Casa De Oro Center

Inspectors wroteBased on record review and interview, the facility failed to ensure medical records were complete and accurate for 2 (R #16 and R #17) of 3 (R #16, R #17, and R #18) residents reviewed for Percutaneous Endoscopic Gastrostomy tube (PEG, a flexible feeding tube inserted through the abdomen into the stomach to deliver nutrition, fluids, and medications directly) when staff failed to document flushing R #16 and R #17's PEG tubes. This deficient practice could likely cause staff to not have the most accurate resident information and adversely impact the care staff provides.

Inspectors wroteBased on record review and interview, the facility failed to ensure medications were administered as ordered by the physician for 1 (R #3) of 3 (R #1, R #2, and R #3) residents reviewed for medication administration when staff failed to ensure narcotic (medication used to treat moderate to severe pain) medications were not administered earlier than ordered. This deficient practice could likely lead to adverse side effects (unwanted, harmful, or unintended reactions to medications or treatments, ranging from mild annoyances to life-threatening conditions) due to overmedication.

Inspectors wroteBased on record review and interview, the facility failed to ensure medical records were complete and accurate for 1 (R #3) of 3 (R #1, R #2, and R #3) residents reviewed for medication administration when staff failed to document narcotic medication administration on the MAR for R #3. This deficient could likely cause staff to not have the most accurate resident information if the records are inaccurate or missing adversely impact the care staff provides.

Inspectors wroteBased on record review and interview, the facility failed to follow procedures in accordance with professional standards of food service safety, when staff failed to: 1. Ensure the chemical sanitation concentration was checked during dish washing machine use after each meal service. 2. Maintain refrigerator temperatures in the upright refrigerator in the kitchen. 3. Maintain freezer temperatures in the upright freezer in the kitchen. These failures have the potential to affect all 134 residents in the facility who eat food prepared in the kitchen. Residents were identified by the Resident Matrix provided by the DON on 01/26/26. If the facility fails to adhere safe food storage practices, then residents are likely to be exposed to foodborne illnesses.

Inspectors wroteBased on observations and interview, the facility failed to treat residents with respect and dignity for 6 (R #24, R #38, R #44, R #111, R #141, and R #142) of 6 (R #24, R #38, R #44, R #111, R #141, and R #142) randomly observed residents, when staff failed to knock on resident's doors before entering their room. This deficient practice could likely cause residents to feel anxious or depressed and like they are not valued.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure care plan revision and care plan meeting requirements occurred for 5 (R #2, R #12, R #14, R #24, and R #33) of 5 (R #2, R #12, R #14, R #24, and R #33) residents when the staff failed to: 1. Revise the care plan with the most current resident information for R #24 and R #33. 2. Have the required IDT members participate in the care plan meeting for R #2, R #12, R #14, and R #33. These deficient practices could likely result in the care plan not being updated with the most current resident conditions and appropriate interventions, staff being unaware of changes in care provided, and residents not receiving the care related to changes in their health status or healthcare decisions.

Inspectors wroteBased on record review, observation, and interview, the facility failed to meet professional standards of practice for 4 (R #2, R #3, R #33, and R #127) of 8 (R #2, R #3, R #7, R #8, R #33, R #77, R #106, and R #127) residents reviewed for medical care, when staff failed to: 1. Update an order for R #2's fluid restriction. 2. Monitor R #3's blood sugar levels and signs and symptoms of high blood sugar or low blood sugar. 3. Schedule a follow-up appointment for R #33's nail care. 4. Update an order for R #127's wound care. These deficient practices could likely lead to the residents not receiving the care needed to attain their highest practicable wellbeing.

Inspectors wroteBased on observation, record review, and interview, the facility failed to properly store and secure medications for all 20 residents on the 400 hall (residents were identified by the resident matrix provided by the Administrator on 01/26/26), when staff failed to ensure: 1. The medication cart was secured. 2. Medications were not expired in treatment cart for R #21, R #43, R #86, and R #134. This deficient practice could likely result in residents obtaining medications not prescribed to residents, and that are no longer effective, resulting in adverse side effects.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents obtained dental services for 2 (R #9 and R #11) of 2 (R #9 and R #11) residents sampled for dental services, when staff failed to ensure residents receive routine and/or 24-hour emergency dental care. Dental services include an annual inspection of the mouth for signs of disease, dental cleaning, fillings, or minor partial or full denture adjustments, treatment of acute pain in teeth, gums, or palate; broken, or otherwise damaged teeth, or any other problem of the oral cavity. This deficient practice is likely to cause the resident unnecessary pain, embarrassment over the condition/appearance of teeth, potential dental or oral complications, and overall health complications.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents did not receive psychotropic medications (group of drugs that affect behavior, mood, thoughts, or perception) unless the medication was medically necessary for 1 (R #7) of 5 (R #2, R #3, R #7, R #8, and R #106) residents reviewed for unnecessary medications, when staff failed to ensure PRN psychotropic medications were not prescribed for longer than 14 days without a written rationale from the provider. This deficient practice could likely result in residents receiving medications longer than needed without a rationale from the provider causing a higher risk of adverse side effects (unwanted, harmful, or abnormal result).

Inspectors wroteBased on record review and interview, the facility failed to provide the required transfer information for 1 (R #136) of 2 (R #6 and R #136) residents sampled for hospitalizations when staff failed to: 1. Notify the resident and resident representative(s) of the resident's transfer to the hospital in writing and in a language and manner they understand. 2. Send a written copy of the Transfer Notice to the Ombudsman (an advocate for residents in nursing homes and assisted living facilities). 3. Ensure the resident and their representative received a written notice of the bed hold policy which indicated the duration the bed would be held. [...]

Inspectors wroteBased on record review, observation, and interview, the facility failed to provide activities of daily living (ADL) assistance for 1 (R #33) of 4 (R #10, R #24, R #33, and R #77) residents reviewed for ADL care when staff failed to provide R #33 nail care. This deficient practice is likely to affect the dignity and health of the residents.

Inspectors wroteBased on record review the facility failed to ensure residents received quality treatment and care for 1 (R #106) of 6 (R #2, R #24, R #40, R #47. R #56 and R #106) residents reviewed for accidents when staff failed to ensure resident received follow-up treatment. This deficient practice could likely lead to resident's needs not being met and/or a worsening of their medical condition and prognosis.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide foot care for 1 (R #33) of 4 (R #2, R #22, R #24, and R #33) resident reviewed for foot care when staff failed to provide nail care for R #33's toenails. This deficient practice could likely cause podiatric complications (foot and toenail health issues such as ingrown toenails, fungal infections, and trauma-related injuries).

Inspectors wroteBased on record review and interview, the facility failed to ensure the consultant pharmacist's recommendations were reviewed and implemented by the physician and/or the physician provided documentation of a rationale (a set of reasons or a logical basis for a course of action or a particular belief) for not following the consultant pharmacist's recommendation in the resident's medical record for 1 (R #2) of 5 (R #2, R #3, R #7, R #8, and R #106) residents reviewed for unnecessary medications. This deficient practice could likely result in residents receiving medications that are no longer necessary and may cause unnecessary drug interactions (changes to medication action caused by being combined with other foods, beverages, or drugs) or adverse side effects (unwanted, undesirable effects from medication).

Inspectors wroteBased on observation, record review, and interview, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to prevent the development and transmission of communicable diseases and infections for 2 (R #10 and R #77) of 3 (R #10, R #77, and R #127) residents reviewed for pressure wounds and respiratory care when staff failed to: 1. Follow enhanced barrier precautions (EBP, an infection control intervention) for R #127. 2. Change R #10's nasal cannula (a lightweight, flexible, medical-grade tube used to deliver supplemental oxygen (0.5-6 liters per minute) directly into the nostrils for respiratory support, allowing for mobility, eating, and speaking) as ordered. [...]

Inspectors wroteBased on record review the facility failed to report allegations of 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) to the State Agency within 24 hours of allegation for 3 (R #16, R #17, and R #24) of 3 (R #16, R #17, and R #24) residents reviewed for misappropriation of property, when staff failed to: 1. Report an allegation of misappropriation (diversion of medication) for R #16 with in 24 hours of becoming aware of the allegation. 2. Report the allegations of misappropriation (diversion of medication) for R #17 and R #24 when staff became aware of the allegation. [...]

Inspectors wroteBased on record review and interview, the facility failed to thoroughly investigate an allegation of misappropriation of property (the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent) 7 (R #16, R #17, R #18, R #24, R #25, R #26, and R #27) of 7 (R #16, R #17, R #18, R #24, R #25, R #26, and R #27) residents reviewed when staff failed to: 1. Document interviews with residents for the investigation of allegation of misappropriation of resident's narcotic (a substance used to treat moderate to severe pain. Narcotics are like opiates such as morphine and codeine but are not made from opium) medication. 2. Document interviews with staff for the investigation of allegation of misappropriation of resident's narcotic medication. 3. [...]

Inspectors wroteBased on record review and interview, the facility failed to meet professional standards of practice for 4 (R #16, R #17, R #18, and R #24) of 4 (R #16, R #17, R #18, and R #24) residents reviewed for misappropriation of property, when staff failed to: 1. Ensure narcotic (a substance used to treat moderate to severe pain. Narcotics are like opiates such as morphine and codeine but are not made from opium) medications were not administered earlier than ordered for R #16 and R #17. 2. Ensure staff notified the provider when R #16 and R #17 required pain medications more frequently than ordered. 3. Ensure R #16 and R #24 did not receive narcotic medications at a higher dose than ordered. 4. Ensure staff document the narcotic medication administration on the MAR for R #16, R #17, R #18, and R #24. 5. Reassess R #16, R #17, R #18, and R #24. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure pharmaceutical services (the direct, responsible provision of medication-related care) were met when staff failed to keep controlled drug records (mandatory documentation required by the Drug Enforcement Agency (DEA))to track the complete life cycle of controlled substances, including their acquisition, administration, dispensing, and disposal. The purpose is to prevent diversion and ensure accountability for potentially addictive and illicitly traded drugs) for controlled medication (drugs or chemicals that the government regulates because they can be easily abused and lead to addiction.) for 4 (R #17, R #24, R #25 and R #27) of 7 (R #16, R #17, R #18, R #24, R #25, R #26, and R #27) residents reviewed for misappropriation of property. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure medications were administered as ordered by the physician for 2 (R #3 and R #18) of 3 (R #3, R #17, and R #18) residents reviewed for medication administration when staff failed to: 1. Ensure narcotic (a substance used to treat moderate to severe pain. Narcotics are like opiates such as morphine and codeine but are not made from opium) medications were not administered earlier than ordered for R #3. 2. Ensure R #18 did not receive narcotic medication at a higher dose than ordered. This deficient practice is likely to result in a residents having adverse effects (unwanted, harmful, or abnormal result).

Inspectors wroteBased on record review and interview, the facility failed to ensure medical records were complete and accurate for 6 (R #16, R #17, R #18, R #24, R #25, and R #27) of 6 (R #16, R #17, R #18, R #24, R #25, and R #27) residents reviewed for misappropriation of property when staff failed to: 1. Document narcotic medication administration on the MAR for R #16, R #17, R #18, R #24, R #25, and R #27. 2. Ensure R #16's order on his controlled drug record matched the order. These deficient practices have the potential to negatively impact the care staff provide to meet residents' needs due to missing or inaccurate records and resident information.

Inspectors wroteBased on record review and interview, the facility failed to keep residents free from accidents for 3 (R #1, R #2, and R #3) of 3 (R #1, R #2, and R #3) residents sampled for elopement when staff failed to do the following: 1. Recognize the elopement risk for R #1 and R #3. 2. Secure the exit doors and the exterior gates of the facility before and after R #1, R #2 and R #3 eloped on 04/20/25 and 04/22/25. These deficient practices resulted in multiple elopements/attempted elopements: 1. R #2 eloped on 04/20/25, 2. R #3 eloped on 04/22/25 with R #1, 3. [...]

Inspectors wroteBased on observation, interview, record review the facility failed to secure medications in a medication cart and a treatment cart for all 37 residents on the 500 unit (residents were identified by the census list provided by the Administrator on 05/07/25). This deficient practice could result in residents obtaining medication not prescribed to them resulting in adverse side effects.

Inspectors wroteBased on interview, the facility failed to report elopements to the State Agency (SA) for 2 (R #1 and R #3) of 3 (R #1, R #2 and R #3) residents sampled for elopement, when they failed to report to the state agency an elopement by R #1 and R #3 on 04/22/25. If the facility fails to report allegations of elopement to the SA, then residents could likely suffer serious bodily injury as a result of the elopement.

Inspectors wroteBased on record review and interview, the facility failed to have the physician document the required discharge information in the resident's medical records for 1 (R #26) of 1 (R #26) residents reviewed for discharges. This deficient practice could likely cause an unsafe discharge due to a lack of information or documentation.

Inspectors wroteBased on record review and interview, the facility failed to revise the care plan for 3 (R #8, R #9, and R #10) of 3 (R #8, R #9, and R #10) residents reviewed for Resident/Patient/Client Neglect. This deficient practice could likely result in staff being unaware of changes in care to be provided and residents not receiving the care related to changes in their health status or healthcare decisions.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a discharge planning process for 1 (R #26) of 1 (R #26) resident reviewed for discharge planning, when they failed to: 1. Develop the R #26's individualized discharge goals and needs. 2. Include R #26 and R #26 PoA/family in the discharge planning. Theses deficient practices are likely to prevent a safe transition from the facility to the resident's post-discharge setting.

Inspectors wroteBased on record review and interview, the facility failed to ensure staff completed a discharge summary that included a recapitulation (a summary describing the resident's course of treatment while residing in the facility), and a list of all medication at the time of discharge for 1 (R #26) of 1 (R #26) residents sampled for discharge from the facility. This deficient practice could likely lead to the receiving facility, community agency, or family members not knowing what the current care needs and/or current medications the resident needs.

Inspectors wroteBased on observation and interview, the facility failed to ensure appropriate treatment and services for Foley Catheter tubing (soft plastic or rubber tube that is inserted to the bladder to drain the urine and is connected to a collecting bag) care for 1 (R #13) of 1 (R #13) randomly observed resident. This deficient practice could likely result in residents getting infections.

Inspectors wrotePast Noncompliance Based on record review and interview, the facility failed to ensure wound care orders were implemented, wound care was completed, and staff documented that the wound care was performed for 1 (R #1) of 3 (R #1, R #2, and R #17) residents reviewed for pressure ulcers (damage to an area of the skin caused by constant pressure on the area for a long time). These deficient could likely result in the provider being unaware of the resident's current condition, leading to inconsistent interventions and worsening of pressure ulcers.

Inspectors wroteBased on interview and record review, the facility failed to keep residents free from abuse for 3 (R #12, R #94, R #117) of 3 (R #12, R #94, and R #117) residents sampled for abuse when staff failed to: 1. Prevent staff from being verbally abusive to R #12. 2. Prevent R #94 from being physically abused, which caused injuries to R #94 face, neck, and hands. 3. Prevent R #117 from being fearful of staff who provide care. These deficient practices likely resulted in physical harm to the residents and psychosocial distress (unpleasant emotions associated with a highly stressful situation).

Inspectors wroteRecite from 06/20/24 Based on observation, record review, and interview the facility failed to report alleged allegations of abuse to the State Agency for 4 (R #12, R #16, R #94 and R #117) of 5 (R #12, R #16, R #94, R #117 and R #133) residents sampled for abuse, when they failed to; 1. Report R #12's allegation of abuse within 2 hours. 2. Submit R #16's 5 day follow-up report to the state agency within 5 working days. 3. Report R #94's allegation of abuse within 2 hours 4. Report R #117's allegation of abuse within 2 hours If the facility fails to report allegations of abuse and the results of the investigations to the State Survey Agency, then corrective action may not be taken, and residents could likely suffer serious bodily injury. The facility's failure to report witnessed abuse of R #117 by RN #24 likely resulted in RN #24 being able to physically abuse R #94 a few hours later.

Inspectors wroteBased on interview, the facility failed to provide Quality Assurance and Performance Improvement (QAPI) training to staff. This could affect all 127 residents in the facility (residents were identified by the resident matrix provided by the Administrator on 09/16/24). This deficient practice could likely result in staff being unable to identify opportunities for improvement, address gaps in systems or processes, develop and implement an improvement or corrective plan, and continuously monitor the effectiveness of interventions.

Inspectors wroteBased on interview and record review, the facility failed include performance reviews as part of their 12 hours of annual training for 3 (CNA #34, CNA #35, and CNA #36) of 3 (CNA #34, CNA #35, and CNA #36) CNAs sampled for 12 hours of annual training. This deficient practice could likely result in staff being under trained and providing inadequate care.

Inspectors wroteBased on observation and interview the facility failed to provide a comfortable and homelike environment for 6 (R #4, R #31, R #36, R #45, R #46, and R #110) of 8 (R #4, R #31, R #36, R #45, R #46, R #64, R #109, and R #110) residents sampled for environment, when they failed to: 1. Repaint and match the existing paint from scuff marks and damage on the walls and doors. 2. Keep air/heat vents clean and uncovered with plastic. 3. Keep resident's commode in safe working condition. 4. Keep crash carts (a wheeled container carrying medicine and equipment for use in emergency resuscitations) free of bugs. These deficient practices could likely cause residents to feel like they are not living in a comfortable home-like environment and like they are not valued.

Inspectors wroteBased on record review and interview the facility failed to develop and implement a comprehensive person-centered care plan for 2 (R #14 and R #123) of 8 (R #14, R #16, R #29, R #40, R #118, R #123, R #292 and R #293) residents reviewed for care plans. Failure to develop and implement a resident centered care plan may result in staff's failure to understand and implement the needs and treatments of residents possibly resulting in worsening of medical condition.

Inspectors wroteRecite from 06/20/24 Based on record review, observation, and interview, the facility failed to ensure care plans were reviewed and revised for 9 (R #4, R #12, R #45, R #60, R #81, R #109, R #110, R #111, and R #118) of 9 (R #4, R #12, R #45, R #60, R #81, R #109, R #110, R #111, and R #118) residents reviewed for care plans when they failed to: 1. Have the required Interdisciplinary Team (IDT, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) members participate in the care plan meeting for R #4, R #45, R #60, R #81, and R #109. 2. Have the care plan meeting within seven days after the completion of the Minimum Data Set assessment (MDS, part of the U.S. federally mandated process for clinical assessment of all residents in Medicare or Medicaid-certified nursing homes. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 (R #23) of 1 (R #23) residents reviewed for hospice services, when they failed to ensure the facility received documentation regarding the services provided to R #23 by hospice staff. This deficient practice could likely lead to staff not being aware of the services that are provided by the hospice staff and residents needs not being met and/or a worsening of their condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep residents free from accidents for 1 (R #12) of 1 (R #12) residents reviewed for falls, when staff failed to identify and implement interventions to prevent R #12 from falling. This deficient practice could likely result in residents being at risk of serious harm or injury.

Inspectors wroteBased on record review and interview, the facility failed to ensure ongoing communication and collaboration with the dialysis (clinical purification of blood as a substitute for the normal function of the kidney) facility regarding dialysis care and failed to monitor the resident before and after dialysis treatment for 1 (R #111) of 1 (R #111) residents reviewed for dialysis care. This deficient practice could likely result in the facility being unaware of the resident's condition, possible complications that arise during dialysis treatment, and residents may not receive the appropriate monitoring and care.

Inspectors wroteBased on observation, record reviews and interviews, the facility failed to ensure the facility had sufficient staff to meet the needs of 2 (R #12 and R #66) of 2 (R #12 and R #66) residents reviewed for staffing when staff failed to: 1. Get R #12 up and ready on the morning of 09/30/24. 2. Answer R #12's call bell within a timely manner. 3. Offer baths or showers to R #66 as scheduled. These deficient practices are likely to cause residents psychological distress, make them feel as if they are not valued, and negatively impact resident comfort.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents did not receive psychotropic medications (antidepressants, anti-anxiety medications, stimulants, antipsychotics, and mood stabilizers) unless the medication was necessary to treat a specific psychiatric diagnosis (mental illness, symptoms or condition that greatly disturbs your thinking, moods, and/or behavior) for 2 (R #6 and R #54, ) of 5 (R #6, R #14, R #26, R #40 and R #54, ) residents reviewed for unnecessary medications. This deficient practice could likely result in residents receiving medications without a medical reason and being at a higher risk of adverse side effects (unwanted, harmful, or abnormal result).

Inspectors wroteBased on observation and interview, the facility failed to properly store medications when they failed to: 1) Document temperatures for the East and [NAME] Unit medication refrigerators. 2) Secure a treatment cart that stored medications on the 500 Unit. These failures had the potential to affect all 127 residents in the facility (Residents were identified by the resident census provided by the Administrator on 09/16/24). These deficient practices could likely result in residents obtaining medications that are no longer effective or that are not prescribed to them resulting in adverse side effects.

Inspectors wroteBased on record review and interview, the facility failed to: 1. Keep food in the freezer with dates properly visible. 2. Document the temperature of the snack refrigerators on the East and [NAME] Unit. This failure could potentially affect all residents in the facility who eat food prepared in the kitchen (residents were identified by the census provided by the Administrator on 09/16/24). If the facility fails to adhere to safe food storage, residents could likely be exposed to foodborne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins).

Inspectors wroteBased on record review and interview, the facility failed to update the medical record for 1 (R #20) of 6 (R #12, R #13, R #20, R #23, R #60, and R #66) residents reviewed for advanced directives when they failed to update the resident's code status. This deficient practice is likely to result in residents not having their wishes honored if a life threatening event occurred.

Inspectors wroteBased on record review and interview, the facility failed to ensure the Minimum Data Set Assessment (MDS, part of the U.S. federally mandated process for clinical assessment of all residents in Medicare or Medicaid-certified nursing homes. It is a core set of screening, clinical and functional status elements, including common definitions and coding categories, which forms the foundation of a comprehensive assessment) was accurate for 2 (R #12 and R #14) of 10 (R #12, R #13, R #14, R #20, R #23, R #40, R #60, R #81, R #118 and R #292) residents review for MDS assessment accuracy. This deficient practice could likely result in the facility not having an accurate assessment of the residents' needs.

Inspectors wroteBased on record review and interview, the facility failed to meet professional standards of care for 1 (R #293) of 1 (R #293) residents reviewed for wound care when they failed to complete wound care as ordered. This deficient practice could likely result in delays in wound healing or worsening of wound condition.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents received care and treatment for pressure ulcers (an injury to skin and underlying tissue resulting from prolonged pressure on the skin) in accordance with professional standards of care (reasonable degree of care a person should provide to another person, typically in a professional or medical setting) for 1 (R #12) of 2 (R #12 and R #23) residents reviewed for pressure ulcers, when staff failed to: 1. Notify the provider that R #12 had a pressure injury to her right heel. 2. Document in the medical record interventions, staff provided to heal or prevent worsening of the pressure injury to R #12's right heel. These deficient practices could likely result in the provider being unaware of the resident's current condition leading to inconsistent interventions and worsening of pressure ulcers.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure proper management of enteral tubes (a device utilized to provide liquid nutrition, hydration and medications via a tube into the stomach or intestine) for 2 (R #13 and R #14) of 2 (R #13 and R #14) residents reviewed for tube feeding when they failed to: 1. Administer R #13's feeding during the times ordered by the physician. 2. Provide care for R #14's enteral tube insertion site (percutaneous endoscopic gastrostomy/PEG; medical procedure in which a tube is passed into a patient's stomach through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate). These deficient practices could likely lead to malnutrition, weight loss, and infection.

Inspectors wroteBased on record review and interview, the facility failed to ensure pharmaceutical services (the direct, responsible provision of medication-related care) were met for 1 (R #133) of 3 (R #6, R #31, and R #133) residents reviewed for medications when they failed to provide routine medication for a resident. This deficient practice could likely lead to unresolved medical issues.

Inspectors wroteBased on record review and interview, the facility failed to ensure the consultant pharmacist's recommendations were reviewed and implemented by the physician or the physician provided a rationale for not following the consultant pharmacist's recommendation for 2 (R #6 and R #54) of 2 (R #6 and R #54) residents reviewed for unnecessary medications. This deficient practice could likely result in residents receiving medications that are no longer necessary and may cause unnecessary drug interactions (changes to medication action caused by being combined with other foods, beverages, or drugs) or adverse side effects (unwanted, undesirable effects from medication).

Inspectors wroteBased on record review and interview, the facility failed to ensure medical records were complete and accurate for 1 (R #40) of 8 (R #14, R #16, R #29, R #40, R #118, R #123, R #292 and R #293) residents reviewed for documentation accuracy. This deficient practice has the potential to negatively impact the care staff provide to meet residents' needs due to missing or inaccurate records and resident information.

Inspectors wroteBased on observation and interview, the facility failed to safeguard resident medical record information for all 126 residents (residents were identified by the census provided by the Administrator on 06/17/24). This deficient practice could likely result in the residents' information being viewed by unauthorized residents, visitors, and staff.

Inspectors wroteBased on interview, and record review, the facility failed to ensure there was a functional system in place to ensure staff could initiate / not initiate cardiopulmonary resuscitation (CPR; any medical intervention used to restore circulatory and/or respiratory function that has ceased) during an emergency for all 73 residents who were Full Code (individual wants resuscitation and all life saving measures during a medical emergency) when they failed to: 1) Check pulse and air way on R #1 2) Ensure staff knew what procedure to follow in an emergency. 3) Track staff's CPR certification to ensure the certification was up to date. Residents were identified by the resident code list provided by the Administrator on [DATE]. [...]

Inspectors wroteBased on record review and interview the facility failed to report injuries of unknown source within two hours to the State Agency (SA) for 1 (R #11) of 1 (R #11) residents sampled for abuse. If the facility fails to report allegations of abuse or neglect to the SA within two hours, then residents could likely continue to be abused or suffer serious bodily injury.

Inspectors wroteBased on record review and interview the facility failed to ensure that residents, their representatives, and the Ombudsman received a written notice of transfer as soon as practicable for 1 (R #21) of 1 (R #21) residents reviewed for hospitalization. This deficient practice could likely result in the resident or their representative not knowing the reason or location the resident was discharged .

Inspectors wroteBased on record review and interview, the facility failed to ensure residents and their representatives received a written notice of the bed hold policy which indicated the duration the bed would be held for 1 (R #21) of 1 (R #21) residents reviewed for hospitalization. This deficient practice could likely result in the resident and/or their representative being unaware of the bed hold policy upon return from the hospital.

Inspectors wroteBased on record review, and interview, the facility failed to ensure staff revised the care plan for 1 (R #1) of 3 (R #1, R #2, and R #11) residents to reflect R #1 ate independently and did not need supervision/cue/assistance with meals. This deficient practice could likely result in staff being unaware of changes in the care provided, and residents not receiving the care related to changes in their health status or healthcare decisions.

Inspectors wroteBased on record review and interview, the facility failed to ensure medical records were complete and accurate for 1 (R #11) of 3 (R #1, R #2, and R #11) residents reviewed for documentation accuracy. This deficient practice has the potential to negatively impact the care staff provide to meet residents' needs due to missing or inaccurate records and resident information.

Inspectors wroteBased on observation and interview, the facility failed to provide a comfortable and homelike environment for all 126 residents (residents were identified by the census provided by the Administrator on 06/17/24) when they failed to pick up dirty used tissue from the floor. This deficient practice could likely cause residents to feel like they are not living in a comfortable home-like environment and like they are not valued.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents were treated with respect and dignity for 1 (R #22) of 1 (R #22) residents randomly sampled, when the facility failed to allow R #1 to close her door for privacy. This deficient practice could likely result in residents feeling insecure, angry, and that their feelings and right to privacy are unimportant to the facility staff.

Inspectors wroteBased on interview and record review, the facility failed to provide written notice for room/roommate change for 1 (R #22) of 2 (R #22 and R #23) residents sampled for notification of change. This deficient practice could likely cause residents to become anxious and depressed if they are not given written room/roommate change notices.

Inspectors wroteBased on record review and interview, the facility failed to notify the resident or the resident representative of a transfer to the hospital and room for 2 (R #13 and R #22) of 2 (R #13 and R #22) residents reviewed for change of condition, when they failed to: 1. Notify R #13's representative of R #13's change in condition which required hospital transfer. 2. Notify R #23 about the reason for transferring her from one room in the facility to another room in the facility. These deficient practices could likely result in the resident and the resident representative being unable to provide advocacy and make medical decision when needed, cause residents to become anxious, depressed, and believe that their feelings and preferences are unimportant to the facility staff.

Inspectors wroteBased on interview, observation, and record review, the facility failed to keep residents free from involuntary seclusion for 1 (R #23) of 1 (R #23) residents sampled for elopement (an act or instance of leaving a safe area or safe premises, done by a person with a mental disorder or cognitive impairment) risk, when they failed to implement and document the following: 1. The clinical criteria (rules or standards on which a decision or judgment is made to determine medical necessity) met for placement in the secured/locked area by the resident's physician along with information provided by members of the interdisciplinary team (IDT team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities). 2. [...]

Inspectors wroteBased on record review and interview the facility failed to report to the State Survey Agency within five (5) days of the incident for 11 (R #3, R #5, R #6, R #7, R #8, R #9, R #12, R #21, R #22, R #23, and R #24) of 11 (R #3, R #5, R #6, R #7, R #8, R #9, R #12, R #21, R #22, R #23, and R #24) residents sampled for abuse when they failed to report the results of all investigations of abuse or accidents within five days to the State Agency. If the facility fails to report the results of the investigations to the State Agency within five days, then corrective action may not be taken and residents could likely continue to be abused and/or suffer serious bodily injury.

Inspectors wroteBased on record review and interview, the facility failed to notify the resident and resident's representative(s) of the transfer in writing for 2 (R #12 and R #13) of 2 (R #12 and R #13) resident sampled for hospitalizations when they failed to: 1. Notify the resident and the resident's representative(s) of the transfer to the hospital in writing and in a language and manner they understand for R #13. 2. Include in the notice a statement of the R #12 and R #13's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request. 3. Include in the R #12 and R #13's notice the address (mailing and email) of the Office of the State Long-Term Care Ombudsman. 4. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure residents or their representatives received a written notice of the bed hold policy which indicated the duration the bed would be held for 1 (R #13) of 1 (R #13) residents reviewed for hospitalization. This deficient practice could likely result in the resident and/or their representative being unaware of the bed hold policy upon return from the hospital.

Inspectors wroteBased on record review and interview, the facility failed to revise the care plan for R #11's refusals for Physical Therapy (PT; the treatment of disease, injury, or deformity by physical methods such as massage, heat treatment, and exercise rather than by drugs or surgery), Occupational Therapy (OT; a form of therapy for those recuperating from physical or mental illness that encourages rehabilitation through the performance of activities required in daily life), and Speech Therapy (ST; training to help people with speech and language problems to speak more clearly) for 1 (R #11) of 1 (R #11) resident reviewed for care plans. This deficient practice could likely result in staff being unaware of changes in care provided, and residents not receiving the care related to changes in their health status or healthcare decisions.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents did not receive unnecessary psychotropic drugs (any drug that affects brain activities associated with mental processes and behavior) for 1 (R #2) of 1 (R #2) residents reviewed for unnecessary psychotropic medications. When the facility failed to: 1. Follow the Mental Health Nurse Practitioner's recommendation to complete a gradual dose reduction (GDR; gradually lowering the dosage of medication over a period of time) or discontinue lorazepam for R #2. 2. Ensure that R #2's antipsychotic medication order was limited to 14 days. 3. Consistently monitor R #2's behaviors to determine the continued need for lorazepam (medication used to treat severe agitation, trouble sleeping and especially anxiety and anxiety disorders).

Inspectors wroteBased on record review and interview, the facility failed to ensure medical records were complete and accurate for 2 (R #13 and R #22) of 2 (R #13 and R #22) residents reviewed for accuracy of documentation. This deficient practice has the potential to negatively impact the care staff provide to meet residents' needs due to missing or inaccurate records.

Inspectors wroteBased on observation, record review and interviews, the facility failed to maintain appropriate staffing levels to meet the needs of the residents,when they failed to: 1) answer call lights timely, 2) have more than one CNA for 700 unit for 13 residents where 5 residents were on contact precautions. 3) Not able to honor resident preference when to get out of bed for R #103 and shower preference for R #76 This deficient practice has the potential to affect all 127 residents (residents were identified by the resident matrix as provided by the Administrator on 11/13/23). This deficient practice could likely affect direct resident care and limit residents' abilities to obtain the best possible care while in the facility.

Inspectors wroteBased on observation, record review, and interview the facility failed to maintain proper infection prevention measures by not: 1. Properly doffed (removed) personal protection equipment (PPE; clothing, gloves, face shields, goggles, facemasks, gowns and/or respirators or other equipment designed to protect the wearer from injury or the spread of infection or illness) after they exited the room of a resident on transmission-based precautions (TBP; residents who are known or suspected to be infected or colonized with infectious agents). 2. Ensuring a trash can for doffed PPE was available inside of resident's room. 3. Ensuring contract staff properly wore their N95 masks (respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles). 4. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide reasonable accommodations of resident needs and preferences for 1 (R #28) of 1 (R 28) residents reviewed for choices, by not letting R #28 return to his room when he asked. This deficient practice could likely result in the resident's life style, personal choices, needs, and preference not being met which could result in loss of dignity and resident rights.

Inspectors wroteBased on interview and record review, the facility failed to provide quarterly statements for resident's personal funds entrusted to the facility for 1 (R #106) of 2 (R #13, and R #106) residents sampled for personal funds. If residents are not provided quarterly statements for their personal funds accounts, then residents could experience anxiety and depression, because they don't know how much money they have.

Inspectors wroteBased on record review and interview, the facility failed to notify the physician for 1 (R #237) of 1 (R #237) reviewed for insulin, when they failed to notify the physician about R #237's frequent refusal of insulin. This deficient practice could likely result in the physician being unaware of residents' current condition resulting in delay in treatment.

Inspectors wroteBased on observation and interview the facility failed to provide a comfortable and homelike environment for 20 (R #12, R #19, R #26, R #28, R #36, R #37, R #39, R #42, R #49, R # 56, R #59, R #67, R #72, R #75, R #79, R #96, R #103, R #104, R #126, & R #237) of 20 (R #12, R #19, R #26, R #28, R #36, R #37, R #39, R #42, R #49, R # 56, R #59, R #67, R #72, R #75, R #79, R #96, R #103, R #104, R #126, & R #237) residents sampled for environment, when they failed to: 1. Repaint and match the existing paint from scuff marks and damage on the walls and doors. 2. Keep air/heat vents uncovered with trash bags. 3. Serve residents lunch on tableware. 4. Protect residents against the loss of personal property. This deficient practice could likely cause the resident and/or the resident's family frustration with the loss of personal belongings, and cause them to feel like they are not valued.

Inspectors wroteBased on record review and interview, the facility failed to ensure the Ombudsman received a written notice of transfer as soon as practicable for 2 (R #37 and R #131) of 2 (R #37 and R #131) residents reviewed for hospitalization. This deficient practice could likely result in the Ombudsman not knowing the reason or location the resident was discharged .

Inspectors wroteBased on record review and interview, the facility failed to develop and implement a comprehensive person-centered care plan for 1 (R #89) of 7 (R #28, R #31, R #44, R #75, R #89, R #106 and R #184) residents reviewed for comprehensive care plans. Failure to develop a comprehensive person-centered care plan could likely result in staff's failure to understand the needs, preferences, and treatments for residents to achieve their highest level of well-being.

Inspectors wroteBased on record review and interview, the facility failed to revise the care plan for 5 (R #31, R #59, R #82, R #49, and R #237) of 6 (R #28, R #31, R #59, R #82, R #49, and R #237) residents reviewed for care plan revisions. This deficient practice could likely result in staff being unaware of changes in care being provided and residents not receiving the care related to changes in their health status or healthcare decisions.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 (R #49) of 1 (R #49) resident reviewed for skin conditions, when they failed to remove R #237's hemodialysis catheter (HD) (catheter is an access point, meaning an entrance and exit point, for the blood during hemodialysis treatment) dressing when the provider ordered it on 05/30/23. This deficient practice could likely lead to residents needs not being met and/or a worsening of their condition.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure that residents received appropriate treatment and services to prevent further decrease in range of motion for 1 (R #76) of 1 (R #76) residents reviewed for restorative therapy, when they failed to initiate a restorative nursing program (RNP; nursing service that often follows skilled rehabilitation services provided by physical or occupation therapists with the goal to maximize function and prevent functional decline in residents dependent on staff for certain actions). This deficient practice could likely result in decreased mobility or a decrease in residents' abilities to participate or perform their own activities of daily living (ADLs).

Inspectors wroteBased on interview and record review, the facility failed to complete performance reviews at least every 12 months for 1 (CNA #35) of 3 (CNA #35, CNA #36, and CNA #37) CNAs sampled for 12 hours of annual training. This deficient practice could likely result in staff being undertrained and providing inadequate care.

Inspectors wroteBased on record review and interview, the facility failed to ensure staff received the appropriate training and skills to provide services for 3 staff (LPN #1, CNA #1, and CNA #2) of 3 staff (LPN #1, CNA #1, and CNA #2) reviewed for behavioral health training. This deficient practice is likely to result in residents not getting the care and assistance needed and may trigger behaviors that lead to injuries or mental anguish.

Inspectors wroteBased on record review and interview, the facility failed to act upon the pharmacy recommendations for 1 (R #72) of 5 (R #28, R #29, R #72, R #79, and R #82) residents reviewed for unnecessary medications. This deficient practice could likely result in residents being at a higher risk of adverse side effects and residents receiving medications that are no longer necessary.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents did not receive antipsychotic medications unless the medication was necessary to treat a specific psychiatric condition or diagnosis and was documented in the medical record for 1 (R #29) of 5 (R #28, R #29, R #72, R #79, and R #82) residents reviewed for unnecessary medications. This deficient practice could likely result in residents receiving medications without a medical reason and being at a higher risk of adverse side effects (unwanted, harmful, or abnormal result).

Inspectors wroteBased on observation and interview, the facility failed to properly store medications for all 54 residents on 400 and 500 unit (residents were identified by the resident matrix provide by the Administrator on [DATE]), when they failed to: 1) Secure a medication cart on 500 Unit, 2) Have an expiration date for R #15's medication, 3) Log the temperatures in the medication refrigerator on the 400 Unit. This deficient practice could likely result in residents receiving medications that are expired, not stored at the proper temperature, or not prescribed to them resulting in adverse side effects.

Inspectors wroteBased on interview and observation, the facility failed to ensure meals were served at an appetizing temperature and were palatable (pleasant to taste) for 7 (R #23, R #51, R #71, R #72, R #103, R #111, and R #237) of 7 (R #23, R #51, R #71, R #72, R #103, R #111, and R #237) residents reviewed for meal quality. This deficient practice could likely reduce residents' ability to eat and enjoy meals, decreasing their quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accommodate resident's food preferences for 1 (R #49) of 3 (R 49, R #76, and R #237) reviewed for food. If residents are unable to have their food preferences, then they could suffer weight loss, depression, and/or anxiety.

Inspectors wroteBased on observation and interview, the facility failed to store and serve food under sanitary conditions in accordance with professional standards of food service safety for all 127 residents who ate food prepared in the kitchen in the facility (residents were identified by the resident matrix provided by the Administrator on 11/13/23), when they failed to: 1. Serve meal trays covered, 2. Have staff wear a hairnet on while in the kitchen. If the facility fails to adhere to safe food handling practices and hygiene practices, residents could likely to be exposed to foodborne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins).

Inspectors wroteBased on record review and interview, the facility failed to notify the Therapy Department of a referral for 1 (R #31) of 2 (R #31 and R #76) residents reviewed for physical therapy (PT; the treatment of disease, injury, or deformity by physical methods such as massage, heat treatment, and exercise) and occupational therapy (OT; a form of therapy that encourages rehabilitation through the performance of activities required in daily life such as eating dressing). This deficient practice could likely result in residents not receiving therapy services as needed or ordered to improve or maintain their physical functional ability.

Inspectors wroteBased on record review and interview, the facility failed to ensure documents were complete and accurate for 2 (R #27 and R #44) of 2 (R #27 and R #44) residents who were reviewed for documentation, when they failed to accurately document: 1. Showers for R #27. 2. Wound Care for R #44. This deficient practice could likely result in staff not having the information they need to provide competent, comprehensive care and services if vital information is missing from the documents.

Inspectors wroteBased on interview and record review, the facility failed complete 12 hours of annual training that included the performance reviews and the facility assessment for 2 (CNA #36 and CNA #37) of 3 (CNA #35, CNA #36, and CNA #37) CNAs sampled for 12 hours of annual training. This deficient practice could likely result in staff being under trained and providing inadequate care.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents or their representatives received a written notice of their bed hold policy which indicated the duration the bed would be held for 1 (R #37) of 2 (R #37 & R #131) residents reviewed for hospitalization. This deficient practice could likely result in the resident and/or their representative being unaware of the bed hold policy upon return from the hospital.