Buena Vista Care Center

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to protect Resident 1's right to be free from physical abuse by another Resident (Resident 2), for one of three sampled residents reviewed for abuse. * During resident activities, a facility staff member witnessed Resident 2 hit Resident 1 on the chin, with a clenched fist. This failure to prevent physical abuse had the potential to result in serious injury and/or psychosocial harm to Resident 1.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to thoroughly investigate an allegation of resident-to-resident physical abuse, for two of three residents (Residents 1 and 2) reviewed for abuse. * The facility failed to interview other residents present at the time of a physical altercation between Residents 1 and 2. The failure to interview all potential witnesses to an allegation of resident-to-resident physical abuse potentially inhibited the facility's ability to determine if resident abuse occurred and posed the risk for further abuse.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the food safety and sanitation requirements were met in the kitchen. * The facility failed to ensure the kitchen equipment was kept in sanitary condition. * The facility failed to ensure the kitchen equipment was cleaned properly. * The facility failed to ensure the hair restraints were worn. These failures had the potential to pose the risk for exposure to food-borne illnesses in a medically vulnerable population of 87 residents who received food prepared in the kitchen.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to maintain the infection control practices to help prevent the development and transmission of diseases and infection. * The facility's Infection Prevention and Control Surveillance Logs for 2025 were incomplete and inaccurate. * The facility's Infection Control Committee Meeting Minutes and data presented were inaccurate for 2025. * LVN 4 failed to ensure the GT syringe was properly cleaned prior to storage. * The facility failed to ensure N95 masks stored in Medication Cart C were not expired. * LVN 1 failed to perform hand hygiene during the blood glucose check monitoring for Residents 64 and 77. Additionally, LVN 3 failed to perform hand hygiene during the blood glucose check monitoring for Residents 1 and 43. [...]

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to follow up with the physician regarding the residents on the antibiotic therapy who did not have true infections based on the McGeer's criteria listed in the Infection Prevention and Control Surveillance Logs for 2025 and for three nonsampled residents (Residents 46, 47, and 65) * Residents 46, 47, and 65's physicians' were not notified to reevaluate their antibiotics when their infections did not meet the McGeer's criteria. In addition, the facility's Infection Prevention and Control Surveillance Logs were incomplete and failed to show the dates/times when the IP followed up with the physicians for other residents who were prescribed antibiotics whose infections did not meet the McGeer's criteria. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the residents were free from unnecessary psychotropic drugs for one final sampled resident (Resident 2) and two nonsampled residents (Residents 5 and 7) reviewed for unnecessary medications. * The facility failed to document the nonpharmacological interventions to be attempted prior to administering Resident 2's alprazolam (antianxiety) medication. * The facility failed to document the nonpharmacological interventions to be attempted prior to administering Resident 5's trazodone medication. * The facility failed to implement the nonpharmacological interventions prior to administering the trazodone (antidepressant medication) to Resident 7. [...]

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to develop the resident-centered care plans to reflect the individual care needs of two of 19 final sampled residents (Residents 8 and 52). * The facility failed to develop a care plan for a new diagnosis of a UTI [a common bacterial infection in the urinary system (kidneys, bladder, ureters, urethra)] for Resident 8 when the resident returned from the acute care hospital. * The facility failed to develop a comprehensive individualized care plan to address Resident 52's weight loss of 21 lbs. in six months. These failures posed the risk of not providing appropriate and individualized care to Residents 8 and 52 to meet their highest practicable mental health and well-being.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to provide the individualized and ongoing activity program to meet the needs and interests of one of three final sampled residents (Resident 67) reviewed for activities. * The facility failed to provide room visits for Resident 67 as per the activities plan of care. This failure had the potential for the resident to experience feelings of social isolation.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the quality care and services were provided for one final sampled resident (Resident 64) and two nonsampled residents (Residents 66 and 77) observed for blood glucose monitoring. * LVN 1 failed to discard the first drop of blood during the blood glucose check for Residents 64, 66 and 77. * LVN 1 failed to rotate the injection site when administering the insulin (medication to help lower blood sugar) to Resident 64. These failures had the potential for the residents not to receive the necessary care and services to maintain their highest physical well-being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent the development or worsening of pressure injuries (damage to the skin and underlying tissue from prolonged pressure, often over bony areas) for one of two final sampled residents (Resident 69) reviewed for pressure injuries. * The facility failed to ensure Resident 69 had weekly assessments documented for a Stage 2 pressure injury (partial-thickness skin loss where the epidermis and part of the dermis are damaged) to the coccyx. This had the potential for Resident 69's Stage 2 pressure injury to worsen and not provided appropriate care.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the necessary care and services were provided for one of one final sampled resident (Resident 1) reviewed for accident hazards. * The facility failed to timely monitor and document the neurological assessments for Resident 1's unwitnessed fall incident on 5/1/25. This failure had the potential to place the resident at risk for serious injury.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the pharmaceutical services to ensure accurate reconciliation and administration of the medications. * The facility failed to ensure the oral and IV emergency medication kits were replaced timely. * The facility failed to ensure the administration of the controlled medications for Residents 53 and 81 were documented in the MAR. * LVN 4 failed to administer the full dose of the cranberry supplement via GT for Resident 2. These failures had the potential for diversion of the controlled medication, medication administration error, and negative residents outcomes.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 23.08% (for six medication errors out of 26 total opportunities). One of six licensed nurses (LVN 4) who were observed during medication administration was found to have errors. * LVN 4 failed to ensure all the medication residual was administered via GT to Resident 2 for six of 14 medications administered. This failure had the risk for the resident to have potential side effects or complications related to the medications.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure food served was palatable, attractive, and at a safe and appetizing temperature for two of 87 Residents (Residents 53 and 81) who received food prepared in the kitchen. * Resident 53 and 81's meals were delivered and served cold. * Resident 53's beef was tough to cut with a knife and difficult to chew. These failures had the potential for decreased meal intake which could result in weight loss, decreased nutritive value, and negatively impact the residents' quality of life for all 87 residents who received food prepared in the kitchen.

Inspectors wroteBased on observation, interview, facility P&P review, and document review, the facility failed to ensure the facility's P&P on Foods Brought by Family/Visitors was followed. * The facility failed to ensure the safe food handling practices of outside food were explained to family/visitors in a language and format they understood. This failure had the potential to cause foodborne illness to the medically vulnerable resident population who consumed food [NAME] from outside resources.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to maintain the essential equipment in a clean, sanitary, and safe operating condition for one of two washing machines inspected (Washing Machine 1). * Washing Machine 1 was observed with dark red, green, and white build up on the inner door window. In addition, the rubber lining of the inside of the washing machine door was observed with thick brown and white build up. These failures had the potential for the essential equipment to not function in the way it was intended and expose the residents to unsafe practices.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to facilitate the resident's preferences and choices for shaving for one of 19 final sampled residents (Resident 41). * The facility failed to assist Resident 41 with her hygiene preferences in regard to shaving her facial hair and underarms. This failure posed the risk of the resident not being able to choose their hygiene preferences.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medical record for two of 19 final sampled residents (Residents 9 and 13) were complete and accurately documented. * The facility failed to ensure Resident 9's blood pressure (BP) access site was accurately documented in the resident's medical record. *The facility failed to ensure Resident 13's POLST Section D was completed and the social services' documentation was accurate. These failures had the potential for the residents' care needs not being met as their medical information was inaccurate.

Inspectors wroteBased on interview, facility document review, and facility P&P review, the facility failed to conduct a thorough abuse investigation for one of five sampled residents (Resident 1) as evidenced by: * The facility did not interview the other resident, Resident 3 who was mentioned on interview to have caused distress to Resident 1. This failure posed the risk of not identifying if other residents were affected by the reported abuse allegation.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to maintain the highest physical well-being for one of five sampled residents (Resident 5). * The facility failed to provide the wound care treatments for Resident 5's left foot wounds as ordered by the physician. This failure had the potential for Resident 5 to not receive the appropriate care and services to treat his left foot wounds.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of three sampled residents (Resident 3) remained free from the accident hazards. * The facility failed to implement the bilateral floor mats as per the physician's order and plan of care for Resident 3 who was a high risk for falls and had a history of falls with injuries. This failure had the potential to place Resident 3 at risk for serious injury.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the appropriate pain management was provided for one of three sampled residents (Resident 2). * The facility failed to ensure Resident 2 was consistently provided the non-pharmacological pain interventions prior to the administration of acetaminophen (analgesic) medication. This failure had the potential to put Resident 2 at risk for ineffective pain management and adverse effects related to the use of unnecessary pain medication.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent the development of new pressure ulcers and promote the healing of existing pressure injuries for one of three sampled residents (Resident 2). * The facility failed to provide Resident 2 with an alternating pressure pad as recommended by the Wound Consultant. This failure posed the risk for worsening of the existing pressure injuries or development of new pressure injuries for this resident.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the medical record for one of five sampled resident (Resident 2) was complete and accurate. * The facility failed to ensure the attempts to obtain and schedule a vascular consult for Resident 2 were documented. This failure had the potential for the resident's care needs not being met as their medical information was incomplete and inaccurate.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure food safety and sanitation guidelines were followed when: 1. The cool down process for time, temperature control for safety (TCS) food, food that need to be kept at specific temperatures to prevent bacteria growth and foodborne illnesses, was not monitored. 2. Food preparation surfaces were not sanitized. 3. Fresh lettuce was not washed prior to use. 4. A sanitizing solution was not available for manual dishwashing in emergency situations. 5. Gloves were not used appropriately. 6. Facial hair was not covered. 7. Two of 14 kitchen employees had drinking cups or personal drinking containers in the kitchen. 8. One of 14 kitchen employees wore artificial nails and jewelry during food preparation. 9. [...]

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to effectively respond to the repeated concerns of cold food brought up in the monthly Resident Council meetings. This failure resulted in the Resident Councils concerns of cold meals being an ongoing issue, putting the residents at risk of undesirable outcomes.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure the menus were followed for 20 of 84 residents (two final sampled residents, Residents 1 and 31; and 18 nonsampled residents, Residents 2, 4, 9, 13, 15, 17, 21, 24, 51, 57, 59, 65, 69, 74, 85, 86, 446, and 791) who received a pureed diet; and 27 of 84 residents (two final sampled residents, Residents 27 and 31; and 25 nonsampled residents, Residents 2, 4, 7, 9, 13, 14, 17, 24, 32, 37, 38, 41, 45, 46, 49, 51, 57, 59, 61, 60, 69, 70, 80, 85, 791) who received a fortified diet when: 1. The pureed green bean recipe was not followed, 2. The correct portion size was not utilized for the pureed meat, 3. Mashed potatoes were not served to pureed diets, 4. Menu changes were not documented or approved by the Registered Dietitian, and 5. Fortified diets were not followed. [...]

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the infection control practices were followed for two of 20 final sampled residents (Resident 33 and 75) and three nonsampled residents (Residents 41, 61 and 791); in the laundry area; devices surfaces cleaning; hand washing; and preventing Legionella. In addition, the facility failed to ensure the infection control ;surveillance log was accurate. * Resident 41's bedside commode was not clean. * Resident 61's flush syringe touched the resident's blanket and the RN fanned the resident's uncapped iv port with her hand . * The facility's infection control surveillance logs were inaccurate. * The facility's laundry area had multiple infection control concerns. * The facility's decorative fountain was not monitored to prevent Legionella. [...]

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to maintain the essential equipment in the safe operating conditions when: * The ice machine was not clean. * The ice machine was not cleaned and sanitized as per the manufacturer's instructions. * The ice storage bin did not have an air gap to prevent backflow. These failures had the potential for the essential equipment not functioning in the way they were intended and in turn cause contamination of food, leading to illnesses for the residents.

Inspectors wroteBased on observation, interview, medical record review, and P&P review, the facility failed to ensure the medications were safely administered for one of 20 final sampled residents (Resident 35) and one nonsmapled resident (Resident 69) to self- administer medications. * Resident 69 was observed to have two bottles of Nerve Shield Pro (used as supplement for Brain & Nervous System Health, Neuropathy, Nerve Pain) at the bedside and had self-administered the medication. * Resident 35 was observed to have Tums (medication to relieve heartburn/stomach upset) tablet at bedside. These failures had the potential to negatively impact the residents' physiological well-being and administer the medications inaccurately.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to develop and implement a comprehensive person-centered care plan for one of 20 final sampled residents (Resident 67) and one nonsampled residents (Resident 41). * Resident 41's care plan failed to address the use of a bedside commode. * Resident 67's care plan failed to address the resident's psychosocial needs and failed to implement non-pharmacological interventions attempted for his behaviors were documented for risperidone use. These failures posed the risk of the residents not receiving services that were person-centered to meet the specific needs of each resident.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to provide an ongoing program to provide activities designed to meet the specific needs of the residents and encouraging both independence and interaction in the community for two of 20 final sampled residents (Residents 66 and 67). This failure posed the risk of not supporting the residents' psychosocial well-being.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 20 final sampled residents (Resident 12) and one nonsampled resident (Resident 57) were free from the accident hazards. * The facility failed to store the razors in a secure area when not in use. This failure had the potential to place Residents 12 and 57 at risk for serious injury.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to provide the necessary care and services to maintain the IV access for one of one final sampled resident (Resident 66) reviewed for IV care. * The facility failed to to ensure the IV catheter site for Resident 66 was labeled. This failure had the potential to delay the identification of catheter related complications for Resident 66.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the respiratory care orders were properly maintained and administered as ordered for two of 20 final sampled residents (Residents 1 and 83). * The facility failed to follow the physician's order for Resident 83's oxygen therapy. * The facility failed to ensure Resident 1's oxygen tubing was dated. These failures had the potential for the residents to not receive oxygen as ordered and adequate respiratory care.

Inspectors wroteBased on observation, interview, record review and the facility P&P, the facility failed to ensure pharmaceutical procedures were followed for one of one final sampled residents (Resident 27) investigated for pain and one of two residents (final sampled resident, Resident 35) reviewed for self-administration of medication * Resident 27's Percocet (an opioid based pain reliever) was removed from the supply but not documented as administered in the MAR on six occasions. * Resident 35 was observed with the medications at bedside. Resident 35 did not have a physician's order, assessment, and care plan for the self-administration of medications. These failures had the potential to put the resident at risk of unsafe pharmaceutical practices.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the following was completed for two of 20 final sampled residents (Residents 66 and 67): * Non-pharmacological interventions for Resident 67's risperidone were not documented * There was no clear indication for Resident 67's risperidone * The valproic acid level was not completed for Resident 67's use of valproic acid * There was no montioring and no documentation for discoloration related to Resident 66's use of humalog These failures posed the risk of inadequate monitoring.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of five residents (one final sampled resident, Resident 30) reviewed for unnecessary medications was free from unnecessary psychotropic (medications which affect the brain and the nervous system to treat mental illness and conditions which impact behavior and emotions) drugs. * The facility failed to ensure Resident 30 was properly monitored for orthostatic blood pressures (measure the blood pressure while laying down or sitting and again upon standing up) as ordered by the physician for the use of the olanzapine (a medication for mental disorders including schizophrenia and bipolar disorder). This failure had the potential for Resident 30 to experience adverse consequences from the psychotropic medication.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 7.69 %. * The facility failed to ensure LVN 3 administered Resident 75's metformin HCl (medication to lower blood sugar) and cholecalciferol (vitamin D supplement) as ordered. This failure had the potential to cause negative outcome for Resident 75.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure proper medication storage when: * The facility failed to ensure the expired medications were removed from Medication Cart C. * The facility failed to store internal and external medications separately. These failures had the potential to negatively impact the residents' well-being, and medication errors.

Inspectors wroteBased on observation, interview and facility document review, the facility failed to ensure the CDM was competent in managing the day-to-day functions of the food services department. In addition, the facility failed to ensure the RD had adequate oversight of the food service department. This failure to employ staff with the skills and abilities to effectively implement departmental processes in accordance with standards of practice had the potential to jeopardize the health and well-being of the 84 residents who received food prepared in the kitchen.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure nutritive value was preserved when pureed vegetables were prepared two hours prior to meal service and held on a hot steam table. This failure had the potential for the resdients who received a pureed diet to not meet their nutritional needs.

Inspectors wroteBased on observation, interview and facility document review, the facility failed to ensure 20 residents of 84 (three final sampled residents, Residents 12, 30, and 47; and 17 nonsampled residents, Residents 11, 14, 16, 18, 29, 32, 41, 49, 50, 63, 66, 68, 71, 80, 84, 444, and 791) who were on mechanically altered diets received ground meat. This failure had the potential for these residents to be at risk for choking.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medical records were complete and accurately documented for three of 20 final sampled residents (Resident 30, 33, and 60) and one closed record (Resident 90). * The facility failed to ensure Resident 33's blood pressure access site was accurately documented in the resident's medical record. * Resident 60's TAR had two blank treatment administrations. * Resident 90's POLST was incomplete. * The facility failed to ensure the scratched-out Depakote dosage on Resident 30's Facility Verification of Informed Consent form was signed and dated and failed to complete the informed consent when a change of indication for the use of Olanzapine was noted as per the physician's order for Resident 3. [...]

Inspectors wroteBased on observation, interview, facility P&P review, and facility document review, the facility failed to ensure the kitchen was free from flies. This failure posed the risk for pests to contaminate the resident's food.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of one final sampled resident (Resident 75) reviewed for Foley catheter care had a dignity bag to cover the urinary catheter drainage bag. This failure had the potential to compromise Resident 75's rights to be treated with respect and dignity.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to maintain a comfortable temperature level for one of 20 final sampled residents (Resident 33). This failure had the potential to negatively affect the resident's health and well-being.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the comprehensive plan of care was revised to reflect the residents' current care needs and interventions for one of of 20 final sampled residents (Resident 67) and one nonsampled resident (Resident 41) . * Residents 41 and 67's care plan problem addressing their Covid-19 (Coronavirus disease- infectious disease caused by the SARS-CoV-2 virus) diagnoses and use of the antibiotic medication were not revised after the residents' Covid-19 symptoms resolved and were no longer on the antibiotic medication. This failure posed the risk of not providing the residents with individualized and person-centered care.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure a sack lunch was provided to one of 20 final sampled residents (Resident 33) during dialysis days. This failure posed the risk for possible medical complications for Resident 33.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to notify the physician of a change of condition for one of two sampled residents (Resident 1). * Resident 1 had a change of condition on 10/7/23 at 2106 hours, in which her blood pressure was measured at 196/90 mmHg and another change of condition on 10/18/23 at 1622 hours, in which her blood pressure was measured at 180/86 mmHg. The facility failed to conduct a change of condition assessment specific to Resident 1's episodes of hypertension and failed to notify Resident 1's physician in accordance with the facility's P&P. This failure posed the risk for changes in Resident 1's health condition not being identified, potentially delaying necessary care and treatment, which posed the risk for negative health outcomes to Resident 1. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the reasonable accommodations to meet the care needs of three nonsampled residents (Residents A, B, and C). * The facility failed to ensure Resident A's call light was within reach. * The facility failed to ensure Resident B had a call light attached to the wall and available for use. * The facility failed to ensure Resident C's call light was answered promptly. These failures had the potential to negatively impact the resident's psychosocial well-being or delay to provide care and services to the residents.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to notify the residents of a change in the lunch menu when Brussel sprouts were not available for lunch as per the facility's menu. This failure resulted in the residents not receiving their meal as per the menu, which had the potential to negatively impact the residents' well-being.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure the food safety and sanitation requirements were met in the kitchen as evidenced by the following: * The facility failed to air dry the blender during the puree preparation. * The facility failed to ensure the kitchen utensils had smooth cleanable surface. * The facility failed ensure the appropriate food grade sanitizing wipes were used to disinfect countertops and tables where the food was prepared. * The facility failed to ensure the chlorine test strips had not expired. * The facility failed to ensure the kitchen staff performed hand hygiene and changed gloves during dishwashing. * The facility failed to ensure the labeling and dating of the foods stored in the refrigerator, freezer, and open, dry storage area. [...]

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to implement their infection control surveillance program in accordance with the facility's P&P. * The facility failed to implement their infection control surveillance program for the months of [DATE] through [DATE]. The facility conducted surveillance of resident infections based on whether the residents were prescribed antimicrobial medications. The facility failed to determine whether the residents who exhibited signs and/or symptoms of infections and were not prescribed antimicrobial medications met the facility's criteria for infection (McGeer's Criteria), and thus failed to include these residents in the facility's infection control surveillance program. [...]

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure the confidential resident roster for the last recertification survey was removed from the survey binder. This failure had the risk of exposing the residents' confidential information.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to inform and provide the written information regarding the rights to formulate the advance directive to one of 25 final sampled residents (Resident 5). This had the potential for violating the resident's rights to formulate an advance directive.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the necessary treatment and services were provided to prevent the risk of contractures for one of 25 final sampled residents (Resident 30). * Resident 30's splints were not applied to her bilateral elbows as ordered. This failure posed the risk for this resident to develop complications from immobility and not achieve their highest practicable level of independence.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services for the GT feeding for one of 25 final sampled residents (Resident 74). * The facility failed to ensure Resident 74 received the accurate amount of water in between medications during the medication administration. This failure posed the risk for complications related to the use of the GT.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to provide the necessary respiratory care for one of 25 final sampled residents (Resident 24). * The facility failed to follow a physician's order for the administration of continuous oxygen for Resident 24. This failure had the potential to negatively impact Resident 24's medical condition.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided for one of 25 final sampled residents (Resident 27). * The facility failed to notify the physician when Resident 27's medications were not administered during dialysis days. In addition, the facility failed to ensure the physician's order for a 1200 ml fluid restriction (a diet which limits the amount of daily fluid consumption) was followed and carried out accordingly. This had the potential to negatively impact the resident's well-being.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to administer the medications as ordered for one nonsampled resident (Resident 42). * The facility staff failed to administer Resident 42's medications within 60 minutes of the scheduled time at 0900 hours. This placed the resident at risk for delays in treatment and increased risk of adverse events.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of 25 final sampled residents (Resident 30) were free from unnecessary psychotropic medications. * Resident 27's psychiatrist failed to document the reason why the GDR for the use of Seroquel as recommended by the pharmacist was contraindicated for Resident 27. This failure had the potential for Resident 27 to experience adverse effects or receive unnecessary antipsychotic medications.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medication error rate was below 5%. * The facility's medication error rate was 20.5 %. This had the potential to negatively impact the residents' health outcomes.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure one of 25 final sampled residents (Resident 27) received two medications scheduled at 0900 hours as per the physician's orders and facility's P&P. This failure had the potential for negatively affect the resident's well-being.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the medications were safely stored and properly labeled. These had the potential for medication errors.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the medical records for six of 25 final sampled residents (Residents 11, 33, 41, 69, 73, and 74) and one nonsampled resident (Resident 48) were accurate and complete. This failure had the potential for the residents' care needs not being met as their medical information was incomplete.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to accurately determine whether six of 25 final sampled residents (Residents 30, 33, 71, 74, 85, and 88) and seven non-sampled residents (Residents A, B, C, D, E, 22, and 31) who were prescribed antibiotics had met the McGeer's criteria. As a result, the facility failed to inform the residents' physicians that the residents did not meet McGeer's Criteria for true infections and potentially inhibited the residents' physicians from discontinuing the unnecessary antibiotics. This potentially resulting in adverse reactions associated with antibiotics and the development of antibiotic resistant bacteria.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the freezer compartment inside the medication refrigerator was free of ice buildup. This had had the potential for the refrigerator not being maintained in a safe operating condition.

Inspectors wroteBased on observation, interview and medical record review, the facility failed to accurately complete the MDS for one of 25 final sampled residents (Resident 43). This posed the risk of the resident not receiving an individualized plan of care based on the resident's specific needs. * Resident 43 was dependent on oxygen. The facility failed to code the use of oxygen in the quarterly MDS dated [DATE].

Inspectors wroteBased on observation and interview, the facility failed to ensure the garbage and refuse (nonhazardous solid waste) were properly stored for two of the three garbage dumpsters. The lid of one garbage dumpster was missing and the lid of the other dumpster was left partially open. This failure had the potential to harbor pests or rodents which carry diseases.