Burbank Healthcare & Rehab

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure comprehensive and accurate Fall Risk Evaluation (a process used by healthcare providers to determine a person's likelihood of falling) were completed and updated to identify residents at risk for falls for three of three sampled residents (Resident 1, Resident 2, Resident 3), when: 1. The facility failed to complete Resident 1's quarterly Fall Risk Evaluation. 2. The facility failed to assess Resident 2's risk for a fall after Resident 2 had a fall on 7/9/2026. 3. The facility failed to accurately document Resident 3's Fall Risk Evaluation dated 6/21/2026. These failures placed Residents 1, 2, and 3 at increased risk for recurring falls and fall-related injuries by failing to accurately identify, reassess, and respond to changes in residents' fall risk status in accordance with professional standards of practice.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 2) who complained of pain received medication according to the physician orders. This failure had the potential to result in unmanaged pain and inadequate pain symptom control for Resident 2.

Inspectors wroteBased on interview and record review, the facility failed to ensure medications were available and administered as ordered for one of three sampled residents (Resident 2) when Resident 2 who had an active physician's order for Tramadol-Acetaminophen (a prescription medicine that combines two different pain relievers, tramadol and acetaminophen, to treat moderate to severe short-term pain) to be administered as needed for pain for 14 days, however the medication was unavailable, and Resident 2 went approximately two and a half days without access to the prescribed medication during the active order period. This failure had the potential to result in unmanaged pain and inadequate pain symptom control for Resident 2.

Inspectors wroteBased on interview and record review, the facility failed to maintain medical records in accordance with acceptable professional standards and practices for two of three sampled residents (Resident 1 and Resident 3) when:1. Resident 1's Fall Risk Evaluation (a comprehensive clinical assessment to identify the specific factors that increase a person's likelihood of falling), dated 7/17/2026, was incomplete.2. Resident 3 had a fall on 6/21/2026 and the Fall Risk Evaluation, dated 6/21/2026, did not reflect the resident's fall and was inaccurate. This deficient practice resulted in inaccurate documentation of Resident 1's and Resident 3's records.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement physician order for fluid restriction (a medical directive that limits the total amount of liquid a person can drink or eat each day) for one of three sampled residents (Resident 1) receiving dialysis (a treatment to cleanse the blood from wastes and extra fluids artificially through a machine when the kidney(s) have failed) services when water pitcher was at resident's bedside during an observation on 7/17/2026. This failure had the potential to place Resident 1 at risk for fluid overload (a medical condition when there is too much fluid in the body's bloodstream and tissues) and edema (a medical term for swelling caused by excess fluid trapped in the body's tissues).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection prevention and control practices were followed when isolation linen cart (a dedicated mobile storage unit used to manage contaminated supplies specifically for residents under isolation precautions [a resident is placed on special safety restrictions to stop the spread of a contagious germ to others]) was overfilled, with bags of linen stacked above the rim of the cart and with trash overflowing during an observation on 7/17/2026. This failure had the potential to contaminate the care environment, increase the risk of cross contamination, and place residents at risk for infection.

Inspectors wroteBased on interview and record review, the facility failed to prevent a fall and injury for one of three sampled residents (Resident 1), who was confused, identified as a fall risk, had difficulty in walking, and had repeated falls in the facility. The facility failed to:1. Provide supervision to Resident 1 when staff (unspecified) placed Resident 1 in the hallway unattended.2. Place resident (Resident 1) on areas visible by staff and within easy reach when they (Resident 1) get up in accordance with Resident 1's care plan titled, Actual Fall. with date initiated on 6/1/2026. As a result, Resident 1 fell in the hallway on 6/18/2026 at around 12:50 p.m., sustaining a scalp laceration (a torn, ragged cut or tear in the skin and tissue) with bleeding and severe pain in the left hip. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services in accordance with physician orders and individualized care plan for three of three sampled residents (Resident 1, Resident 2, and Resident 3) when the facility failed to: 1. Ensure physician's ordered wheelchair alarms (physical or electronic device that monitors resident movement and alerts the staff when movement is detected) stayed connected for Resident 1 and Resident 2 while they were seated in their wheelchairs.2. Implement Resident 3's care plan intervention for one-to-one (1:1) supervision for safety and close supervision. These failures increased the risk for falls and potential injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 3) received care in a manner that maintained the resident's dignity and respect when Certified Nurse Assistant (CNA) 1 did not fully close the privacy curtains while providing personal care. This failure had potential to negatively affect the Resident 3 sense of dignity and respect during the care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 2) received their physician-ordered regular diet. Resident 2 was served a soft and bite size (soft, tender, and moist) diet instead of the prescribed regular texture diet. This failure had the potential to result in unnecessary diet restrictions, decreased meal satisfaction, and reduced nutritional intake.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection prevention and control practices were followed when Certified Nurse Assistant (CNA) 1 placed soiled linen and soiled brief directly on the floor while providing care for one of three sampled residents (Resident 3). This failure had the potential to contaminate the care environment, increase risk of cross contamination, and place residents at risk for infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident who received hemodialysis (a medical treatment that acts as an artificial kidney, filtering waste products and extra fluid from the blood when kidneys are not working well) received treatment in accordance with professional standards of practice for one of three sampled residents (Resident 2) by failing to ensure clear communication between the facility, dialysis center, and the physician for timely administration of Resident 2's medications. This deficient practice had the potential to delay care and negatively affect Resident 2's well-being.

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) for one of three sampled residents (Residents 1) by failing to: 1. Ensure the dosage for Resident 1's Ivermectin (an antiparasitic medication [medications used to treat infections caused by parasites, such as worms, mites] used to treat infections and skin conditions like scabies [a highly contagious skin condition caused by mites]. Ivermectin dosing for adults is based on weight: 0.2 milligram [mg-unit of measurement] per kilogram (kg-unit of measurement] of body weight) order was accurate based on Resident 1's weight. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who was cognitively impaired (refers to difficulties with thinking, learning, remembering, and using judgment, among other mental abilities), had a safe discharge by failing to: 1. Ensure Resident 1 received a 30-day-written notice of discharge.2. Create a discharge care plan upon Resident 1's admission.3. Ensure the Social Services Director (SSD) informed Family Member (FM) 1 during a telephone call about Resident 1's Notice of Medicare Non-Coverage regarding appeal rights and the process to appeal the discharge. 4. Identify Resident 1's discharge needs before the discharge on [DATE].5. Include FM 1 in Resident 1's discharge planning process.6. Conduct an interdisciplinary team (IDT) meeting prior to Resident 1's discharge on [DATE].7. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the personal items of clothing of one of three sampled residents (Resident 1), who was cognitively impaired (refers to difficulties with thinking, learning, remembering, and using judgment, among other mental abilities), were not lost. This deficiency practice resulted in Resident 1 being discharged to home in a hospital gown with no shoes.

Inspectors wroteBased on interview and record review, the facility failed to conduct a baseline initial comprehensive assessment for functional capacity for one of three sampled residents (Resident 1), who was cognitively impaired (refers to difficulties with thinking, learning, remembering, and using judgment, among other mental abilities). This deficiency practice resulted in Resident 1 being discharged to home without proper assessment to determine Resident 1's needs at home.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its infection control measures for seven of eight sampled residents (Residents 3, 4, 2, 7, 8, 6, and 5) while the facility had scabies (a contagious skin infestation caused by tiny, eight-legged mites called Sarcoptes scabiei) outbreak (a sudden, unexpected increase in the number of cases of a disease in a specific area or population). The facility: 1. Failed to ensure Restorative Nursing Assistant 1 (RNA) 1 change gowns before providing care between Resident 3 and Resident 4 who were on contact isolation (infection control procedure used in healthcare to prevent the spread of germs transmitted by direct or indirect contact).2. Failed to ensure Certified Nursing Assistant 2 (CNA 2) wear PPE before delivering breakfast tray to Resident 2 who was on contact isolation.3. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the Resident's Representative (RR- is a person chosen by a resident-or legally authorized-to act on their behalf to manage care, access personal information, or make decisions, particularly if the resident is incapacitated) for one of three sampled residents (Resident 6) who had a Power of Attorney (POA- a legal document that allows someone else to act on your behalf) of Resident 6's changes in conditions on 3/16/2026, and 3/18/2026. This failure had violated Resident 1's and RR's right to be informed and had the potential to increase Resident 1's and RR level of anxiety (an intense, persistent, and often overwhelming feeling of worry, dread, or unease).

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a person-centered care plan (a tool that ensures residents receive personalized, comprehensive, and goal-oriented care in a nursing home setting) for one of five sampled residents (Resident 5) regarding skin scraping (a quick, minor medical procedure where a doctor uses a dull blade to gently rub or scrape the top layer of skin to collect a small sample). This failure had the potential for delays in the delivery of necessary care and services and could place Resident 5 at risk for scabies (a contagious skin infestation caused by tiny, eight-legged mites called Sarcoptes scabiei).

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) for one of five sampled residents (Residents 5) by failing to administer clobetasol (medication used to treat severe skin conditions by reducing itching, redness, and swelling) on 4/23/2026, as per physician order. This failure had the potential to result in medication errors and could worsen Resident 5's dermatitis (common condition that causes swelling and irritation of the skin).

Inspectors wroteBased on interview and record review, the facility failed to maintain accurate and complete medical record for one of three sampled residents (Resident 3) by failing to document contact isolation (a safety measure used in hospitals to prevent the spread of germs that are transferred by touching a patient or items in their room) monitoring on 4/22/2026, during night shift. This failure had the potential to cause confusion in Resident 3's care and the medical records containing inaccurate documentation.

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) for one of three sampled residents (Residents 1) by failing to: 1. Ensure administration of cephalexin (medication used to treat infection) and clindamycin (medication used to treat infection) on 3/14/2026, at 9 p.m., as ordered by the physician.2. Ensure administration of cephalexin and clindamycin on 3/21/2026, at 9 p.m. to complete the seven days course of the antibiotic (medication used to treat infection) as ordered by the physician. These failures had the potential to result in medication errors and could worsen Resident 1's cellulitis (a skin infection that causes swelling and redness).

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) who tested negative for skin scraping (a diagnostic procedure where a healthcare provider uses a scalpel blade to gently scrape the top layer of skin, usually over a burrow [hole], to collect samples) for scabies (a parasitic infestation caused by tiny mites that burrow into the skin and lay eggs, causing intense itching and a rash) was not given permethrin (medication used to treat scabies and lice) and ivermectin (medications used to treat scabies). [...]

Inspectors wroteBased on interview and record review, the facility failed to implement its policy for antibiotic (medication used to treat infection) stewardship (efforts in doctor's offices, hospitals, long-term care facilities and other health care settings to ensure that antibiotics are used only when necessary and appropriate, means prescribing the right drug at the right dose at the right time for the right duration) by failing to monitor Resident 1 for the adverse effects (undesired or harmful effects) of clindamycin (medication used to treat infection) on 3/8/2026. This failure had the potential to increase antibiotic resistance (do not respond to a drug) and had the potential for Residents 1 to experience an adverse reaction.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the comprehensive care plan (a plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs) was revised for two of three sampled residents (Resident 1 and 2) when: 1. On 3/15/2026, Resident 1 was transferred to the general acute care hospital (GACH) for altered level of consciousness (a state of reduced alertness or inability to arouse due to low awareness of the environment) and was diagnosed with opioid intoxication [a class of medication that produce powerful pain-relieving effects and have the potential to cause drowsiness, constipation, and respiratory depression] that overwhelms the body's tolerance). 2. On 3/12/2026, Resident 2 was transferred to the GACH for psychiatric (relating to mental illness) evaluation. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident has the right to be free from physical restraint for one of four sampled residents (Resident 2). The facility failed to ensure Resident 2's bed was not placed against the wall to restrain the resident's movements. This deficient practice violated Resident 2's right to be free from physical restraints.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Certified Nursing Assistants (CNA 1 and CNA 2) performed proper hand hygiene after providing Activities of Daily Living (ADLs) (e.g., bathing, dressing, and toileting) for one of four sampled residents (Resident 4). This deficient practice had the potential to result in the transmission of infectious organisms and cross-contamination to other residents, staff, and visitors.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents were treated with respect and dignity in a manner that promotes maintenance or enhancement of their quality of life by failing to ensure Certified Nurse Assistants (CNA) did not provide feeding assistance while for three of ten residents (Resident 18, 107, and 67) observed during the Dining task. This deficient practice had the potential to result in a decrease in psychosocial well-being for the residents leading to an overall decline and malnutrition (a serious condition that happens when your diet does not contain the right amount of nutrients).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident medication self-administration was clinically appropriate and failed to honor the resident's right to self-administer medications for one of ten sampled residents (Resident 55) reviewed under the Accidents care area by failing to perform a medication self-administration assessment when staff had knowledge that the resident kept medication at the bed side for self-administration. This deficient practice violated the residents' right to self-administer medications and had potential for the residents to experience adverse effects (an undesired effect of a drug or other type of treatment) of the medication. Cross-reference F689.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignity including the right to be free from physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the resident's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) for four of five sampled residents (Resident 104, 62, 187, and 78) reviewed for physical restraints, by failing to: 1. Ensure Resident 104 did not have pillows and a rolled towel tucked under the resident's fitted sheet bilaterally (both sides) on 3/9/2026 and 3/11/2026. 2. Ensure a restraint assessment was completed prior to the use of bed placed against the wall for Resident 62. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were screened using the Preadmission Screening and Resident Review (PASRR - a federal requirement to help ensure that individuals are not appropriately placed in nursing homes for long-term care) for a mental disorder (MD) or intellectual disability (ID) prior to admission and that individuals identified with serious mental illness (SMI) and/or ID/developmental disability (DD)/related conditions (RC) receive the care and services in maintaining his/her highest practicable level in the most appropriate setting for three of three sampled residents (Residents 3, 62, and 17), by: 1. Failing to submit a new Level I PASRR for Residents 3 and 62 who had discrepancy in the previous PASRR Level I Screening. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a tool that ensures residents receive personalized, comprehensive, and goal-oriented care in a nursing home setting) for four of 34 sampled residents (Residents 66, 179, 142, and 97) by failing to ensure: 1. Resident 66 had a care plan on the use of psychotropic medication (prescription drugs that change brain chemistry to alter mood, thoughts, behavior, or perception) Divalproex sodium (a prescription medication used to calm overactive nerves in the brain) and anticoagulant (a type of medicine that prevents blood from clotting (or clumping) too easily) enoxaparin sodium (a prescription medication used to prevent and treat harmful blood clots). 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the environment was free of accident hazards for twelve of 14 sampled residents (Residents 180, 72, 179, 12, 1, 104, 55, 9, 21, 183, 22, and 78) reviewed for accidents by failing to ensure: 1. Residents 180, 72, 179, and 12 did not have a furniture or equipment on top of the floor mat (specially designed mats provide cushioning and support to patients who are at risk of falling, helping to prevent serious injuries). 2. Residents 180, 1, 72, 104, and 55 did not have medications or biologicals (medicines derived from living organisms-such as humans, animals, or microorganisms-rather than being created from chemicals) left at the bedside. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respiratory care provided to residents was consistent with professional standards of practice for three (3) of 3 sampled residents (Resident 128, Resident 1, and Resident 66) reviewed for respiratory care by failing to ensure: 1. Resident 128's oxygen (O2) via nasal cannula (NC - a simple, two-pronged device that delivers extra oxygen to the nose) tubing was not touching the floor. 2. Resident 1's nebulizer (device that transforms liquid medicine into a fine, breathable mist) mask and tubing, dated 2/22/2026, was discarded and replaced with a new nebulizer mask and tubing. 3. Resident 66's nebulizer tubing and mouthpiece, dated 2/23/2026, was discarded and replaced with a new nebulizer tubing and mouthpiece. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Have Trelegy (a medication used to treat chronic obstructive pulmonary disease [COPD - a disease causing shortness of breath and chest congestion) oral inhalation for Resident 33 available in the facility between 8/1/2025 and 3/9/2026, observed during Medication Administration Task. 2. Reconcile (the process of comparing transactions and activity to supporting documentation) six (6) medication emergency kits (eKIT - storage container for emergency use medications) containing Controlled Substances (CS- medications which have a potential for abuse and may also lead to physical or psychological dependence, also known as Controlled Medications [CM]) and document on the CS accountability log for March 2026, in two (2) of 2 inspected Medication Rooms (Medication room [ROOM NUMBER] and 2). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five (5) percent (%). Three (3) medication errors out of 32 total opportunities contributed to an overall medication error rate of 9.38% affecting two (2) of four (4) residents observed for medication administration (Resident 33 and 184). The medication errors were as follows: 1. Resident 33 did not receive brimonidine (a medication used for glaucoma [a condition of increased pressure in the eyeball]) drops and Trelegy (a medication used to treat chronic obstructive pulmonary disease [COPD - a disease causing shortness of breath and chest congestion due to mucus) oral inhalation as ordered by Resident 33's physician. 2. Resident 184 did not receive Systane (a medication used for dry eyes) drops as ordered by Resident 184's physician. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were free of any significant medication errors (the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order, manufacturer's specifications, and accepted professional standards) by not: 1. Administering Trelegy (a medication used to treat chronic obstructive pulmonary disease [COPD - a disease causing shortness of breath and chest congestion]) to Resident 33 between 8/1/2025 and 3/9/2026. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to store medications in accordance with manufacturer specifications, professional principles and facility policy and procedures (P&P) by failing to: 1. Remove and discard from use one (1) open Aplisol (also known as Tubersol - medication used to diagnose tuberculosis [infection in the lungs]) vial for facility stock, in accordance with manufacturer's requirements and facility policy and procedures in 1 of two (2) inspected Medication Rooms (Medication room [ROOM NUMBER]). 2. Store one lorazepam (a medication used to treat anxiety and restlessness) oral concentrate (a solution with increased strength) bottle in the refrigerator for Resident 128 in accordance with the manufacturer's requirements in one of three inspected medication carts (Medication Cart 1 Station 1.) 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen reviewed during the Kitchen task by failing to: 1. Ensure perishable items, hotdogs, were disposed of by the best by date of 2/3/2026. 2. Ensure six (6) plates of salad were labeled with a prepared date. 3. Ensure 10 prepared bowls of ice cream were labeled with a prepared date. These deficient practices had the potential to result in harmful bacterial growth and cross- contamination (the process by which bacteria, chemicals, or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication administration record (MAR - a record of all active physician orders and medications administered to a resident) was not falsified by documenting Trelegy (a medication used to treat chronic obstructive pulmonary disease [COPD - a disease causing shortness of breath and chest congestion due to mucus]) was administered once a day between 8/1/2025 to 3/9/2026 when it was unavailable in the facility for one (1) of four (4) residents observed for medications administration (Resident 33). This deficient practice increased the risk that Resident 33 could have experience worsening COPD, causing difficulty in breathing and possibly resulting in hospitalization and/or death. Cross-reference F755, F759, and F760.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections by failing to ensure: 1. Resident 182's call light (a button, cord, or remote device in a hospital or nursing home room that allows a resident to electronically alert nurses or staff that they need assistance) was not inside the trash can and was sanitized before handing it off to the resident for use during random resident screening. 2. The mobile linen carts on the units were not covered with a permeable (material that allows liquid to pass through)/mesh material observed during infection control task. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that essential equipment was maintained in a safe and working condition when: 1. One (1) of 1 sampled walk-in freezer reviewed during the Kitchen task had ice build-up inside the freezer. This deficient practice had the potential to result in an injury among staff and cross-contamination (the process by which bacteria, chemicals, or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) of food items. 2. 1 of 1 sampled resident (Resident 33) Resident 33's call light (a button or device a resident uses to get help from staff) was not properly connected to the wall panel during an observation on 3/9/2026.

Inspectors wroteBased on interview and record review, the facility failed to honor the resident's right to be informed in advance by the physician or other practitioner or professional, of the risks and benefits of proposed care, treatment and treatment alternative or option for one of one sampled resident (Resident 66) reviewed for informed consents (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) by failing to ensure Resident 66's informed consent on the use of psychotropic medication (a drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) (Buspirone, a prescription medication used to treat chronic anxiety and manage daily anxiety symptoms, such as irritability and restlessness) matches the physician's order. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep the call light (an alerting device for nurses or other nursing personnel to assist a patient when in need) and bed remote control within reach of the resident for two of six sampled residents (Residents 182 and 140) reviewed under environment task. This deficient practice had the potential for Residents 182 and 140 unable to summon health care worker for help and to adjust the bed for comfort as needed.

Inspectors wroteBased on interview and record review, the facility failed to complete the Advanced Directive Acknowledgement Form (a form that shows a person was given information about their medical wishes and rights) was complete for one of three sampled residents (Resident 14). This deficient practice had the potential to result in Resident 14's healthcare wishes not being known or followed, placing the resident at risk of receiving unwanted or inappropriate treatment.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from unnecessary psychotropic medication (medications that affect the mind, emotions, and behavior) and the use of chemical restraints (any drug that is used for discipline or staff convenience and not required to treat medical symptoms) for one of five sampled residents (Resident 9) reviewed for unnecessary medications by failing to ensure quetiapine fumarate (an atypical antipsychotic drug [treats symptoms of psychosis-such as hallucinations, delusions, and severe agitation]) was prescribed and monitored for specific, measurable behavioral manifestations. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure timely submission of a completed Minimum Data Set (MDS - a resident assessment tool) for two of three sampled residents (Residents 21 and 50) reviewed for Resident Assessment task, by failing to: 1. Transmit (electronic submission of MDS to the Centers of Medicare & Medicaid Services [CMS - a federal agency that administers major healthcare programs]) the Quarterly MDS Assessment timely for Resident 21. 2. Transmit the admission MDS Assessment timely for Resident 50. These deficient practices had the potential to negatively affect the provision of necessary care and services needed by Residents 21 and 50.

Inspectors wroteBased on interview and record review, the facility failed to accurately code the Minimum Data Set (MDS-a resident assessment tool) by failing to ensure the MDS assessment of one of three sampled residents (Resident 189) was transmitted accurately when a discharge assessment was submitted on 2/20/2026 and remained discharged from the facility. Resident 189 returned to the facility at 1:30 p.m. on 2/21/2026. This deficient practice had the potential to cause confusion and delay in the delivery of necessary care and services to Resident 189.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received care consistent with professional standards of practice to prevent pressure injury (also called pressure ulcer, the breakdown of skin integrity due to pressure) for one of one sampled resident (Resident 128) reviewed under pressure injury by failing to ensure Resident 128's low air loss mattress (LALM, a special type of air mattress that uses a constant, gentle flow of air through microscopic holes to keep the skin dry and prevent pressure wounds) was replaced timely when the LALM was beeping indicating low pressure with an orange light and the resident appeared sunken into the bed. This deficient practice placed Resident 128 at risk for the development and worsening of pressure injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were incontinent of bladder received services and assistance for two of four sampled residents (Resident 38 and Resident 180) reviewed for urinary tract infection (UTI, a common infection that occurs when bacteria enters and multiplies in the urinary system, which includes the kidneys, bladder, and urethra) by failing: 1. To ensure Resident 90's urinal bottle (a handheld container designed for collecting urine) was not hanging on the side of the trash can. 2. To ensure Resident 180's urinal bottle was labeled. These deficient practices had the potential for the residents' urinal bottle to be contaminated which may lead to development of urinary tract infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the staff providing care and services to the resident who has a feeding tube (soft plastic tubes through which liquid nutrition travels through the gastrointestinal tract [the series of organs that food and liquids pass through as they are digested, absorbed, and leave the body as feces]) are aware of, competent in, and utilize facility protocols regarding feeding tube nutrition and care for one of ten sampled residents (Resident 1) observed during Dining Observation by failing to ensure Licensed Vocational Nurse (LVN) 1 checked the gastrostomy tube (g-tube - a small tube placed through the skin directly into the stomach to deliver nutrition, fluids, and medications) placement prior to administering Jevity 1.5 (a high-calorie, liquid nutrition formula designed for people who cannot eat enough food by [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure parenteral fluids (liquids, such as medication or nutrition, that are administered to the body by bypassing the digestive system) were administered consistent with professional standards of practice to one of one sampled resident (Resident 179) reviewed for hydration by failing to ensure the Resident 179's peripheral intravenous (IV - within a vein) line (a small, flexible plastic tube (catheter) inserted through the skin into a small vein-usually in the hand, arm, or foot-to deliver fluids and medications directly into the bloodstream) had the date and initials of the licensed nurse who inserted the IV line or changed the IV dressing. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide pain management consistent with professional standards of practice and the residents' goals and preferences for two of two sampled residents (Resident 62 and 142) reviewed for Pain care area, by failing to: 1. Follow the physician order for pain consult referral for Resident 62. This deficient practice had the potential to result in mismanagement of resident pain resulting in limited resident participation in activities of daily living (ADLs - activities such as bathing, dressing, and toileting a person performs daily) and mobility. 2. Ensure Licensed Vocational Nurse (LVN) 4 assessed Resident 142's pain level prior to administrating the pain medication and to accurately document Resident 142's pain in the Medication Administration Record (MAR). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents who received hemodialysis (HD - also known as dialysis, process of removing waste products and excess fluid from the body) received treatment consistent with professional standards of practice for one of one sampled resident (Resident 59) reviewed under the Dialysis care area by failing to ensure communication with the HD Center (a specialized outpatient facility that provides HD) when Licensed Vocational Nurse (LVN) 4 failed to follow-up with the HD Center when the Dialysis Communication Record form was not completed on 3/6/2026 and 3/9/2026. This deficient practice placed the resident at risk for a delay in care and services related to HD.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident receive treatment and care in accordance with professional standards of practice for one of one sampled resident (Resident 153), by failing to arrange Resident 153's transportation to their Oncology (the specialized branch of medicine dedicated to the diagnosis, treatment, and prevention of cancer [a group of diseases characterized by the uncontrolled proliferation of cells]) appointment. This deficient practice resulted in a missed Oncology visit on 3/10/2026 for Resident 153.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adaptive feeding equipment (specialized tools and utensils designed to assist individuals with limited motor skills, strength, or coordination in eating independently and safely) or one (1) out of 1 sampled resident (Resident 160) observed during dining observation facility task on 3/9/2026, lunch time. This deficient practice had the potential for Resident160 to have a decline in function and loss of independence.

Inspectors wroteBased on interview and record review, the facility failed to implement its antibiotic stewardship program (a coherent set of actions which promote using antimicrobials responsibly) that includes antibiotic (ATB, a medicine that fights bacterial infections by killing bacteria or stopping them from multiplying) use protocols and a system to monitor antibiotic use for two of two sampled residents (Residents 179 and 1) reviewed for antibiotic use by failing to ensure: 1. Resident 19's use of antibiotic Ertapenem Sodium had monitoring for adverse effects (a harmful, undesired, or unexpected symptom that happens after taking a medication, having a medical procedure, or being exposed to a substance). 2. Resident 2's Linezolid (a type of medication that is used to treat different types of infection) was started timely. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide at least 80 square feet (sq ft - unit of measurement) per resident in 41 of 72 rooms (Rooms 101, 103, 105, 106, 116, 119, 120, 121, 122, 123, 125, 126, 128, 130, 131, 133, 135, 201, 202, 203, 204, 205, 208, 209, 210, 211, 214, 216, 217, 218, 219, 220, 221, 222, 224, 225, 228, 229, 230, 231, and 232). The room size for these rooms had the potential to have inadequate space for resident care and mobility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure there were safe and sanitary food preparation practices in the kitchen when kitchen staff failed to:1. Calibrate thermometers on 3/3/2026 and 3/4/2026.2. Monitor and document Refrigerator 1, Refrigerator 2, Freezer 1, and Freezer 2 temperatures on 3/3/2026 p.m. shift and 3/4/2026 a.m. shift. These deficient practices had the potential to result in harmful bacterial growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) in medically compromised residents who received food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure interventions to prevent falls were in place for one of three sampled residents (Resident 3) by failing to implement floor mats (a thick, soft foam pad placed on the floor next to a bed or chair) as ordered by the doctor when on 3/4/2026 during an observation no floor mat where noted in Resident 3's room, who was identified as a fall risk (how likely a person is to lose their balance and fall causing potentially injury). This deficient practice placed Resident 1 at increased risk of having a serious injury after a fall.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement contact isolation precautions (infection control measures used in the healthcare settings to prevent the spread of infections transmitted by direct or indirect contact with a resident or their environment) for one of three sampled residents (Resident 1) when Resident 1 was suspected and exhibited signs and symptoms (indicators of an illness, injury, or condition) consistent with Clostridiodes (known before as Clostridium) Difficile infection (CDI or C. difficile - bacteria that causes severe, diarrhea [loose, watery stools], and inflammation [swelling] of the colon) on 1/18/2026 and subsequently tested positive for CDI on 1/20/2026, by failing to:1. Ensure Resident 1, who showed signs and symptoms of CDI on 1/18/2026, was not sharing the same room with Resident 2 and Resident 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of a misappropriation of resident property (the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent) of one of four sampled residents (Resident 4) to the State Survey Agency (SSA) when Family Member (FM) 1 allegedly took Resident 4's wallet and charged $500 on Resident 1's credit card. This deficient practice had the potential to place Resident 1 at increased risk for further abuse which could have led to additional unreported incidents and delay the SSA's ability to promptly investigate the allegation of a misappropriation of resident property.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a person-centered Care Plan (a plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs) for one of three sampled residents (Resident 2) to address that Resident 2 was immunocompromised (having a weakened immune system that cannot fight infections and diseases as effectively as a healthy one) and had high risk for infection. This failure had the potential to delay provision of necessary care for Resident 2 and placed Resident 2 at risk of developing an infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the comprehensive care plan (a plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs) was revised for two of three sampled residents (Resident 2 and 3) when facility staff cohorted (grouping residents together based on their infection status to prevent the spread of illness to healthy residents) Residents 2 and 3 with Resident 1 who was suspected with Clostridium Difficile infection (CDI or C. difficile - bacteria that causes severe, diarrhea [loose, watery stools], and inflammation of the colon) on 1/18/2026 and tested positive for CDI on 1/20/2026. This deficient practice had the potential to delay provision of care for Resident 2 and Resident 3. [...]

Inspectors wroteBased on interview, and record review, the facility failed to implement its policy for the antibiotic (medication used to treat infection) stewardship (efforts in doctors' offices, hospitals, long-term care facilities, and other health care settings to ensure that antibiotics are used only when necessary and appropriate, means prescribing the right drug, at the right dose, at the right time, for the right duration) program for one of three sampled residents (Resident 1) by failing to monitor Resident 1 for the adverse effects (undesired or harmful effects) of levofloxacin (antibiotic medication used to treat infection) from 12/23/2025 to 12/29/2025. These failures had the potential to increase antibiotic resistance (don't respond to a drug) from unnecessary or inappropriate antibiotic use and had the potential to result in Resident 1 to experience an adverse reaction. [...]

Inspectors wroteBased on interview, and record review, the facility failed to develop and implement a person-centered care plan (a tool that ensures residents receive personalized, comprehensive, and goal-oriented care in a nursing home setting) for one of three sampled residents (Resident 1) to address Resident 1's refusal of Restorative Nursing Assistance (RNA- provide specialized rehabilitative care, helping residents regain independence with daily activities like walking, bathing, and eating, under the supervision of licensed nurses and therapists) services. This failure had the potential to result in a delay in the delivery of necessary care and services.

Inspectors wroteBased on interview, and record review, the facility failed to ensure residents with or without limited range of motion (ROM - movement of the joints) received appropriate treatment and services to increase, prevent, or maintain the ROM mobility for one of three sampled residents (Resident 1) who had a physician's orders for Restorative Nursing Assistance (RNA) ambulation five times a week. This failure resulted in Resident 1 not receiving RNA ambulation and placed Resident 1 at risk for decline in physical function. During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 11/21/2025, with diagnoses that included unspecified (unconfirmed) acute kidney failure (when the kidneys suddenly cannot filter waste products from the blood), difficulty in walking and generalized weakness. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain an accurate and complete medical record for one of three sampled residents (Resident 1) by failing to document the time of the Physician notification and the Physicians' response after the facility's notification of Resident 1's abnormal (result that falls outside the reference range) blood test result on 12/26/2025. This failure had the potential to result in medication errors, cause confusion in care and the medical records containing inaccurate documentation.

Inspectors wroteBased on interview and record review, the facility failed to notify the resident and the resident's representative (RR - a person authorized by State or Federal law including but not limited to agents under power of attorney [POA - a legal document that allows someone else to act on your behalf]) of the transfer or discharge and the reasons for the move in writing for two of three sampled residents (Residents 1 and 2). These failures had the potential for incomplete information conveyed to Residents 1 and 2 or their RR and could have violated residents and RR's rights to appeal (the process in which cases are reviewed by a higher authority) transfer or discharge.

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents received care consistent with professional standards of practice for one of three sampled residents (Resident 1) by failing to notify the physician on 9/1/2025, when Resident 1 had a 20 millimeter of mercury (mmHg - unit of pressure commonly used for blood pressure readings) decrease in systolic blood pressure (sbp - top number of the blood pressure that represents the pressure in your arteries when your heart pumps blood out to the rest of your body). This failure had the potential to place Resident 1 at risk of orthostatic hypotension (a condition where blood pressure drops significantly when a person stands up from a lying or sitting position) and could negatively impact residents' well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure medical records were complete and accurately documented for two of three sampled residents (Residents 1 and 2), when Resident 1 and Resident 2's Inventory Lists, on the Discharge portion, were left blank. This failure had the potential for Resident 1 and Resident 2's personal belongings to be lost.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 1) were free of significant medication error when Licensed Vocational Nurse (LVN) 1 failed to follow the doctor's ordered parameters (specific instructions from a doctor on exactly how and when to give a medication) for administering valsartan (a medication used to treat high blood pressure and heart failure [a condition in which the heart muscle can't pump enough blood to meet the body's needs for blood and oxygen]) to Resident 1. This failure resulted in LVN 1 administering valsartan to Resident 1 without first assessing Resident 1's blood pressure and heart rate per the doctor's order.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement their infection control policy for one of three sampled residents (Resident 1) when Licensed Vocational Nurse (LVN) 1: 1. Did not wear gown and gloves prior to entering Resident 1's room, which was placed on contact isolation precautions (a facility procedure to stop the spread of germs by requiring hand hygiene and the use of gown and gloves before entering a resident's room, followed by its removal when exiting a resident's room). 2. Placed a medicine cup, containing crushed medications mixed with applesauce, inside a medication cart next to a glucometer (an electronic device used for multiple residents that measures the amount of sugar in the blood). These deficient practices had the potential to spread infection to Resident 1 and to other residents within the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medical record of one of two sampled residents (Resident 2) was complete and accurately documented, when the facility failed to complete their designated form after performing a deep clean (a detailed cleaning process that targets hard-to-reach areas in order to kill germs and prevent the spread of infection) of Resident 2's room. This deficient practice resulted in an incomplete medical record for Resident 2.

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) for one of three sampled residents (Resident 1) by failing to follow Resident 1's physician order to administer valsartan (medication used to treat high blood pressure) for systolic blood pressure (sbp- the top number in a blood pressure reading, indicating the pressure in your arteries when your heart beats) above 100 millimeters of mercury (mmHg-a standard unit of pressure). This failure had the potential to result in medication error and could cause Resident 1's uncontrolled hypertension (HTN-high blood pressure).

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow professional standards of practice for one of three sampled residents (Resident 3) by failing to: 1. Ensure Resident 3 had physician orders for the resident's indwelling urinary catheter (a flexible plastic tube inserted into the bladder that helps provide continuous urinary drainage) care and monitoring. 2. Ensure Resident 3's indwelling urinary catheter was monitored for signs and symptoms of urinary tract infection (UTI - an infection in any part of the urinary system [kidneys, bladder, or urethra]). 3. Ensure Licensed Vocational Nurse (LVN) 2 and LVN 3 did not perform indwelling urinary catheter treatments on Resident 3 without a physician orders. 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of three sampled residents (Resident 3 and Resident 5) with indwelling urinary catheter (a flexible plastic tube inserted into the bladder that helps provide continuous urinary drainage) received proper care and services by failing to: 1. Ensure Resident 3's urine output was monitored for presence of hematuria (blood in the urine). 2. Ensure Resident 3's indwelling urinary catheter tubing was anchored (secured) to the resident's thigh. These deficient practices resulted to Resident 3's urinary catheter tubing and drainage bag with dark yellow to dark red, cloudy urine with visible sediments and hematuria during an observation on 4/10/2025 at 10:40 a.m. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a comprehensive, person-centered care plan with measurable objectives and interventions for one of seven sampled residents (Resident 3) was created and implemented that addressed Resident 3's indwelling urinary catheter (a flexible plastic tube inserted into the bladder that helps provide continuous urinary drainage). This deficient practice had placed Resident 3 at risk for not receiving the necessary services and assistance that can result in resident injury or serious condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 3) received care consistent with professional standards of practice to prevent pressure ulcers (PU, a localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure, or pressure in combination with shear) by failing to ensure Resident 3's low air-loss mattress (LALM - a mattress composed of inflatable air cushions that is used to relieve pressure on body parts) was set to appropriate setting per manufacturer's guidelines. This deficient practice had placed Resident 3 at risk for the development of pressure ulcers.

Inspectors wroteBased on interview and record review, the facility failed to ensure the medical records of one of seven sampled residents (Resident 1) were maintained in accordance with accepted professional standards and practice, complete, and accurately documented by failing to ensure Certified Nursing Assistant (CNA) 2 documented Resident 3's percentage of food eaten on the correct time. This deficient practice resulted in inaccurate information on Resident 1's medical records and had the potential for delayed and inaccurate medical interventions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have a system-wide (something that extends or exists throughout a system) method of accountability for controlled medications (drugs that are regulated by the government because it may be abused or cause addiction) and ensure safeguarding of controlled medications for two of nine sampled residents (Resident 1 and Resident 2) by: 1. Failing to ensure licensed nurses document the administration of controlled substances in Resident 1's electronic Medication Administration Record (eMAR- an electronic report detailing the drugs administered to a resident) 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the resident's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) for six of eight sampled residents (Residents 31, 5, 30, 63, 33, and 151) investigated during review of physical restraints care area by failing to ensure: 1. [...]

Inspectors wroteBased on interview and record review, the facility's licensed nursing staff failed to provide care in accordance with professional standards to four (4) out of 4 sampled residents (Residents 49, 159, 73, and 100) investigated under insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) insulin administration sites. These deficient practices had the potential for adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin such as lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received care consistent with professional standards of practice to prevent pressure injury (also called pressure ulcer, the breakdown of skin integrity due to pressure) for four of five sampled residents (Residents 124, 30, 110, and 100) investigated under pressure injury by failing to ensure: 1. Resident 124 and 100's Low Air Loss Mattress (LALM, a mattress that helps prevent and treat pressure wounds by circulating air and relieving pressure on the body) machine was labeled accurately. 2. Residents 30's LALM was set according to resident's weight. 3. Resident 110's LALM had a physician's order. 4. Resident 110's LALM was set to the correct weight. These deficient practices had the potential for development and worsening of pressure ulcers/injuries to residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment was free of accident hazards for four of eight sampled residents (Residents 124, 2, 174, and 334) investigated under accidents, and for one of eight sampled residents (Resident 129) reviewed under physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the resident's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) care area by failing to: 1. Ensure Resident 124, 2, and 174's fall mat (a cushioned floor pad designed to help prevent injury should a person fall) did not have a furniture or equipment on top of them. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure to dispose of medications in a manner that was not retrievable (able to get back), in one (1) of two (2) inspected Medication Rooms (Medication Room Station 1). 2. Not dispose aerosolized (having tiny particles of matter and gas or liquid that turn into a fine mist to be inhaled) inhaler (a device containing a pressurized canister that is inhaled and delivers medication to the lungs) in the pharmaceutical (any medication/drug or dietary supplement for use by humans) waste bin (specialized container for disposing pharmaceutical waste) in one (1) of two (2) inspected Medication Rooms (Medication Room Station 1). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one (1) of five (5) sampled residents (Resident 132) drug regimen was free from unnecessary medications (any medication in excessive dose, excessive duration, without adequate monitoring) in accordance with the facility policy and procedures (P&P) by failing to ensure Resident 132 had a specific, measurable target behavior related to the use of quetiapine (an antipsychotic [medication capable of affecting the mind, emotions, and behavior] used to treat mental illness). This deficient practice had the potential to place Resident 132 at risk for significant adverse effects (unwanted, unintended results) from the use of unnecessary antipsychotic drugs, which could result to impairment or decline in the resident's mental, physical condition, functional, and psychosocial status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a medication error rate below 5 percent (%) by having two (2) medication errors out of 29 opportunities contributing to an overall error rate of 6.9% for two (2) out of three (3) sampled residents (Resident 28 and 39) observed during the Medication Administration facility task. The medication errors were as follows: 1. Resident 28 did not receive a dose of oyster shell calcium (a medication used as a dietary supplement to provide support to bones) as ordered by Resident 28's physician, and 2. Resident 39 did not receive a dose of docusate (a medication used to treat symptoms of gas such as painful pressure, fullness, and bloating) at the scheduled time as ordered by Resident 39's physician. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free of any significant medication errors: 1. For one (1) of three (3) sampled residents (Resident 28) investigated under medication administration by failing to administer epoetin alfa (a medication used to treat anemia [a blood disorder when the body doesn't produce enough red blood cells,]) as prescribed by Resident 28's physician. As a result, Resident 28 received two (2) doses of epoetin alfa, against the physician orders. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Remove and discard from use one expired anastrazole (a medication used for breast cancer) medication bottle for Resident 173, in accordance with facility and manufacturer's requirements in one of two inspected medication rooms (Medication room [ROOM NUMBER].) 2. Label one budesonide and formoterol (a combination medication used to treat chronic obstructive pulmonary disease [COPD]- a disease that blocks air flow and makes breathing difficult]) inhalation aerosol (form of medication that is inhaled) for Resident 94 with an open date, in accordance with facility requirements and manufacturer's requirements in one of four inspected medication carts (Medication Cart 1). 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the menu and did not meet nutritional needs of 123 of 168 residents on regular texture diets (diet with no restriction) when staff did not level off the scoop when scooping rice and carrots from the steamtable to the resident's plates. This failure had the potential to result in increased food and nutrient intake resulting to unintended (not done on purpose) weight gain and increased in blood sugar levels for residents on consistent carbohydrate diet ([CCHO] diet with the same amount of carbohydrates per meal).

Inspectors wroteBased on observation, interview and record review, the facility failed to prepare foods in a form designed to meet individual needs when residents on puree diet/level four (4) (food that are soft and pudding-like consistency) received puree spinach that was too sticky and did not fall from the spoon during a spoon tilt test (a method used to determine the stickiness of food and ability of the food to hold together). This deficient practice had the potential to cause coughing, choking (to keep from breathing the normal way) and death for 24 of 168 residents on puree/level 4 diet.

Inspectors wroteBased on observation, interview, and record review, the facility failed meet three (3) of 3 sampled resident's (Resident 34, Resident 1, and Resident 20) food preferences when: a. Resident 34 disliked green beans and was given green beans for lunch. b. Resident 1 was restricted lactose (a sugar present in milk) and lactose containing product (yogurt, ice cream, cream, cheese, sour cream, salad dressing) by indicating Resident 1 was allergic (affected with an immune reaction that occurs when the body mistakenly identifies a certain food as harmful, and reaction could lead to various symptoms ranging to mild and life-threatening) to lactose when Resident 1 was not allergic to lactose and liked lactose and lactose-containing product except milk to drink. c. Resident 20 disliked milk products and was given milk shakes for lunch. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: a. Three (3) of five (5) green racks had chips in the walk-in refrigerator. b. Food preparation surfaces and kitchen equipment were not cleaned and sanitized. 1. Two (2) green racks had dust buildup in the walk-in refrigerator. 2. Walk-in freezer's roof and right-side wall had ice crystal buildup. 3. Bottom shelves of the reach-in refrigerator had dust and dirt debris. 4. Dry storage room floor had food debris. 5. Juice machine filter had dust buildup and racks are sticky and dusty to touch. 6. Scoops and paper drawer had food debris. 7. Ice container had white residue buildup. 8. Coffee machine hot waterspout (a tube or lip projecting from a container, through which liquid can be poured) had dried up mineral water buildup. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow through their submitted application to the State Agency 1 (SA 1) for the change of medical director to comply with the State and Federal requirement for 12 months of 12 months (12/20/2023 to 12/20/2024). This deficient practice had the potential to result in delay in the medical director's ability to implement necessary changes or improvements in care practices, negatively affecting the quality-of-care residents receive.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections by: 1. Failing to ensure the oxygen (O2) nasal cannula (NC) tubing (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) was kept off the floor for one (1) of 1 sampled resident (Resident 159) investigated during a random observation. 2. Failing to ensure the staff washed or sanitized their hands prior to distributing trays and assisting residents to eat in the Dining Room Area for Station 2 and failed to offer hand hygiene to the residents prior to eating during Dining Observation Task. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure (P&P) related to a resident's decision-making process for informed consent (IC-voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) for one of six sample residents (Resident 37) by obtaining a consent for an antipsychotic medication from the resident without capacity to make medical decisions. This failure had the potential for Resident 37 to not understand his treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the resident's right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm by one resident towards another) for one of three sampled residents (Resident 85) when on 12/10/2024 at 1:30 p.m., Certified Nursing Assistant 3 (CNA 3) and Resident 999 witnessed Resident 73 pull Resident 85's right arm (while he was on his wheelchair going to the bathroom accompanied by CNA 3) while passing Resident 73's bed (who was sitting at the edge of his bed) leading to both residents landing on the floor. This deficient practice resulted in Resident 85 being subjected to physical abuse by Resident 73 while under the care of the facility. Resident 85 sustained a superficial scratch on his right cheek. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to thoroughly investigate a physical abuse (deliberately aggressive or violent behavior with the intention to cause harm by one resident towards another) allegation for one of three sampled residents (Resident 85) by failing to include in their final investigation report the precipitating factors (a specific event or trigger to the onset of the current problem) that led to Resident 73 pulling Resident 85's right arm on 12/10/2024 at 1:30 p.m. while passing Resident 73 who was sitting at the edge of the bed. Resident 185 was on his wheelchair on the way to the bathroom accompanied by Certified Nursing Assistant 3 (CNA 3). The incident led to both residents landing on the floor with Resident 85 sustaining a superficial scratch on his right cheek. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that the discharge information is documented in the resident's medical record and is communicated to the resident for two of two sampled residents (Resident 54 and 75) investigated under Discharge care area by: 1. Failing to take and document the resident's vital signs prior to discharge for Residents 54 and 75. 2. Failing to provide special instructions for Resident 54 including follow-up with the gastrointestinal (GI - relating to your stomach and intestines physician and list of medications. 3. Failing to accurately document Resident 54's exact discharge location address and contact information. These deficient practices had the potential to result in discontinuity of the residents' care and an unsafe transition of care.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents are screened using the Preadmission Screening and Resident Review (PASRR, a federal requirement to help ensure that individuals are not appropriately placed in nursing homes for long-term care) for a mental disorder (MD) or intellectual disability (ID) prior to admission and that individuals identified with serious mental illness (SMI) and/or ID/developmental disability (DD)/related conditions (RC) receive the care and services in maintaining his/her highest practicable level in the most appropriate setting for two of three sampled residents (Resident 124 and 11) investigated under PASRR care area, by: 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure there was documented evidence that discharge planning arrangements regarding follow-up gastrointestinal (GI - relating to your stomach and intestines consultation was made and provided to the resident upon discharge for one of three sampled resident (Resident 54) investigated under closed records review. This deficient practice had the potential to result in an unsafe discharge, incomplete documentation, and communication of Resident 54's stay in the facility.

Inspectors wroteBased on interview and record review, the facility failed to replace the prescription eyeglasses for one of two sampled residents (Resident 20). This failure had the potential to result in a decline of Resident 20's activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) due to poor vision.

Inspectors wroteBased on interview and record review, the facility failed to ensure an ulnar splint (a device that helps correct and manage a hand deformity that causes fingers to drift away from the thumb) was provided for one of two sampled residents (Resident 2. This failure had the potential to affect Resident 20's range of motion and cause contractures (a stiffening/shortening at any joint, that reduces the joint's range of motion) in her hand.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents with a urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) received appropriate care and services to prevent urinary tract infections (UTI, an infection in the bladder/urinary tract) for three (3) of 3 sampled residents (Residents 49, 153, and 1) investigated under the urinary catheter or UTI care area when the facility failed to ensure Residents 49, 153, and 1's urinary catheter tubing did not have loops while hanging on the side the bed. This deficient practice had the potential for the residents' urine not to flow freely which may lead to development of UTI.

Inspectors wroteb. During a review of Resident 141's admission Record (AR), the AR indicated the facility admitted the resident on 7/6/2023, and readmitted the resident on 10/7/2024, with diagnoses including gastrointestinal hemorrhage (a bleeding disorder in the digestive tract), gastrostomy, and dysphagia (difficulty swallowing). During a review of Resident 141's H&P, dated 10/9/2024, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 141's MDS dated [DATE], the MDS indicated the resident sometimes had the ability to make self-understood and understand others. The MDS indicated the resident had a feeding tube while a resident in the facility. During a review of Resident 141's Order Summary Report, the Order Summary Report indicated the following physician orders: -10/7/2024 Enteral Feed Order. Turn pump on at 12 p.m. and turn off at 8 a.m. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure Nurse Practitioner (NP) obtained an informed consent (IC-voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) for one of six sample residents (Resident 37) for an antipsychotic medication (a substance that can change how a person's brain works and can affect awareness, thoughts, mood, and behavior) from a resident without the capacity to make medical decisions. This failure had the potential for Resident 37 to not understand the risks and benefits of the treatment.

Inspectors wroteBased on interview and record review, the facility failed to ensure that Licensed Vocational Nurse 4 (LVN 4) was competent in implementing the facility's policy and procedure for transfers and discharges for two of three sampled residents (Resident 54 and 75). This deficient practice had the potential to result in a delay of the provision of necessary care and services. Cross-reference:

Inspectors wroteBased on interview and record review, the facility failed to transmit the Minimum Data Set (MDS-a resident assessment tool) Assessments for one of two sampled residents (Resident 102) investigated under Resident Assessments facility task by, failing to transmit Resident 102's MDS Assessments on 1/21/2021 and 4/21/2021. This deficient practice had the potential to negatively affect the provision of necessary care and services needed by the resident.

Inspectors wroteBased on observation, record review, and interview the facility failed to ensure residents receive an accurate assessment, reflective of the residents' status at the time of the assessment for two of two sampled residents (Residents 159 and102) by: 1. Failing to indicate on Resident 159's Minimum Data Set (MDS-a resident assessment tool) Assessment that resident was on dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidneys have failed) investigated under dialysis care area. 2. Failing to accurately code Resident 102's last name on the resident's MDS assessments investigated under the Resident Assessment facility task. This deficient practice had the potential to negatively affect Resident 159 and 102's plan of care and delivery of necessary care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide at least 80 square feet (sq ft - unit of measurement) per resident in 41 of 72 rooms. The room size for these rooms had the potential to have inadequate space for resident care and mobility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of six sampled residents' (Resident 1, 2 and 4) environment remains as free of accident hazards as is possible by failing to: a. Ensure Resident 2's wound cleanser was not left unattended on the resident's bedside table. b. Conduct an inventory of Resident 4's belongings thoroughly on admission to ensure the resident did not have access to a bottle of chlorhexidine gluconate (an antiseptic agent that had been shown to decrease microbial flora on the skin and prevent infection risks). Licensed Vocational Nurse 2 (LVN 2) observed Resident 4 holding a bottle of chlorhexidine gluconate against the resident's mouth. c. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure clinical records were complete and accurately documented for one of six sampled residents (Resident 4) by failing to ensure Resident 4 ' s clinical history and diagnosis were accurately documented in the resident ' s clinical records. This deficient practice had the potential for delayed and inappropriate medical interventions for Resident 4.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement comprehensive care plans for one of three sampled residents (Resident 2) by: 1. Failing to implement an intervention in Resident 2 ' s care plan titled Residents ' preference to exercise unsupervised in the patio and parking, dated 9/29/2022, indicating the Physical Therapist (PT) to assess Resident 2 quarterly (every three months) and as needed for safety of gait, transfer, sitting, balance and need for safety device. 2. Failing to implement an intervention in Resident 2 ' s care plan titled, At risk for fall risk for fall related to episode of going unsupervised to the front patio, dated 10/3/2022, indicating Receptionist 1 (RCP 1) will oversee Resident 2 when the resident goes to the front patio unsupervised. 3. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to implement infection control measures for five of ten staff (Receptionist 1 [RCP1], Laundry Staff 1 [LS 1, LS 2, Housekeeper 1 [HSK 1] HSK 2 during a Coronavirus Disease 2019 (COVID-19, a very contagious disease that affects the lungs) outbreak (a sudden rise in the incidence of a disease) by: 1. Failing to ensure RCP 1 wore a face mask while assisting visitors in the reception area. 2. Failing to ensure RCP 1 inform visitors of COVID-19 outbreak and the use of N95 mask during outbreak. 3. Failing to ensure HSK 1 and HSK 2 wore a face mask while talking to each other inside the laundry room. 4. Failing to ensure LS 1 and LS 2 wore a face mask covering their nose and mouth while inside the laundry room with HSK 1 and HSK 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 2) was provided adequate supervision by failing ensure Receptionist 1 (RCP 1) call for staff assistance when RCP 1 did not visually see Resident 2 in the front patio. Resident 2 was observed walking in the facility parking lot alone and unsupervised on 6/17/2024. This deficient practice placed Resident 2 at risk for fall and injury.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free of any significant medication errors (one which causes the resident discomfort or jeopardizes his or her health and safety) by: 1. Failing to provide documented evidence that lispro (medication used to lower glucose [sugar] level in the blood) four units was given to Resident 1 on 4/16/2024 and 4/18/2024 at 5:15 p.m. 2. Failing to provide documented evidence that Lantus (a long-acting [slowly absorbed after being administered, and maintains its effects over a long period of time] man-made-insulin used to control high blood sugar) 21 units was given to Resident 1 on 4/16/2024, 4/18/2024, and 4/19/2024 at 9 p.m. 3. Failing to ensure lispro was not given for blood sugar below 100 on 5/14/2024 at 7:15 a.m., when Resident 1's blood sugar level was 93. 4. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) who was receiving apixaban (blood thinner or anticoagulant-a medication used to treat and prevent blood clot [a sticky lump that forms when blood dries up or becomes thick]) was monitored for signs of bleeding. This deficient practice placed Resident 1 at risk for adverse reactions including bleeding easily and bruising.

Inspectors wroteBased on interview and record review, the facility failed to develop a baseline individualized care plan for one of three sampled residents (Resident 1). Resident 1 had no care plan to address safety and supervision related to history of leaving against medical advice. On 4/29/2024 facility admitted Resident 1 from General Acute Care Hospital 1 (GACH 1) with two history of leaving against medical advice and on 4/30/2024, Resident 1 eloped from the facility. This deficient practice had the potential for Resident 1 to not receive appropriate care and treatment specific to their needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident was provided supervision to prevent leaving without a physician's order for one of three sampled residents (Resident 1). On 4/30/2024 Activity Coordinator (AC) entered the pin code to open the elevator going down and left Resident 1 and Family Member 1 (FM 1) unsupervised. This deficient practice resulted to Resident 1's leaving the facility without a physician's order and can potentially place Resident 1 at risk for injury, bleeding, infection, and dislodgement (to remove or force out of a particular place) of Jackson Pratt (JP-a surgical suction drain that gently draws fluid from a wound to help you recover after surgery) drain.

Inspectors wroteBased on interview and record review, the facility failed to maintain a complete and accurate medical records in accordance with accepted professional standards for one of three sampled residents (Resident 1) who eloped on 4/30/2024. This deficient practice had the potential to result in confusion in the care and services rendered to Resident 1 and resulted in inaccurate information entered into Resident 1's clinical record.

Inspectors wroteBased on interview and record review, the facility failed to have a discharge planning process (process that generally begins on admission and involves identifying each resident ' s discharge goals and needs, developing and implementing interventions to address them, and continuously evaluating them throughout the resident ' s stay to ensure a successful discharge) for five of 11 sampled residents (Residents 1, 8, 9, 10, and 11). The facility failed to: 1. Develop a Discharge Care Plan for Residents 1, 8, 9, 10, and 11 since admission to the facility. 2. Ensure regular re-evaluation of Residents 1, 8, 9, 10, and 11 to identify changes that require modification of the discharge plans. 3. Discuss, make referrals, and document in the clinical record when Resident 1 manifested interest in returning to the community. 4. [...]

Inspectors wroteBased on interview and record review, the facility failed to employ a qualified social worker (an individual with a minimum of a bachelor ' s degree in social work or a bachelor ' s degree in a human services field including, but not limited to, sociology [study of social life, social change, and the social causes and consequences of human behavior], gerontology [study of the biological, psychological, and social aspects of aging], special education, rehabilitation counseling, and psychology [scientific study of the mind and behavior]; and one year of supervised social work experience in a health care setting working directly with individuals) on a full-time basis. This deficient practice placed all residents in the facility at risk of not receiving their needed medically related social services. Cross reference F660.

Inspectors wroteBased on interview and record review, the facility failed to ensure the safety of one of three sampled residents (Resident 1) who was identified as high fall risk. On 1/14/2024 at 9 a.m., Resident 1 ' s Responsible Party 1 (RP 1) informed the facility that the resident had a witnessed fall at 4 a.m. on 1/14/2024. Resident 2, who was alert and awake witnessed Resident 1 on the floor. Resident 1 sustained a skin tear on the right shin. The facility: 1. Failed to assess and monitor Resident 1 after her fall. 2. Failed to report and conduct a thorough investigation of Resident 1 ' s fall. These deficient practices had the potential for exposure to and delayed identification of serious injuries or harm to the resident.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of resident-to-resident abuse within two hours from the initial report of the incident for two of three sampled residents (Resident 1 and Resident 2). On 12/29/2023 at 2:15 p.m., Resident 1 reported to Certified Nursing Assistant 1 (CNA 1) that Resident 2 hit her. The allegation was not reported until 12/30/2023. This deficient practice had the potential to result in unidentified abuse in the facility and had the potential to place Resident 1 at risk for further abuse.

Inspectors wroteBased on interview and record review, the facility failed to report the allegation of visitor to resident abuse to the State Survey Agency (SSA) for one of three sampled residents (Resident 1). This deficient practice had the potential to result in unidentified abuse and failure to protect other residents from abuse.

Inspectors wroteBased on interview and record review, the facility failed to submit the results of the facility investigation on the allegation of abuse within five (5) working days to the State Survey Agency (SSA) for one of three sampled residents (Resident 1). The allegation of abuse happened on 3/4/2023. The facility failed to submit the 5-day investigation report on 3/10/2023. This deficient practice had the potential to delay the investigations and result in failure to protect other residents from abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care in a manner that maintained a resident ' s dignity for one of four sampled residents (Resident 4) by failing to ensure Resident 4 ' s urinary collection bag was covered with a privacy bag. This deficient practice had the potential to affect the self-esteem and self-worth of Resident 4.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 4) urinary catheter (a flexible tube used to empty the bladder and collect urine in a drainage bag) was secured to resident ' s thigh. This deficient practice placed the resident at risk to have a potential dislodgement (forced out of position) of the catheter that may result with a trauma to the urethra (a tube that connects the urinary bladder to the urinary meatus [opening] for the removal of urine from the body of both females and males).

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control measures for one of four sampled residents (Resident 4) by failing to ensure residents urinary catheter tubing (a flexible tube used to empty the bladder and collect urine in a drainage bag) was not touching the floor. This deficient practice had the potential for cross contamination (unintentional transfer of bacteria/germs or other contaminant from one surface to another) of infection.

Inspectors wroteBased on observation, interview, and record review the facility failed to keep the call light (an alerting device for nurses or other nursing personnel to assist a patient when in need) within reach of the resident for five out of 11 sampled residents (Resident 26, 16, 137, 21, and 152). The deficient practice had the potential for residents not being able to summon healthcare workers for help as needed.

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents' medical records were updated regarding advance directive (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them) for seven of 30 sampled residents (Resident 21, 22, 58, 27, 36, 46, and 109) when: 1. Resident 21's Advance Directive Acknowledgement form was not placed in the resident's medical record. 2. Resident 22's Advance Directive Acknowledgement form about the resident's medical wishes was left blank. 3. Resident 58 or his responsible party was not provided information about advance directives. 4. [...]

Inspectors wroteBased on interview and record review, the facility's licensed nursing staff failed to provide care in accordance with professional standards to two out of 11 sampled residents (Residents 146 and 137) by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) insulin (a hormone that lowers the level of sugar in the blood) administration sites. The deficient practice had the potential for adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin such as lipodystrophy (abnormal distribution of fat).

Inspectors wroteBased on observation, interview, and record review the facility failed to provide care consistent with professional standards of practice to prevent pressure ulcer/injury (ulcers that happen on areas of the skin that are under pressure from lying in bed, sitting in a wheelchair, or wearing a cast for a long period) to three out of 11 sampled residents (Residents 110, 153, and 148) by failing to ensure the residents' low air-loss mattresses (LALM, an air mattress covered with tiny holes) were set according to the residents' weights. The deficient practice had the potential for development and worsening of pressure ulcers to the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Include the verifying signatures of either the Director of Nursing (DON) or a Registered Nurse (RN) along with Licensed Vocational Nurse (LVN) on the Antibiotic or Controlled Drug (also known as Controlled Medication or Controlled Substance [CM, CS]- medications which have a potential for abuse and may also lead to physical or psychological dependence) or Controlled Drug Record or Controlled Drug Administration Record accountability logs for three sampled month records (October 2023, November 2023, and December 2023). As a result, control and accountability of controlled substances awaiting final disposition (process of returning and/or destroying unused medications) did not follow the facility policy and procedures. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than 5 percent (%) due to 11 errors observed out of 31 total opportunities (error rate of 35.48%). The medication errors were as follows: 1. Resident 1 received seven medications in a form that was not ordered by Resident 1's physician. 2. Resident 1 did not receive fish oil (a medication used as a dietary supplement to provide support to the heart and brain and may lower blood cholesterol [fat] levels) and vitamin C (a medication used for the growth and repair of tissues in all parts of the body, including skin healing) as ordered by Resident 1's physician. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 17 licensed vocational nurses (LVNs) did not administer expired insulin (a medication used to regular blood sugar levels) to three of ten residents (Resident 22, 73, and 148) observed for medication availability. As a result, Residents 22, 73, and 148 received a total of 61 doses of expired insulin. These practices had the potential to cause Residents 22, 73, and 148 to experience serious health complications due to uncontrolled blood sugar levels, possibly resulting in hospitalization or death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Remove and discard from use one expired insulin (medication used to regulate blood sugar levels) glargine (long-acting insulin) prefilled pen (an injection device containing insulin) for Resident 22, and one insulin Lispro (fast-acting insulin) Kwikpen (type of injection device) for Resident 148, in accordance with manufacturer's requirements in one of three inspected medication carts (Medication Cart 1 Station 1.) 2. Label one lorazepam (a medication used to treat anxiety [state of excessive worry or fear] and restlessness) oral concentrate (a solution with increased strength) bottle with an open date and store in the refrigerator for Resident 165 in accordance with the manufacturer's requirements in one of three inspected medication carts (Medication Cart 1 Station 1.) 3. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure proper sanitation and food handling practices by failing to ensure: 1. A white plastic cup was not used as a scooper and left inside the bin of white flour. 2. Lays Classic (food service package) potato chips wrapped on a thin, clingy plastic wrap was labeled with a date opened and was not left in the dry pantry. 3. Two bananas on a bin dated 12/7/2023 with blackened peel were discarded. These deficient practices had the potential to cause foodborne illnesses (any illness of a toxic or infectious nature contracted through consumption of contaminated water or food).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignity for one of 30 residents (Resident 48) when Certified Nursing Assistant (CNA) 6 was observed standing over Resident 48 while assisting the resident with feeding. This deficient practice had the potential for Resident 48 to feel disrespected.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident who experienced a significant change in status was comprehensively assessed using the Centers for Medicare & Medicaid Services (CMS) Resident Assessment Instrument (RAI) process for one of 30 sampled residents (Resident 28) when the facility did not conduct a significant change assessment on Resident 28's Minimum Data Set (MDS - a standardized assessment and care screening tool) after Resident 28 was discharged from hospice (type of care that focuses on the care, comfort, and quality of life of a person with a serious illness who is approaching the end of life). This deficient practice had the potential to delay care for Resident 28.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for two of 22 residents (Resident 71 and 141) by failing to: a. Develop and implement Resident 71's care plan on the use of antidepressant (Lexapro, a type of medicine used to treat clinical depression [mood disorder that causes a persistent feeling of sadness and loss of interest]). b. Develop and implement Resident 141's care plan on the use of insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood). c. Develop and implement Resident 141's care plan on the use of Eliquis (Apixaban, an anticoagulant [decrease your blood's ability to clot] medication used to treat and prevent blood clots). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a written Discharge Summary, which included a recapitulation (summary) of the resident's stay at the facility for one of three sampled residents (Resident 168) in accordance with the facility policy. This deficient practice had the potential to result in Resident 168 not receiving the necessary information for provision of care when discharged and to ensure safe transition to another setting such as in resident's home.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide an environment that is free from accident hazard to one out of 11 sampled residents (Resident 137) by failing to ensure the bed of Resident 137, who was known to be at high risk for fall with injury, was placed on the lowest position as indicated in the care plan. This deficient practice had the potential for repeated accidents and falls that could lead to fractures (a partial or complete break in bone) and even death.

Inspectors wroteBased on observation, intervention, and record review, the licensed nursing staff failed to ensure one of four sampled residents (Resident 68) receiving enteral water flushes (a way to deliver fluids directly into the stomach or small intestine) received proper care and services consistent with professional standard of care by failing to ensure that Resident 68's hanging water flush bag was labeled with the resident's initials, date, and time hung or administered. This deficient practice had the potential to cause possible complications and risk factors like infection, aspiration (food or fluids entering the lungs), weight loss, and dehydration (a harmful reduction in the amount of water in the body) for Residents 68.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident receive treatment and care in accordance with professional standards of practice to one out of 11 sampled residents (Resident 53) by: 1. Failing to reassess the resident's pain level prior to administering a narcotic (a drug that causes unfeelingness or feeling almost unconscious with inability to act or think normally) pain medication. 2. Not accurately documenting the resident's pain level. These deficient practices resulted in Resident 53 receiving a narcotic pain medication intended and ordered for severe pain (7-10, [0 representing no pain and 10 very much pain]), and had a potential for uncontrolled pain and suffering on the resident.

Inspectors wroteBased on observation, interview, and record review the facility failed to keep the resident's bed in functional condition for one out of 11 sampled residents (Resident 71) by failing to ensure Resident 71's bed was plugged in for the resident to adjust the bed according to her needs. The deficient practice had the potential for delay in the delivery of necessary care and services and discomfort to the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents' bedrooms meet the requirement of 80 square feet (sq. ft., a unit of measure) per resident in multiple resident bedrooms for 41 of 72 rooms (Rooms 101, 103, 105, 106, 116, 119, 120, 121, 122, 123, 125, 126, 128, 130, 131, 133, 135, 201, 202, 203, 204, 205, 208, 209, 210, 211, 214, 216, 217, 218, 219, 220, 221, 222, 224, 225, 228, 229, 230, 231, and 232). This deficient practice had the potential to result in inadequate space to provide safe nursing care, privacy for the residents, and limit the residents' ability to maneuver personal care devices.

Inspectors wroteBased on interview and record review, the facility failed to provide the requested medical records to the responsible party of one of three sampled residents (Resident 1). The facility received the request to release Resident 1 ' s medical records on 9/19/2023. This deficient practice violated the resident ' s rights to secure personal medical records.

Inspectors wroteBased on interview and record review, the facility failed to provide the requested medical records to the legal representative of one of three sampled residents (Resident 3). The facility received the request to release Resident 3 ' s medical records on 9/19/2023. This deficient practice violated the resident ' s rights to secure personal medical records.

Inspectors wroteBased on observation, interview, and record review, the facility with a Coronavirus Disease 2019 (COVID-19- highly contagious respiratory disease is thought to spread from person to person through droplets released when an infected person coughs, sneezes or talks) outbreak (sudden increase in number of cases), failed to implement infection control practices for three of five sampled staff by: 1. Failing to ensure Certified Nursing Assistant 1 (CNA 1) tied the back of his protective gown before going inside Resident 1 and Resident 2' s room who was positive for COVID-19. 2. Failing to ensure Social Service Designee 1 (SSD 1) wore protective mask covering her nose and mouth while speaking to the admission Director (AD). 3. Failing to ensure AD wore protective mask while speaking to SSD 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect one of three sampled residents (Resident 1) from physical abuse inflicted by Resident 2. On 9/12/2023 at 5:35 p.m., while in the activity/dining room, Resident 2, who had episodes of aggressive and agitated behaviors, without provocation hit, grabbed, and pulled Resident 1 ' s right arm. In response to the attack from Resident 2, Resident 1 in defense hit, grabbed, and pulled Resident 2 ' s left arm. As a result, Resident 1 sustained a skin tear (a wound caused by shear [cut], friction, and / or blunt force resulting in separation of skin layers) on the back of the right hand measuring 4 centimeters (cm - a unit of measurement) in length by 4 cm in width. Resident 2 sustained a skin tear on the left arm measuring 4 cm by 4 cm. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that six of seven sampled licensed vocational nurses (LVNs 1, 3, 4, 5, 6, and 7) worked within their scope of practice. LVNs were performing resident assessments without reporting to a registered nurse (RN) to conduct a complete assessment. This deficient practice placed the residents at risk for not receiving the appropriate care and services necessary to meet their medical, physical, mental, and psychosocial needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide supervision for two of three sampled residents (Resident 1 and Resident 2), who were both assessed with agitation and aggressive behavior, had a physical altercation in the TV room in the presence of five facility staff. None of the five facility staff present in the TV room responded to stop the physical altercation between Resident 1 and Resident 2. As a result, on 9/12/2023 at 5:35 p.m., Resident 1 and Resident 2 both sustained skin tears (wounds caused by shear [cut], friction, and/or blunt force resulting in separation of skin layers) from the physical altercation.

Inspectors wroteBased on interview and record review, the facility failed to follow infection control procedures for one of three sampled residents (Resident 1) by failing to: a. Ensure facility staff performs hand hygiene (hand washing with soap and water and use of alcohol-based hand sanitizer) before wearing gloves and rendering wound care. b. Ensure facility staff ' s protective equipment (PPE - equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) was worn inside the facility. The face mask was not covering Licensed Vocational Nurse 1 (LVN 1) ' s nose and mouth while rendering wound care and talking to the resident. These deficient practices placed Resident 1 at risk for exposure and contracting infections.