out of the facility). This failure resulted in Resident 1 in not receiving his personal property and the risk for negatively impacting Resident 1's psychosocial well-being.

Inspectors wroteBased on observation and interview, the facility failed to maintain a homelike environment when seven Resident rooms were dirty and unkept. These failures had the potential to negatively impact the residents' feelings of self-worth and self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the privacy of one of ten sampled residents (Resident 8) during wound care. This failure resulted in Resident 8 being exposed during wound care to anyone walking by his room, denying Resident 8's right to privacy and dignity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain its infection prevention control program when infection control practices, including Enhanced Barrier Precautions (EBP-a set of measures used to prevent the spread of infection) were not maintained during wound care for one of ten sampled residents (Resident 8). This failure had the potential for cross-contamination (the transfer of harmful bacteria, parasites, or viruses from one person, object, or place to another) to Resident 8 and to residents residing in the facility, negatively impacting their health and well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure Resident 2 ' s rights were protected when, a. Resident 2 left the facility in the morning of 9/1/24, and upon his return in the afternoon, he was not allowed to enter the facility; b. The facility told Resident 2 he left AMA (choosing to leave against medical advice), but did not provide Resident 2 an explanation, a copy of the AMA form, or notify Adult Protective Services (APS, provides emergency intervention for vulnerable dependent adults and seniors) per their policy; and, c. Resident 2 was hospitalized on [DATE], and the hospital attempted to transfer him back to the facility on 9/2/24, but the facility refused to allow him to return. [...]

Inspectors wroteBased on interview, and record review, the facility failed to report a change of condition (COC- a change in the resident's normal physical, mental, or behavioral state) for one of two sampled residents (Resident 1) to the physician when Resident 1 had a weight loss of 6 lbs. (pound- a unit for measuring weight) on 8/6/24. This failure had the potential for a delay in staff intervention and care and to cause a decline in function in Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure activities of daily living (ADL- essential self-care tasks related to personal care such as dressing, eating, bathing, grooming, and toileting) were provided to maintain good hygiene for one of two sampled residents (Resident 1) when: 1) Resident 1's shirt was dirty with multiple stains; and, 2) Resident 1's hair was tangled and not brushed. This failure resulted in Resident 1 not being well groomed, and had the potential to cause psychosocial distress.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 1) received respiratory care according to professional standards when Resident 1's oxygen order was not followed. This failure placed Resident 1 at risk for respiratory distress and inadequate medical treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet food storage and food service practices that met professional standards for food service safety when: 1) Kitchen staff did not consistently use a beard guard while in the kitchen, 2) Food not consistently labeled appropriately, 3) Expired foods were not discarded, 4) Refrigerated and frozen food was not consistently covered, 5) Ice build-up was found around the freezer door and fans, 6) Grime and debris was found on kitchen equipment, 7) Kitchen had multiple walls with large areas of chipped paint showing dry wall, rusted equipment, and corroded metal surfaces, 8) Dishwasher gauge was not consistently showing wash temperature; and, 9) Resident refrigerator with food items was not consistently labeled. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 6 of 23 sampled residents (Resident 143, Resident 9, Resident 89, Resident 67, Resident 81, Resident 65) and one unsampled resident (Resident 61) had their call lights within reach per facility policy. This failure had the potential to allow for unmet needs of the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a resident specific care plan (provides direction on the type of nursing care the resident may need based on their health, medication, mental, and or psychosocial needs) for 4 of 23 sampled residents (Resident 9, Resident 63, Resident 67, and Resident 89) when: 1. Resident 63 had no smoking care plan, 2. Resident 9 and Resident 89 had no communication care plan; and, 3. Resident 67's communication care plan intervention of a communication board was not implemented. These failures placed the residents at risk to not have appropriate, consistent, and individualized care to meet their needs and provide for their safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 3 of 23 sampled residents (Resident 63, Resident 294, and Resident 22) were assisted with their Activities of Daily Living (ADLs- normal daily functions required to meet basic needs) when: 1.) Resident 63 and Resident 294 had long fingernails with dirty substances underneath the fingernails; and, 2.) Resident 294 did not receive showers since admission, and Resident 22 did not receive showers for 2 weeks. These failures had the potential to result in Resident 63, Resident 294, and Resident 22's poor personal hygiene, low self-esteem, psychosocial decline, and risk for infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an environment was free of hazards for a census of 91 when the Maintenance Director (MD) did not use a dial stem thermometer (a metal pointer on a circular scale to indicate temperature measurements) to measure and check the temperature of the hot water in residents' rooms. This failure had the potential to affect all residents' safety and to cause skin burns.

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote dignity and respect for 1 of 23 sampled residents (Resident 295) when Resident 295's indwelling urinary catheter (a tube inserted into the bladder to drain or collect urine) bag was not covered with a privacy bag. This failure had the potential to cause Resident 295 to feel demeaned and disrespected.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a homelike environment for 1 of 23 sampled residents (Resident 55) when Resident 55's room light did not work. This failure violated Resident 55's right to a homelike environment and had potential to negatively impact Resident 55's psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of the twenty-three sampled residents (Resident 57) received care which met professional standards when Resident 57 received her morning medications without staff identifying and explaining what those medications were for. This failure had the potential for Resident 57 of not knowing what medications she took and its indication for use.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate services necessary to ensure 3 of 23 sampled residents' (Resident 9, Resident 89, and Resident 67) communication abilities including language did not diminish when there was no interpretation services available in the facility for non-English speaking residents. This failure allowed for a lack of communication between the residents and staff which could lead to unmet needs of the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet the interests and support the physical, mental, and psychosocial needs for one of twenty-three sampled residents (Resident 37) when in-room activities were not provided for Resident 37 who preferred to remain in her room. This failure had the potential to affect the psychosocial needs and wellbeing of Resident 37.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received the proper assistive device to maintain vision function for 1 of 23 sampled residents (Resident 59) when Resident 59 did not receive an ophthalmologist (a physician specializing in medical and surgical diagnosis and treatment of eye disorders) referral consultation to obtain a pair of eye glasses. This failure resulted in a delay of services for Resident 59 and placed Resident 59 at risk for impaired psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received proper foot care when 1 of 23 sampled residents (Resident 59) did not receive podiatry (the medical care and treatment of the human foot) services. This failure had the potential to affect Resident 59's foot health contributing to injury and/or infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe medication storage practices for one out of two medication rooms (a locked room for storage of prescription, non-prescription and controlled medications) and two out of four medication carts (mobile cart that stored resident's medication and supplies) with a census of 97 when expired (outdated) medications were stored in medication carts, and hazardous (drugs that pose short-or long-term harm upon exposure to human via skin or inhalation) medications were not safely stored and labeled as hazardous. These unsafe medication storage practices could contribute to medication error and unsafe medication use.

Inspectors wroteBased on interview, and record review, the facility failed to ensure pneumococcal vaccination (infection caused by a bacteria immunization status) was obtained, offered, and/or facility provided vaccination education for one of five sampled residents (Resident 65) when Resident 65 had no record of a pneumococcal vaccination on file. This failure increased the risk of Resident 65 to acquire, transmit, or experience complications from pneumococcal disease.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a clean and comfortable environment for a census of 90 residents living in the facility, when: 1. Resident 1 had a bed without a mattress stored in her room, 18 inches from her bed; 2. room [ROOM NUMBER] had gouges on the wall and black colored substance on the floor and the wall, and extended a quarter of the way up the wall; 3. Resident 4's room had a non-functioning toilet in the bathroom that was filled with feces and had a strong odor; 4. room [ROOM NUMBER] had an overbed table that was dirty with white debris and other miscellaneous debris; 5. The east long shower had dirty floors, black substances in the corners and along where the walls met, and a pink substance which extended up approximately 4 inches from floors; and, 6. The facility carpets were stained. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure garbage and refuse was disposed of properly when three large garbage bins were left open, and two garbage bags were broken open on the ground with garbage and refuse in the surrounding area, for a census of 90 residents. These failures had the potential to attract rodents and pests to the garbage bins and facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure 1 of 12 sampled residents (Resident 4) received vision services in a timely manner when Resident 4's referral to an ophthalmologist (a doctor who specializes in vision care) was not made. This failure resulted in Resident 4 not receiving services to address her sight loss and resulted in Resident 4 feeling anxious about her vision.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide oxygen therapy consistent with professional standards of practice when: Resident 2 did not receive oxygen per physician orders. This failure resulted in Resident 2's oxygen requirements not being met and had the potential to negatively affect his health and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide 1 of 12 sampled residents (Resident 4) a room equipped with a bathroom, or quick access to bathroom facilities, when Resident 4 ' s toilet was out of order for 10 days. This failure increased the risk of urinary tract infection or constipation for Resident 4. During a concurrent observation and interview with Resident 4, in Resident 4's room, on 12/1/23, at 9:45 AM, Resident 4's bathroom was noted to have a handwritten sign on the door which indicated, This Bathroom is Out of Order Pls [please] Do not open. Resident 4 stated she placed the sign on the door herself. When the door was opened there was a strong smell of feces in the bathroom. When the toilet lid was opened the smell became overpowering. The toilet was filled with feces. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe and functional environment for 1 of 12 sampled residents (Resident 12) when Resident 12's television was taped to small entertainment center for stability. This failure had the potential to result in injury to residents, staff, and visitors entering Resident 12's room.