Caretel Inns of Linden

Inspectors wroteThis citation pertains to intake Number 2970791. Based on observation, interview and record review, the facility 1) Failed to ensure that residents were monitored per orders for weight change. 2)Failed to ensure that a change of condition assessment was documented when a significant weight loss was identified, and. 3) Failed to update and revise a resident-centered care plan; resulting in delayed care contributing to a 9.23% weight loss in 7 weeks for one resident (Resident #1) of three residents reviewed for quality of care with weight loss.

Inspectors wroteThis citation pertains to Intake Number 2792791. Based on observation, interviews and record review, the facility failed to protect the resident's right to be free from physical abuse for one resident (Resident #102) by another resident (Resident #103), who attacked the resident at the dining room of nine (9) residents reviewed for abuse, resulting in a skin tear to R102's right hand and possible infection of the open wound.

Inspectors wroteThis citation pertains to Intake Numbers 2741938 and 2745566. Based on observation, interview and record review the facility failed to prevent significant medication errors for one resident (Resident #101) of 7 residents reviewed for medication errors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to 1) Have an active plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the increased potential to result in water borne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among any or all of the residents in the facility; 2) Complete routine resident and staff Infection Surveillance, including audits/environmental rounds, analyze data for trends and report findings and 3) Ensure the appropriate use of Personal Protective equipment, per Standards of Practice, which could lead to an outbreak of infectious organisms, and illness. Facility Infection Control On 9/09/2025 at 10:48 AM during an interview with IP/Infection Preventionist “H”, she said she was new to the role. [...]

Inspectors wroteBased on observation and record review, the facility failed to ensure that the appropriate backflow prevention was installed on cross connections. This deficient practice increases the likelihood of contamination of the water supply due to a backflow event, potentially affecting all residents, staff, and visitors who consume water at the facility.

Inspectors wroteThis Citation Pertains to Intake Numbers 2586675 and 2594091. Based on observation, interview, and record review the facility failed to provide a clean, comfortable and home like environment to ensure that resident rooms, bathrooms and common areas were clean, for residents on the 100 hall and for a Confidential Group of Residents on the 100, 200 and 300 halls, resulting in an unclean physical environment, resident dissatisfaction and complaints regarding the lack of cleanliness, and Infection Control practices. Environment During a tour of the building on 9/3/2025 at 7:45 AM, there were multiple observations of unclean resident rooms on the 100 hall. Several rooms were noted to have a strong, foul odor including room [ROOM NUMBER] and #114. Many rooms were cluttered with items, including items on the floor, windowsills and other surfaces. [...]

Inspectors wroteThis Citation Pertains to Intake Number 2586675. Based on observation, interview and record review the facility failed to review and revise Care Plans to ensure a resident-centered comprehensive care plan for four residents (#21, #22, #60 and #67) of 40 residents reviewed, resulting in the residents (#21, #22, #60 and #67) lacking a Care Plan with resident specific interventions. Resident #21 Accidents Falls A record review of the Face sheet and electronic medical record indicated Resident #21 was admitted to the facility on [DATE] with diagnoses Dementia mood disturbance with anxiety, and weakness. Per the progress notes, Resident #21 was receiving Hospice services. On 9/03/2025 at 10:03 AM, Resident #21 was observed in the hallway with her legs hanging over the side of a broda chair. She was leaning forward and trying to move the chair. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure that medications and supplements were labeled, stored and disposed of properly, resulting in expired supplements in the medication room, expired over the counter medication and loose and unlabeled medications in the medication carts.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly dispose of waste and maintain dumpster area to mitigate the presence of insects and rodents, potentially affecting all residents, staff, and visitors in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were treated in a respectful and dignified manner for 2 Residents (#22 and #59) from a facility census of 52 residents, resulting in missing items not being replaced in a timely manner for Resident #22 and some confidential group of residents were unable to reenter the building nor reach the facility by phone for reentry after hours or after outside visitation with family and friends.

Inspectors wroteBased on interview and record review, the facility failed to ensure Code Status was accurately documented and accessible in the medical record Care Plan for one resident (#21) of 1 reviewed for Advance Directives, resulting in the potential for miscommunication of code status which could lead to a lack of appropriate interventions for care. Resident #21 Advance Directives NotesA record review of the Face sheet and electronic medical record indicated Resident #21 was admitted to the facility on [DATE] with diagnoses Dementia mood disturbance with anxiety, and weakness. Per the progress notes, Resident #21 was receiving Hospice services. A review of the Face sheet for Resident #21 identified, Code Status: (Advance Directives)- Code Status: DNR. A review of the Documents section of the electronic medical record identified an assessment form titled, Code Status Form for Resident #21. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure PASARR assessments were completed yearly and posted into the residents' clinical record for two residents (R#7 and R#10) of 3 residents reviewed for coordination of PASSAR and Assessments. Findings Include:On 9/4/25 at 2:30 PM, a review of R7's Pre-admission Screening and Resident Review (PASARR) was conducted. It revealed that R7 did not have one on file for 2025. The last PASARR in R7's File was dated7/3/2024. No other PASSAR Forms were found in R7's Electronic Medical Record. On 09/04/2025 2:58 PM, R10's PASARR was reviewed. An outdated Level I PASARR was found dated 12/20/2021. Another outdated PASSAR Level I and Level II dated August 16, 2024, was found. There was no assessment dated 2025 posted. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that a wound was assessed with appropriate treatment for one resident (R6) and hospice orders were in place for two residents (R60 and R65) of three residents reviewed for quality of care, resulting in missing treatments for a wound and the absence of hospice treatment orders.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate supervision and revise the care plan to prevent falls for one resident (Resident #7) of three residents reviewed for falls and accidents.

Inspectors wroteBased on interview and record review the facility failed to ensure consents were signed and behavior monitoring was provided for psychotropic medications for two residents (R13, R60) of two residents sampled for psychotropic medications, resulting in the lack of consents and behavior monitoring.

Inspectors wroteBased on interview and record review the facility failed to ensure resistance patterns of organisms were identified and reviewed in the antibiotic stewardship meeting, resulting in the potential exposure of infection and ineffective antibiotic use for all 52 residents in the facility. Facility Infection Control On 9/09/2025 at 10:48 AM during an interview with IP/Infection Preventionist H, she said she was new to the role. She started in December 2024 and completed the CDC/Center for Disease Control and Preventions Certificate training course for Long Term Care/LTC on 4/6/2025. When asked to review the Infection Surveillance data for the prior year, September 2024 through September 2025, The IP H said she began collecting Infection Surveillance in April 2025, and surveillance prior to that was completed by someone else. [...]

Inspectors wroteBased on interview, and record review the facility failed to ensure residents were 1) Consistently assessed for Influenza and Pneumococcal vaccinations on admission, per Standards of Practice, 2) Provided an educational vaccination information statement for each vaccination, and 3) Documented vaccination information in the residents' medical record, which could potentially affect all residents, including Residents #27, #30, #68 and #70, reviewed for infections, resulting in the potential for exposure to Influenza and Pneumococcal disease, and severe illness.

Inspectors wroteBased on interview, and record review the facility failed to ensure that residents were 1) Consistently assessed for Covid-19, per Standards of Practice, 2) Provided an educational vaccination information sheet for each vaccination, and 3) Documented vaccination information in the residents' medical record, which could potentially effecting all residents, including Residents #27, #30, #68 and #70, reviewed for vaccinations, resulting in the potential for exposure to Covid-19 and severe illness. FacilityInfection Control On 9/09/2025 at 11:25 AM, during an interview with Infection Preventionist/IP H, she was asked about resident vaccinations for Influenza/FLU and Pneumonia. She said she was currently working with a local pharmacy to implement a vaccination clinic in October 2025 to provide FLU, Pneumonia and Covid vaccinations for the residents. [...]

Inspectors wroteThis Citation Pertains to Intake Numbers MI00149339 and MI00149518. Based on observation, interview, and record review the facility failed to provide a clean, comfortable and home like environment by failing to ensure that residents' rooms were clean, for two resident's (#1 and #5) and there was enough linen to accommodate residents' needs, resulting in an unclean physical environment, resident dissatisfaction and complaints regarding the lack of cleanliness and linen. Findings Include: Resident #1: A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #1 was admitted to the facility on [DATE] with diagnoses: Dementia, Schizophrenia, diabetes, COPD, Cognitive communication deficit, Depression, and a history of falls. Hospice care began 12/16/2024. [...]

Inspectors wroteThis Citation pertains to Intake Number MI00148245. Based on observation, interview, and record review, the facility failed to ensure that the bladder scanner for the entire facility was in good repair to clinically assess residents diagnosed with urinary retention for one resident (Resident #500) of 3 residents reviewed with indwelling catheters, resulting in urinary retention, severe abdominal pain and the likelihood of further complications and delayed urinary care needs.

Inspectors wroteThis Citation pertains to Intake Number MI00133932. Based on observation, interview and record review the facility failed to implement and carry out interventions to prevent the development of pressure ulcers for one resident (Resident #39) of three residents reviewed for pressure ulcers resulting in the development of four facility-acquired pressure ulcers (1-Stage 3 and 3-Unstageable).

Inspectors wroteResident #20: A review of Resident #20's medical record revealed an admission on [DATE] with diagnoses that included dementia, chronic obstructive pulmonary disease, weakness and difficulty in walking. A review of the Minimum Data Set assessment revealed the Resident has severely impaired cognition and needed substantial/maximal assistance with most mobility, upper body and lower body dressing and partial/moderate assistance with oral hygiene. A review of Section B-Hearing, Speech, and Vision, the Resident was documented as makes self-understood with ability to express ideas and wants and understood others with clear comprehension. On 8/21/24 at 10:45 AM, an observation was made in Resident #20's room of Resident #20 lying in bed, with a sheet over her and head of bed slightly elevated. The Resident did not engage in conversation and was able to readjust herself in bed. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that a medication cart and a treatment cart were secured, ensure proper labeling of medication and ensure that topical treatments were not stored with oral medications, of two medication carts and one medication room reviewed for medication storage and labeling, resulting in the potential of medications administered with decreased efficacy, improper labeling of medications, ingestion of medications and drug diversion.

Inspectors wroteThis Citation pertains to Intake Numbers MI00143075 and MI00144896. Based on observation, interview and record review, the facility failed to ensure a safe and sanitary environment in resident care areas and in the kitchen area. This deficient practice has the potential to affect all 55 residents who reside in the building, resulting in the potential for injury, dissatisfaction of living conditions and foodborne illness.

Inspectors wroteThis Citation Pertains to Intake Number MI00140086. Based on interview and record review, the facility failed to protect Resident #59's right to be free from sexual abuse by Resident #309, resulting in Resident #309 found alone in Resident #59's room with his hand down her pants. Findings Include: Abuse Resident #59: A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #59 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: Dementia, hypothyroidism and anemia. The MDS dated [DATE] revealed Resident #59 had severe cognitive loss with a Brief Interview for Mental Status (BIMS) score of 1/15. The MDS also indicated the resident needed supervision with mobility. Resident #309: A record review of the Face sheet and MDS assessment indicated Resident #309 was admitted to the facility on [DATE] with diagnoses: [...]

Inspectors wroteThis Citation pertains to Intake Number MI00136526. Based on interview, and record review, the facility failed to retain documentation regarding an injury after a fall investigation was completed and that the documentation was retained for one resident (Resident #56) of three residents reviewed for incident report investigations and retention of documentation, resulting in missed opportunities to prevent potential abuse or neglect, implement corrective measures and appropriate interventions and prevent further harm to occur.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a person-centered baseline care plan to guide the care provided to two residents (Resident #307 and Resident #308) of 34 residents reviewed for care plans, resulting in the failure to provide instructions to the staff for effective and person -centered care to promote well-being and provide an appropriate diet for Resident #307 and dialysis catheter care for Resident #308 . Findings Include: Resident #307: Nutrition A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #307 was admitted to the facility on [DATE] with diagnoses: Cancer of the lung, liver and bone; Pulmonary edema, respiratory failure, pneumonia, and glaucoma. On 8/19/2024 at 4:23 PM, during a tour of the facility, Resident #307 was observed lying in bed with family at the bedside. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive resident-centered care plan for Resident #23's use and maintenance of their CPAP machine for one resident (Resident #23) of 15 residents reviewed for comprehensive care planning, resulting in the potential for unmet care needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement a restorative nursing program for one resident (Resident #25), of three residents reviewed for limited range of motion, resulting in the potential for decline in independence of self-care, physical ability, and overall decreased level of functioning. Findings Include: Resident #25: A review of Resident #25's medical record revealed an admission into the facility on 7/12/19 and re-admission on [DATE] with diagnoses that included kyphosis and scoliosis, bilateral foot drop, weakness, difficulty in walking, chronic pain, muscle wasting and atrophy and need for assistance with personal care. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure interventions were enacted to promote nutrition for two residents (Resident #307 and Resident #308) of 4 residents reviewed for food or nutrition, resulting in Resident #307 and Resident #308 lacking timely assessments and monitoring to aid in identification of nutritional needs. Findings Include: Resident #307: Nutrition A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #307 was admitted to the facility on [DATE] with diagnoses: Cancer of the lung, liver and bone; Pulmonary edema, respiratory failure, pneumonia, and glaucoma. On 8/19/2024 at 4:23 PM, during a tour of the facility, Resident #307 was observed lying in bed with family at the bedside. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that physician's orders and facility policy were followed for enteral feeding for one resident (Resident #39) of one resident reviewed for tube feeding, resulting in the resident not receiving the total ordered amount of enteral feeding and a lack of documentation of the amount of enteral feeding infused.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure proper storage, cleaning and labeling of oxygen/respiratory equipment for Resident #9, Resident #23, and Resident #34, of four residents reviewed for oxygen and respiratory care, resulting in the potential of respiratory infection and deterioration in health and wellbeing.

Inspectors wroteBased on interview and record review, the facility failed to assess, monitor, ensure availability of pain medications and provide pain management for one resident (Resident #307) of 2 residents reviewed for pain management, resulting in the resident's verbalizations of unrelieved pain, frustration and helplessness. Findings Include: Resident #307: A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #307 was admitted to the facility on [DATE] with diagnoses: Cancer of the lung, liver and bone; Pulmonary edema, respiratory failure, pneumonia, and glaucoma. On 8/19/2024 at 4:23 PM, during a tour of the facility, Resident #307 was observed lying in bed with family at the bedside. The resident's family said he was having pain and was not receiving pain medicine that helped. They said the resident also had a cough and wanted some cough syrup. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure dialysis communication forms were complete and included pre-dialysis and post-dialysis assessment, including location and assessment of the dialysis access site, for one resident (Resident #308) of 2 residents reviewed for Dialysis care, resulting in the potential for a decline in condition and the inability for a prompt response to care needs. Findings Include: Resident #308: Dialysis A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #308 was admitted to the facility on [DATE] with diagnoses: Diabetes, chronic kidney disease, requires renal dialysis, Myelodysplastic syndrome, anemia, heart disease and peripheral vascular disease. On 8/20/2024 at 8:55 AM, Resident #308 was observed lying in bed, awake. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that clinical staff postings were 1.) Completed and available for review for multiple days from January 2024- August 2024, including the months of January 2024, February 2024 and July 2024 and 2.) The clinical staff posting was accurate, resulting in the inability for residents and visitors to know what clinical staff were working on those days. Findings Include: FACILITY Sufficient and Competent Nurse Staffing On 8/22/2024 at 9:40 AM, during an interview with the Director of Nursing/DON about nurse staffing, she said the Clinical Staff posting document (Staffing Report) was completed daily by the Scheduler D and posted on the wall by the nurses' desk. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that medications were available and administered timely as ordered for two (2) residents, Resident #30 and Resident #103, of nine (9) residents reviewed for medications, resulting in R30 not receiving her Lidocaine 4% Patch topically and R103 was not given her Lantus insulin injection resulting in the potential for adverse reactions or worsening of diabetes condition for R103 and potential for increased in pain and discomfort for R30 related to delayed or interruption of the medication.

Inspectors wroteBased on interview and record review the facility failed to obtain consent for the use of an antipsychotic medication for one resident (Resident #303) of 5 residents reviewed for unnecessary medications, resulting in the potential for unidentified adverse effects and the receipt of an unnecessary medication. Findings Include: Unnecessary Medications, Psychotropic Medications, and Medication Regimen Review Resident #303: A record review of the Face sheet, assessments and progress notes, indicated Resident #303 was readmitted to the facility on [DATE] with diagnoses: Alzheimer's dementia, depression, anxiety, heart failure, atrial fibrillation, anemia, hypothyroidism and a history of falls. The Minimum Data Set (MDS) assessment was not yet completed. A review of the electronic medical record revealed Resident #303 was a prior resident at the facility between 10/23/2023 and 12/21/2023. [...]

Inspectors wroteThis Citation pertains to Intake Number MI00133932. Based on observation, Interview, and record review, the facility failed to ensure a medication error rate of less than five percent (5%) when two medications were omitted for Resident #30 (R30)when the Lidocaine 4% patch was not available and for Resident #103 (R103) when a scheduled Lantus insulin injection was not available from a total of 32 opportunities resulting in a medical administration error rate of 6.25% with the potential for adverse reactions, increased in pain and suffering, and exacerbation of conditions related to omission of the medication or medication not given timely.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent significant medication errors for one resident (Resident #103) of 9 residents reviewed for medication errors, resulting in the potential for serious adverse effects for insulin omission and pain control management as ordered by the physician, and decline or worsening of medical condition.

Inspectors wroteBased on interview and record review the facility failed to ensure proper communication and documentation of hospice services for one resident (Resident #39) of two residents reviewed for hospice services, resulting in the absence of progress notes in the medical record.

Inspectors wroteThis Citation pertains to Intake Number MI00133932. Based on the interview and record review, the facility failed to maintain an annual-based competencies and education of 12.0 hours for three Certified Nursing Assistants (CNA) reviewed for their annual-based competencies.

Inspectors wroteBased on interview and record review, the facility failed to ensure that there was a process for obtaining Resident Code Status: that it was assessed, documented and accessible in the medical record prior to obtaining a physician's order for Code Status for 6 residents (Residents #2, #4, #13, #26, #50 and #112) of 8 residents reviewed for Advance Directives and Code Status, resulting in the potential for the resident's lack of informed knowledge related to options for code status and miscommunication of code status which could lead to a lack of appropriate interventions for care. Findings Include: Resident #2: Advance Directives A chart review of the Face sheet and Minimum Data Set (MDS) assessment for Resident #2 indicated admission to the facility on [DATE] and readmission on [DATE] with diagnoses: [...]

Inspectors wroteBased on interview and record review, the facility failed to review and revise care plans with resident changes to ensure that interventions necessary for care and services were provided for 5 resident (Residents #2, #4, #44, #51, and #164) of 23 residents reviewed, resulting in the potential for unmet care needs. Findings Include: Resident #2: Accidents A chart review of the Face sheet and Minimum Data Set (MDS) assessment for Resident #2 indicated admission to the facility on 3/21/2017 and readmission on [DATE] with diagnoses: Multiple sclerosis, anxiety, depression weakness, glaucoma, retinal detachment, hypertension, chronic sinusitis. The MDS assessment dated [DATE] revealed the resident had mild cognitive loss with a Brief Interview for Mental Status (BIMS) score of 12/15 and needed some assistance with all care. [...]

Inspectors wroteBased on observation, interview and record review, the facility 1) Failed to label medications appropriately, 2) Discard expired medication and medical supplies, and 3) Ensure that a treatment cart that held prescriptions medication for skin and wounds was properly secured, for one of two medication carts, one of one medication rooms and one of two treatment carts reviewed for labeling and storage of medication, resulting in medical procedures being performed with expired medical equipment and the administration of medications with decreased efficacy.

Inspectors wroteBased on observation, interview, and record review, the facility 1) Failed to ensure that they provided Covid testing with signs and symptoms of infection for one resident (Resident #56); 2) Failed to ensure that Personal Protective Equipment (PPE) was worn per standards of practice for two residents (Resident #18 and Resident #112); 3) Failed to ensure that surveillance was analyzed, trends were identified and corrective measures were implemented; and 4) Failed to ensure that employee illness was tracked and reported to prevent the spread of infection, resulting in the potential for a serious adverse outcome including infectious illness and death if appropriate Infection Prevention and Control Standards of Practice were not enacted. Findings Include: FACILITY Infection Control On 9/19/23 at 1:21 PM, a Contact precautions sign was on the door of Resident #112's room. [...]

Inspectors wroteInitial Kitchen Tour: On 9/19/23 at 11:00 AM, the initial tour of the kitchen was conducted with Dietary Manager/Head Chef G. During the tour, the area in the dining room was observed where coffee containers were positioned to dispense coffee on the counter. Near the end of the counter was a fruit fly trap. An observation was made in that area on the wall of three fruit flies with a dead fly in the trap. When asked about issues with fruit flies, the Dietary Manager reported they had issues with drain flies, indicated pest control had been out and indicated the flies were drain flies. Resident #18: A review of Resident #18's medical record revealed an admission into the facility on 9/17/20 and readmission on [DATE] with diagnoses that included adjustment disorder with anxiety, diabetes, heart failure, chronic kidney disease, peripheral vascular disease, and depression. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide privacy during dental care for one resident (Resident #8) and assist one resident (Resident #33) with putting laundry away or hung up to be ready for use of three residents reviewed for dignity issues, resulting in feelings of embarrassment, and frustration.

Inspectors wroteBased on interview and record review, the facility failed to inform the responsible party of the start of a gradual dose reduction (GDR) for the medication Depakote (a medication used to treat seizure disorders, mental/mood conditions and to prevent migraine headaches), the onset of pneumonia, and dental services) for one resident (Resident #33) of 19 residents reviewed for notification of changes/services and care planning, resulting in the lack of communication to develop coordinated care and treatment decisions.

Inspectors wroteBased on interview and record review, the facility failed to ensure that documentation was in the medical record of discharge summary and physician's order for discharge, and that essential health information was communicated to the hospital upon transfer of one resident (Resident #21) to the emergency room, of three residents reviewed for transfer/discharge, resulting in the potential for lack of communication for the continuation of care.

Inspectors wroteBased on interview and record review, the facility failed to ensure that one resident (Resident #21) had a written notice of transfer provided to the State Ombudsman and to the Resident/Resident Representative regarding their transfer to the hospital for one resident (Resident #21) of three residents reviewed for transfer/discharge, resulting in the Ombudsman not being informed of the transfer or being able to advocate for the Resident if necessary and the Resident Representative being uninformed of health care status and rational requiring hospital treatment.

Inspectors wroteBased on interview and record review the facility failed to develop and implement a comprehensive care plan for one resident (Resident #112) of 23 residents reviewed, resulting in Resident #112 lacking a Hospice care plan, which could result in a lack of coordination of care between the facility and Hospice provider. Findings Include: Resident #112: Hospice and End of Life A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #112 was admitted to the facility on [DATE] with diagnoses: Acute respiratory failure, malnutrition, dysphagia, acute kidney failure, hypertension, GERD, hypothyroidism, heart disease, left lower leg wound infection, anxiety, neuropathy and arthritis. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that assessment and wound care was consistently provided for pressure ulcers for three residents (Resident #18, Resident #38 and Resident #51) of 4 residents reviewed for pressure ulcers and wounds, resulting in residents not receiving the necessary care and services to aid in preventing pressure ulcers or potential worsening of the wounds. Findings Include: Resident #38: A record review of the Face sheet and Minimum Data Set (MDS) assessment for Resident #38 indicated the resident was admitted to the facility on [DATE] with diagnoses: heart failure, cardiomyopathy, chronic kidney disease, hypertension, atrial fibrillation, diabetes, COPD, dysphagia, anxiety, right lower extremity embolism and thrombosis. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the appropriate collection of a urine sample for one resident (Resident #32) and ensure that an indwelling urinary catheter securement device was in place for one resident (Resident #51), of six residents reviewed for catheter and urinary tract infections (UTI), resulting in the potential misdiagnosis of a UTI, delay in treatment, worsening of an infection and the potential for irritation, bleeding and pain at the urinary catheter insertion site.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that residents received pain medication as ordered prior to wound care for one resident (Resident #51) of 1 resident reviewed for pain, resulting in the potential for increased pain and decreased quality of life. Findings Include: Resident #51: Pain Management A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #51 was admitted to the facility on [DATE] with diagnoses: history of squamous cell skin cancer, weakness, hypertension, enlarged prostate, urinary retention, history of urinary tract infections, depression, anxiety, gout, , history of falls and atrial fibrillation. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that dialysis communication forms were complete and included pre-dialysis and post-dialysis assessment; assess the dialysis access sites and accommodate the resident's medication regimen for one resident (Resident #25) of 1 resident reviewed for Dialysis care, resulting in the potential for a decline in condition and the inability for a prompt response to care needs. Findings Include: Resident #25: Dialysis A record review of the Facesheet and Minimum Data Set (MDS) assessment indicated Resident #25 was admitted to the facility on [DATE] with diagnoses: Diabetes, chronic kidney disease, dependence on renal dialysis, heart disease, hypertension, hypothyroidism, peripheral vascular disease, left and right below the knee amputations, neuropathy, anxiety, depression, and weakness. [...]

Inspectors wroteResident #18: A review of Resident #18's medical record revealed an admission into the facility on 9/17/20 and readmission on [DATE] with diagnoses that included adjustment disorder with anxiety, diabetes, heart failure, chronic kidney disease, peripheral vascular disease, and depression. A review of the Minimum Data Set assessment revealed the Resident was cognitively intact and needed extensive assistance with bed mobility, transfers, dressing, personal hygiene, and toileting. Review of the Resident's census revealed the Resident was discharged on 1/31/23 and readmitted on [DATE] and discharged on 2/19/23 and readmitted on [DATE]. A review of Resident #18 wound documentation in the medical record revealed the Resident had an unstageable pressure ulcer to the left heel. The documentation in Wound Rounds, revealed wound site: left heel, Date Identified: 3/31/23; Type: Pressure; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure appropriate narcotic medication practices including: 1) Nurses not signing the shift-to-shift narcotics count report sheet; 2) Nurses not signing on the narcotics log that they removed narcotics from the narcotics drawer for four residents (Residents #4, #14, #25 and #51) and 3) Discrepancies in narcotics orders/packaging and labeling for four residents (Residents #4, #22, #25 and #112) of 18 residents reviewed for narcotics administration, resulting in the potential for inappropriate access to narcotic medications and residents not receiving medications as ordered. Findings Include: Resident #51: A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #51 was admitted to the facility on [DATE] with diagnoses: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the accuracy of a Minimum Data Set (MDS) assessment for one resident (Resident #26) of 23 residents reviewed for MDS assessments, resulting in an inaccurate MDS assessment with the potential for unmet resident care needs. Findings Include: Resident #26: A record review of the Face sheet and Minimum Data Set (MDS) assessment indicated Resident #26 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses: history of a stroke, left side weakness, history of a deep vein thrombosis lower legs, kidney failure, anxiety, depression, urinary retention Dementia, hypertension, and anemia. The MDS assessment dated [DATE] indicated the resident had a Brief Interview for Mental Status (BIMS) score of 11/15 mild cognitive loss and needed assistance with care. [...]