Casa Real

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure a resident was free from physical restraints for 1 (R #1) of 2 (R #1 and #2) residents when staff failed to assess the resident for the use of a seatbelt. If staff do not assess residents before implementing the use of a seatbelt, then residents may experience injury, entrapment, or a decline in independence and participation.

Inspectors wroteBased on observation and interviews, the facility failed to ensure a prescribed medication was kept out of reach and unavailable to 1 (R #1) of 1 (R #1). If the facility does not keep medications protected from unauthorized access, then residents are at risk of accessing the medication, medicating without physician orders, and experiencing adverse effects.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide respiratory care in accordance with professional standards for 1 (R #1) of 2 (R #1 and R #4) residents reviewed for respiratory care when the facility failed to:1. Ensure medical orders indicated when to administer R #1's oxygen.2. Change the oxygen tubing on R #1's portable concentrator (a medical device that provides extra oxygen) and nebulizer (device that converts liquid medication into a fine mist, allowing it to be inhaled directly into the lungs through a mouthpiece or mask). These deficient practices are likely to result in residents receiving too much or not enough oxygen and can lead to worsening of their conditions.

Inspectors wroteBased on observation and interview, the facility failed to ensure nursing staff were competent to provide nursing related services for 1 (R #1) of 3 (R #1, R #2, and R #3) residents reviewed for pressure ulcers (PU; an injury to skin and underlying tissue resulting from prolonged pressure on the skin) due to the Infection Preventionist's (IP) lack of understanding of Enhanced Barrier Precautions (EBP; an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and glove use during high contact resident care activities) requirements for PPE use. This deficient practice is likely to affect all residents that have pressure ulcers and/or wounds by increasing the risk of infections due to repeated and ongoing exposure of infections.

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 1 (R #1) of 3 (R #1, R #2 and R #3) residents, when: 1. The facility failed to post the required Enhanced Barrier Precautions (EBP; an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and glove use during high contact resident care activities) signage for R #1.2. The facility failed to ensure staff utilized EBP during high contact resident care activities. This deficient practice is likely to affect all residents that have pressure ulcers and/or wounds by increasing the risk of infections due to repeated and ongoing exposure of infections.

Inspectors wroteBased on record reviews, observation, and interviews, the facility failed to honor resident's shower preferences for 2 (R #9, and R #13) of 2 (R #9, R #13, and R #15) reviewed for showers. If the facility fails to honor resident preferences, then the residents are likely to feel as if they are not heard and that the facility does not care about their choices.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure that 1 (R #1) of 1 (R #1) resident reviewed for catheter care had a privacy cover on their drainage bag while seated in the dining room during the breakfast food service. This deficient is likely to result in the resident's medical device being visible to other residents and staff, thereby failing to maintain the resident's dignity.

Inspectors wroteBased on observation, and interview, the facility failed to ensure unused medications were properly disposed of on the north hallway, when two medications were observed in the trash bin attached to the medication cart. This deficient practice is likely to affect any resident that may acquire and ingest the medication causing potential medication side effects.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure residents were served meals consistent with posted menus and food preferences for 1 (R #7) of 3 (R #7, R #12, R #14) residents reviewed:R #7 received food that they are allergic to. R #7 did not receive food according to their meal ticket. These deficient practices have the potential to make resident feel unheard, or have an allergic reaction.

Inspectors wroteBased on observation, record and interview the facility failed to ensure R #12 was served food in accordance with his prescribed diet. If the facility fails to provide food as prescribed than residents are likely not able to consume it and experience weight loss and choking risks.

Inspectors wroteBased on observation, and interview, the facility failed to protect residents' personal health information (PHI) by leaving a document unattended containing multiple residents' information (such as names, diagnoses, treatment plans, or room numbers) on top of a south nurse's counter. This deficient practice is likely to result in passerby's to have unauthorized access to sensitive information, putting residents' privacy at risk.

Inspectors wroteBased on observation, interview, and record review; the facility failed to store and serve food under sanitary conditions when staff failed to ensure:1. Food items were labeled and dated in the kitchen refrigerators. 2. Food was stored appropriately and not left open to air in the kitchen refrigerator. 3. Staff personal belongings were not stored next to a food serving line. These deficient practices are likely to affect all 121 residents listed on the resident census list provided by the Administrator on 09/16/25 and are likely to lead to foodborne illnesses in residents if food is not being stored properly and safe food handling practices are not adhered to.

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to maintain a safe, controlled environment for 2 (R #10 and #17) of 2 (R #10 and #17) residents reviewed. The facility failed to:Notify staff of R#10's infection control status by not recognizing R#10's COVID condition and not posting at his doorway a notice of his infectious status. Ensure proper hand hygiene was performed by staff and that a glucometer was cleaned and disinfected which could potentially cause cross-contamination for residents. This deficient practice is likely to result in residents and staff being exposed to infectious diseases that could be transmitted between staff and residents.

Inspectors wroteBased on interviews and record reviews the facility failed to ensure its antibiotic stewardship program was implemented and monitored to prevent the unnecessary use of antibiotic. This deficient practice placed residents at risk for developing antibiotic-resistant infections and adverse drug events.

Inspectors wroteBased on interviews and observation, the facility failed to ensure that a qualified individual was designated as the Infection Preventionist (IP) responsible for the facility's Infection Prevention and Control Program (IPCP). The facility's noncompliance with this requirement has the potential to result in widespread transmission of communicable diseases and infections among residents.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to maintain an environment that was clean, in good condition, and free from clutter for 1 (R #9) of 1 (R #9) resident reviewed for a homelike environment by: The facility was storing unused O2 (oxygen) concentrators (medical device used to deliver O2) in R #9's room. Two respiratory spirometers (instrument used to measure the volume of air that a person can inhale and exhale) were not stored in sealed bags and on top of an open tube of Clotrimazole Cream (antifungal medication) on R #9's shelf next to his bed. Failure to maintain the building in a clean and comfortable manner is likely to result in unsafe conditions and prevent residents from enjoying everyday activities.

Inspectors wroteBased on record review and interview, the facility failed to ensure staff revised the care plan for 5 (R #'s 7, 8, 11, 37 and 60) of 5 (R #'s 7, 8, 11, 37 and 60) residents reviewed by:Staff failed to conduct a quarterly care plan meeting as required and in accordance with their admission date and Minimum Data Set (MDS) assessments for R #7, 8, 11 and 60. Not including use of table during family visits for R #37. This deficient practice is likely to result in residents' care and needs not being addressed if care plans are not updated.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide quality care that meets professional standards for 5 (R #'s 9, 11,32, 97 and 125) of 5 (R #'s 9, 11, 32, 97 and 125) residents when the staff failed to:Obtain physician orders for R #9's use of Clotrimazole Cream (antifungal medication). Follow physician order for enteral feeding maintenance (ongoing process of providing nutrition to the residents who are unable to consume enough nutrients through their normal oral intake) for R #11. Follow physician order for oxygen use for R #32, #97 and #125. These deficient practices are likely to result in residents not maintaining their optimal health as planned by their medical provider.

Inspectors wroteBased on interviews, the facility failed to ensure the facility had sufficient staff to meet the needs of all residents residing in the facility when staff failed to: Offer baths or showers to residents as scheduled. These deficient practices are likely to negatively impact resident safety, comfort, and to impede processes such as timely incontinence care (assisting residents to the bathroom or changing adult briefs), regular turning schedules (moving or turning residents that need assistance and are unable to move on their own), showers, and appropriate assistance with meals.

Inspectors wroteBased on record review and interviews, the facility failed to complete the required pharmacy review of resident medications for 2 (R #'s 4 and 7) of 5 (R #'s 2, 4, 7, 64, and 72) residents reviewed for pharmacy reviews when:The facility failed to provide completed pharmacy reviews for every resident in the facility during the months of October 2024, November 2024, and June 2025. The facility provider did not respond to pharmacist recommendations. The facility providers did not respond to pharmacist recommendations for several weeks after the pharmacist's recommendation. This deficiency practice is likely to result in residents receiving medications that are unnecessary for their health.

Inspectors wroteBased on record review and interviews, the facility failed to complete the required pharmacy review of resident medications for 5 (R #'s 4, 7, 39, 63, and 105) of 8 (R #'s 2, 4, 7, 39, 63, 64, 72, and 105) residents reviewed for pharmacy reviews when:The facility failed to provide completed pharmacy reviews for every resident in the facility during the months of October 2024, November 2024, and June 2025. The facility provider did not respond to pharmacist recommendations. The facility providers did not respond to pharmacist recommendations for several weeks after the pharmacist's recommendation. Initiate a gradual dose reduction (GDR; [...]

Inspectors wroteBased on observation, and interviews, the facility failed to properly store medications in the facility medication cart by ensuring all expired medications are taken out of the medication cart, and not pre-pouring medications. This deficient practice is likely to result in expired medications and medical supplies being used in resident care resulting in residents being at risk of possible infections and not receiving the full benefits of medication.

Inspectors wroteBased on record review and interview, the facility failed to ensure 1 (R #12) of 3 (R #1, 5 and 12) residents reviewed was appropriately discharged when the facility:Provided R #12 a 30-day discharge notice after R #72 wandered into his room and both residents were engaging in sexual behaviors with one another. Requested that R #12 be administered medication to lessen his sexual drive but didn't allow enough time for the medication to take effect before issuing an immediate discharge notice. Ordered for R #12 to have one to one staffing, but while staff stepped away from R #12, R #72 went into R #12's room and both residents were caught engaging in sexual behaviors. Immediately discharged R #12 home with his wife without proper notice, opportunity to prepare for his arrival and option to appeal decision. [...]

Inspectors wroteBased upon record review and interview, the facility failed to provide written notice of discharge to the resident's representative for 1(R #12) of 3(R #1, 5 and 12) residents reviewed for discharged . If the facility is not providing written notice of discharge of a resident, then residents and their representatives will not have the contact information to appeal the decision without having to ask.

Inspectors wroteBased on record review and interview, the facility failed to ensure the Minimum Data Set (MDS; a comprehensive review of the resident's health and functional status) assessment was submitted for finalization within 14 days for 1 (R #5) of 1 (R #5) residents reviewed for Minimum Data Set. If MDS assessments are not completed and submitted in a timely manner, then the resident is likely to receive less than optimal care.

Inspectors wroteBased on record review and interview the facility failed to provide daily care needs including showers, brief changes and urostomy (a medical device used to collect urine after a urostomy, which is a surgical procedure that creates an opening (stoma) in the abdomen for urine to exit the body) bag changes for 3 (R #'s 4, 11, 36) of 3 (R #'s 4, 11, and 36) residents reviewed for care needs. Failure to provide for resident's daily care needs can result in residents feeling dirty, unclean and ashamed.

Inspectors wroteBased on interview and record review the facility failed to follow-up on an issue that that was brought up by the family during a meeting with staff for 1 (R #64) of 1 R (#64) resident if the facility is not following up on issues that affect the residents well being and quality of life then it is likely that the resident will feel unheard and that their issues do not matter to the facility.

Inspectors wroteBased on record review and interview, the facility failed to adequate supervision to prevent resident to resident sexual contact for 2(R #12 and 72) of 2(R #12 and 72) residents reviewed. If the facility is not providing adequate supervision to prevent sexual contact between residents determined to not have the capacity to consent to such contact, then residents are at risk of unwanted contact.

Inspectors wroteBased on record reviews and interviews, the facility failed to provide dialysis (a treatment that helps remove waste products and excess fluids from the blood when the kidneys are not functioning properly) services consistent with professional standards for 1 (R#3) of 1 (R#3) resident reviewed for dialysis care. The facility failed to provide a system of communication between the facility and the dialysis provider. This deficient practice is likely to result in resident condition not being communicated between the facility and dialysis center causing residents to receive inadequate care before, during and after dialysis services.

Inspectors wroteBased on interviews, the facility failed to notify the facility providers (Nurse Practitioner, Physician) and the resident's Power of Attorney (POA- medical decision maker), when a resident experienced a new coccyx (tail bone) pressure ulcer (localized damage to the skin and/or underlying tissue that usually occur over a bony prominence as a result of usually long-term pressure, or pressure in combination with shear or friction) for 1 (R #3) of 1 (R #3) resident reviewed for a change of condition. This deficient practice is likely to result in a delay in treatment or inadequate treatment.

Inspectors wroteBased on record review and interview, the facility failed to provide sufficient preparation for discharge for 1 (R #2) of 2 (R #'s 2 and 3) residents reviewed by not ensuring the referral for services had been received, accepted, and was scheduled to provide care for the resident upon discharge home. These deficient practices could likely result in resident not receiving needed services and having to navigate referral process for services unassisted.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents received the necessary treatment and services to prevent the development and worsening of pressure wounds (also called a pressure injury or pressure ulcer; skin damage which results from unrelieved pressure on the body) for 1 (R #3) of 1 (R #3) resident reviewed when staff failed to: 1. Identify R #3's new coccyx (tailbone) pressure wound with measurements of the new pressure wound, while monitoring for changes in the pressure wound. 2. Complete and document weekly skin evaluations that included R #3's new coccyx pressure wound. These deficient practices are likely to lead to residents developing pressure ulcers and wounds worsening.

Inspectors wroteBased on a record review and interview, the facility failed to ensure shower sheets records were complete for 1 (R #1) of 1 (R #1) resident reviewed for complete and accurate shower documentation. This deficient practice is likely to result in staff not having the information they need to provide competent, comprehensive care and services to residents.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a resident's care plan was revised for 1 (R #1) of 1 (R #1) resident reviewed for care plans when staff failed to update the care plan: 1. To accurately reflect the removal of a bathroom door alarm placed to prompt Certified Nurse Aide (CNA) /staff to check on the resident. 2. To reflect the use of a fall mat (a mat placed on the floor beside a resident's bed in case a resident falls out of bed). 3. To reflect the use of an anti-roll back device (a device used prevent a wheelchair from rolling back and away from the user as they attempt to sit down or stand up from the wheelchair) for R #1's wheel chair. This deficient practice is likely to result in staff not being aware of the residents care needs and preferences, and residents not receiving the needed care.

Inspectors wroteBased on record review and interview, the facility failed to meet professional standards of quality for 1 (R #1) of 1 (R #1) resident reviewed by not obtaining physicians orders to: 1. Install an alarm on R #1's bathroom door. 2. For the use of a fall mat during R #1's seizures. 3. For the use of an anti-roll back device on R #1's wheelchair. If the facility is not ensuring that physician orders are obtained and followed, the residents may not be getting the appropriate treatment and the intended treatment effects.

Inspectors wroteBased on record review and interviews, the facility failed to provide foot care for 1 ( R #1) of 1 ( R #1) resident reviewed for diabetic foot care (involves daily inspection and washing of your feet, keeping toenails trimmed, wearing well-fitting shoes and socks or slippers to protect your feet, getting regular check-ups during healthcare visits to ensure your feet stay healthy and free from complications) If the facility is not ensuring residents toe nails are clipped timely, then residents are likely to experience discomfort or be at risk for infection.

Inspectors wroteBased on observation and interview the facility failed to provide proper infection control practices for 1 (R #1) of 1 (R #1) resident reviewed for infection control by: 1. Not ensuring R #1's bathroom is clean and sanitary. 2 Not ensuring bathroom floor remained free of feces (waste matter discharged from the bowels after food has been digested). 3. Not ensuring handheld shower head was not on the bare floor. 4. Not ensuring wash bins and cloths for a bed bath were left uncovered under the bathroom sink. 5. Not keeping R #1's room and bathroom free of foul odors. Failure to adhere to an infection control program is likely to cause the spread of infections and illness to residents and staff within the facility.

Inspectors wroteBased on observation and staff interviews, the facility failed to ensure the central patio walkway was smooth and level. This affected all residents who use the patio for smoking and other activities. This deficient practice has the potential to cause residents, staff and/or visitors to receive injuries related to tripping and falls.

Inspectors wroteBased on record review and interview, the facility failed to ensure staff allowed a resident to remain in the facility or staff documented the reason for the resident's discharge, the location of the discharge/transfer, the evidence of the facility's efforts to meet the resident's needs prior to discharge, and the instructions for continued care for 1 (R #1) of 1 (R #1) resident reviewed for facility discharges. This deficient practice likely resulted in an unsafe, unplanned discharge in which the facility transferred R #1 to a local shelter without medications and care instructions.

Inspectors wroteBased on record review and interview, the facility failed to ensure staff provided a written notice to a resident which included the reasons for the discharge and to send a copy of that notice to the Ombudsman (an advocate for the residents) for 1 (R #1) of 1 (R #1) resident sampled for discharges or transfers. Without approporiate notice, the resident likely was not able to adequately advocate for his rights and to ensure that he was not inappropriately transfered or discharged .

Inspectors wroteBased on record review and interview, the Certified Nurse Aide (CNA) #1 failed to report a resident's fall with injury to the facility nurse for 1 (R #2) of 1 (R #2) residents reviewed for falls. Failure to report a fall immediately to the nurse to conduct an assessment could likely result in the resident not receiving the necessary care needed for injuries sustained or for prolonged pain and discomfort.

Inspectors wroteBased on record review and interview, the facility failed to ensure 1 (R #3) of 1 (R #3) resident was free from accidents when staff failed to provide adequate supervision while the resident used the toilet. If the care plan is not followed according to the resident's needs then the resident is not likely to get the proper assistance needed which places the resident at an increased risk for injury.

Inspectors wroteBased on record review and interview, the facility failed to protect 1 (R #1) of 3 (R #1-3) residents reviewed from abuse and neglect when a staff member used loud, foul, abusive language and then abandoned R #1 instead of providing care by leaving the unit. This deficient practice is likely resulted in R #1 being left covered in feces.

Inspectors wroteBased on observation and interview, the facility failed to safeguard clinical record information when staff disclosed private health information (PHI) to unauthorized persons for 1 (R #1) of 1 (R #1) resident reviewed. This deficient practice likely resulted in R #1's clinical information not being sufficiently safe guarded.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure an allegation of staff-to-resident abuse was reported within two hours to the State Agency for 1 (R #1) of 1 (R #1) resident reviewed. If the facility is not immediately reporting allegations of abuse and conducting an investigation, residents are likely to be at risk of further abuse.

Inspectors wroteBased on record review and interview, the facility staff failed to prevent an accident when staff did not appropriately transfer 1 (R #2) of 1 (R #2) resident reviewed for accidents. This deficient practice likely resulted in R #2's fractured knee.

Inspectors wroteBased on observation, record review and interview, the facility failed to meet professional standards of quality for 1 (R #) of (R #1) residents reviewed by not administering medications in accordance with the physician's orders. If the facility is not administering medications as prescribed, the resident is likely to not get the therapeutic benefits of medications needed to maintain resident health and well-being.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents received the necessary treatment and services to prevent the development and worsening of pressure wounds (also called a pressure injury; skin damage which results from unrelieved pressure on the body) for 2 (R #50 and #69) of 2 (R #50 and #69) residents reviewed when staff failed to: 1. Timely identify the new wound, monitor for changes in the wound, provide daily treatments as ordered and notify the physician that the wound was worsening for R #50. 2. Complete and document weekly skin evaluations for R #69. This deficient practice likely resulted in R #50's pressure ulcer worsening and leading to an amputation. This deficient practice is also likely to lead to residents developing pressure ulcers and wounds worsening.

Inspectors wroteBased on record review and interview, the facility failed to ensure 1(R #34) of 1(R#34) resident reviewed for dehydration maintain adequate hydration when they failed to: 1. Provide IV (intravenous; a thin plastic tube inserted into a vein using a needle) fluid hydration as ordered by a physician for R #34, 2. Document and monitor fluid intake for R #34. This deficient practice likely resulted in R #34 to have prolonged dehydration and worsened an untreated UTI.

Inspectors wroteBased on record review and interview, the facility failed to provide a discharge summary and post discharge plan of care which included wound care for 1 (R #50) of 1 (R #50) residents reviewed for wounds. This deficient practice likely resulted in R #50's pressure wound worsening and needing emergency care in the hospital.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents received bowel movement (BM) monitoring and interventions for 1 (R #31) of 1 (R #31) residents reviewed when staff failed to: 1. Monitor R #31 for constipation (problem with passing stool). 2. Notify the provider R #31's constipation medication was not working and R #31 did not have a BM days before R #31 went to the hospital. This deficient practice likely resulted in R #31 having ongoing constipation, fecal impaction (hardened stool stuck in rectum or lower colon due to chronic constipation), and abdominal pain.

Inspectors wroteBased on record review, observations and interviews the facility failed to ensure the facility had sufficient staff to meet the needs of all 109 residents residing in the facility when staff failed to: 1. Offer baths or showers to residents as scheduled; 2. Supervise residents during residents smoking times. These deficient practices are likely to negatively impact resident safety, comfort, and to impede processes such as timely incontinence care (assisting residents to the bathroom or changing adult briefs), regular turning schedules (moving or turning residents that need assistance and are unable to move on their own), showers, and appropriate assistance with meals.

Inspectors wroteBased on record review and interview, the facility failed to ensure staff provided residents with a nourishing bedtime snack to ensure there were no more than 14 hours between a substantial evening meal and breakfast the following day for 6 (R #21, R #53, R #36, R #20, R #99, and R #97) of 6 (R #21, R #53, R #36, R #20, R #99, R #97) residents reviewed for snacks. This deficient practice could likely cause frustration and lead to unnecessary hunger.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure unknown food storage containers were labeled and stored appropriately. 2. Ensure a garbage bin was covered and away from ready to eat foods on the food preparation area. 3. Ensure one gallon plastic jug of salsa open to air. 4. Ensure a tray of what appeared to be cake was not labeled or dated. 5. Ensure Dietary Aide serving lunch line was wearing a hair restraint. 6. Ensure one can of chili con carne was not stored on bare floor in dry storage area. 7. Ensure back door of the kitchen area was not propped opened These deficient practices are likely lead to foodborne illnesses and have the potential to affect all 109 residents who eat food prepared in the kitchen identified on the census list provided by the Administrator on 06/23/2024.

Inspectors wroteBased on observation and interview, the facility failed to adequately maintain and implement an infection prevention and control program for all residents by: 1. Not covering laundry carts when in hallway when delivering resident laundry. 2. Staff placing personal protective equipment (respiratory equipment, garments, and barrier materials used to protect rescuers and medical personnel from exposure to biological, chemical, and radioactive hazards.) (PPE) in resident trash cans without liners and resident's room did not have PPE bins resident's room to doff (remove) PPE. These deficient practices are likely to affect all 109 residents in the facility as identified on the census list provided by the Assistant Director of Nursing on 06/22/24. [...]

Inspectors wroteBased on interview and record review, the facility failed to promote resident self-determination through support of resident choice for 2 (R #'s 36 and 89) of 2 (R #'s 36 and 89) residents reviewed for choices by not accommodating R #36 and R #89's choice to have privacy with each other. If the facility is not honoring resident's choices, then residents are likely to have an increase in frustration and depression.

Inspectors wroteBased on record review and interview, the facility failed to: 1. Ensure facesheet matched the advanced directives document [legal document that states a person's wishes about receiving medical care if that person is no longer able to make medical decisions] in the medical record for R #86. 2. Ensure R #100's advanced directive document was available and in her medical chart. 3. Ensure advanced directive that was in the advanced directive book at the nurses station matched what was in the medical record for R #114. If the facility is not ensuring that each resident has the opportunity to execute an advanced directive, then residents are likely not to have their wishes carried out if there is a time when they are not able to make their own healthcare decisions.

Inspectors wroteBased on record review, and interview, the facility failed to ensure staff revised the care plan for 2 (R #'s 1 and 7) of 2 (R #'s 1 and 7) residents reviewed when staff failed to: 1. Update the care plan to include oxygen (O2) usage for R #1. 2. Update the care plan to remove restorative nursing services (person-centered nursing care designed to improve or maintain the functional ability of residents, so they can achieve their highest level of well-being possible) for R #7. These deficient practices are likely to result in residents' care and needs not being addressed if care plans are not updated.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide activities of daily living (ADL; activities related to personal care such as bathing, showering, dressing, walking, toileting, and eating) assistance for baths and showers for 4 (R #'s 41, 50, 69 and 71) of 4 (R #'s 41, 50, 69 and 71) residents reviewed for ADL care. This deficient practice is likely to affect the dignity and health of the residents.

Inspectors wroteBased on record review and interview, the facility failed to provide an ongoing activity program for 4 (R #12, #51, #66 and #86) of 4 (R #12, #51, #66 and #86) residents reviewed for activities. If the facility is not ensuring that all residents are receiving an ongoing activity program, documenting resident refusals and making in room activity accommodations, then residents are likely to demonstrate an increase in isolation and depression.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure that 3 (R #'s 7, 63, and 68) of 3 (R #'s 7, 63, and 68) residents reviewed were free from accidents and hazards by staff not: 1. Completing a fall risk assessment and placing a fall mat (specially designed floor mats placed on the floor at the bed or chair to protect the elderly from serious physical trauma) per physician orders for R #7. 2. Completing smoking assessments quarterly for R #'s 63 and 68. 3. Having staff present during smoking times for R #'s 63 and 68. These deficient practices are likely to put residents at risk of unsafe situations.

Inspectors wroteBased on interview and record review, the facility failed to ensure ongoing communication forms were completed and collaboration (different persons/groups working together) with the dialysis (clinical purification of blood as substitute for normal kidney functioning) facility regarding dialysis care and services for 1 (R #41) of 1 (R #41) residents reviewed for dialysis. If the facility is unaware of the status, condition, or complications that arise during dialysis treatment, then residents are likely to not receive the appropriate monitoring and care they need.

Inspectors wroteBased on record review and interview, the facility failed to ensure for 1 (R #55) of 1 (R #55) resident reviewed for behavioral health concerns received necessary behavioral health care to meet their needs by staff not: 1. Ensure R #68's behavioral health/psychiatric (psych) progress notes were documented for facility staff in R #68's Electronic Health Record (EHR). 2. Referred R #70 to a psych services provider per physician orders. These deficient practices are likely to result in the residents not receiving the behavioral or mental health care and assistance needed to improve mood and reduce depression and anxiety.

Inspectors wroteBased on record review and interview, the facility failed to ensure that the consultant pharmacist recommendations were reviewed and considered each month for 1 (R #97) of 5 (R # 12, 39, 45, 66, and 97) residents reviewed for medication regimen. If consultant pharmacist's recommendations are not reviewed by the facility and health care provider monthly, residents are likely to experience unnecessary drug interactions and adverse side effects.

Inspectors wroteBased on record review and interview, the facility failed to ensure that 1 (R #97) of 5 (R #12, 39, 45, 66, and 97) resident's prescription for a PRN (as needed) psychotropic medication was reviewed and renewed every 14 days by the prescriber. This deficient practice is likely to result in residents receiving medications without regular review or oversight causing over-sedation and other negative side effects.

Inspectors wroteBased on observation and interview, the facility failed to provide a safe, functional, and comfortable environment for all 109 residents by: 1. Not emptying trash bins on a regular basis and allowing them to overflow. 2. Not replacing a broken washer machine and having only one washer which was leaking in laundry room. 3. Leaving cigarette butts on the ground and allowing other residents to pick them up. These deficient practices could likely effect all 109 residents in the facility as identified on the census list provided by the Assistant Director of Nursing on 06/22/24. Failure to have a sanitary facility is likely to cause the spread of infections and illness to residents and staff within the facility.

Inspectors wroteBased on record review and interview the facility failed to provide 1(R #21) of 1 (R #21) resident with their medical records when requested. By not providing the resident with his medical record, the facility is not supporting resident's right to access their records, preventing them from knowing about their medical care and obtaining necessary services.

Inspectors wroteBased on record review and interview, the facility failed to ensure that 1 (R #34) of 1 (R #34) resident reviewed for urinary tract infections (UTI) had a sufficient change assessment (a major decline or improvement in the resident's status that will not normally resolve itself without further intervention by staff or by implementing standard disease-related clinical interventions) completed within 14 days of determining the status change was significant. This deficient practice could likely result in residents not receiving the care and assistance needed.

Inspectors wroteBased on record review and interview, the facility failed to ensure that 3 (R #45, 85 and 100) of 3 (R #s 45, 85 and 100) residents reviewed for Pre-admission Screening and Resident Review (PASRR) (assessment screen performed prior to admission to evaluate resident for mental illness or intellectual disability) identified as having a primary diagnosis of Dementia, received a Dementia waiver. The waiver would exclude these residents from needing a Level 2 screen (an in depth assessment for mental health illness). The Dementia waivers were not obtained by the facility and Level 2 PASRR screenings were not completed. This deficient practice could likely result in residents with physical or intellectual disabilities not receiving appropriate services after admission to the facility.

Inspectors wroteBased on record review, and interview, the facility failed to ensure the residents' ability to perform activities of daily living (ADLs) was maintained for 1 (R #75) of 1 (R #75) resident reviewed for restorative therapy (Restorative services refers to nursing interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible). If the facility does not ensure that residents receive restorative services, then the residents are likely to experience a decrease in their ability to walk, transfer, and do other activities of daily living.

Inspectors wroteBased on observation and interview the facility failed to: 1. Ensure all medications were stored properly and in the original, labeled packaging. 2. Ensure medical supplies in the medication carts were not expired. 3. Ensure medication carts were locked when unattended. 4. Ensure medications were labeled with open date These deficient practices are likely to negatively impact the health of all residents, if staff administered or used potentially compromised or contaminated medications.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure dental services were obtained for 1 (R #114) of 1 (R #114) residents reviewed for dental care and services. This deficient practice could likely result in the residents not receiving dental care and services to meet their needs.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure residents obtained routine dental care for 1 (R #50) of 1 (R #50) resident reviewed for dental services. This failure is likely to result in the resident experiencing pain, embarrassment over condition of teeth, and potential weight loss.

Inspectors wroteBased on record review and interview, the facility failed to ensure Certified Nurse Aides (CNAs) received the required in-service training of no less than 12 hours per year for 2 (CNAs #7 and #8) of 5 (CNAs #7, #8, #9, #10, and #11) CNAs randomly reviewed for required in-service training. This deficient practice is likely to result in the nurses aides not receiving the necessary training to meet the care needs of the residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents who submitted written grievances were informed of the facility's findings and were given a written summary of the grievance conclusion for 8 (R #s 2, 3, 4, 5, 6, 7, 8, 9) of 22 (R #s 1, 2, 3, 4, 5, 6, 7, 8, 9,10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22) residents and or resident's representatives who submitted a grievance to the facility. This deficient practice is likely to result in residents believing the facility did not take their grievances seriously and did nothing to respond to their grievances.

Inspectors wroteBased on record review and interview, the facility failed to ensure 1 (R #1) of 3 (R #'s 1, 2, and 3) residents reviewed for elopement (an unauthorized departure of a patient from an around-the-clock care setting) was free from accidents/hazards by not providing adequate supervision.

Inspectors wroteBased on record review and interview, the facility failed to ensure medications were administered as ordered by the physician for 1 (R #4) of 3 (R #s 1, 3 and 4) residents reviewed for medications. This deficient practice can result in a resident failing to obtain maximum wellness and/or suffer prolonged illness/pain.

Inspectors wroteBased on observation and interviews, the facility failed to: 1) Ensure that opened and accessed (has been opened or accessed the pen should be dated with the last date that the product should be used {expiration date} and discarded within 28 days unless the manufacturer specifies a different {shorter or longer}) for a flexpen (is pre-filled with insulin so you don't have to load it) weren't dated as to when they were initially opened/assessed, by the nursing staff. 2) Ensure that undated medications were not stored with dated medications, that were readily available for resident use, 3) Ensure that expired supplies were not stored with unexpired supplies in the storage rooms, and 4) To properly store medications in medication carts. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow safe food handling practices and proper sanitation practices by: 1. Not labeling food items, in the refrigerator, with dates, 2. Placing uncovered, prepared glasses of juice under a hand sanitizing dispenser, and 3. Not maintaining complete documentation (i.e. temperature log) of refrigerator temperatures located in the nutrition room on the facility's south unit. These deficient practices could likely affect all 105 residents listed on the resident census list provided by the Administrator on 05/15/23, by leading to foodborne illnesses if safe food handling practices are not adhered to.

Inspectors wroteBased on interviews the facility failed to show dignity and respect resident rights to eat in the dining room for 5 (R #6, 29, 73, 74 and 93) of 5 (R #6, 29, 73, 74, and 93) residents interviewed for Resident Council. This deficient practice likely caused residents to feel frustrated and disrespected when the dining room was closed and the residents were given no choice, but to eat in their rooms without any warning or explanation from staff.

Inspectors wroteBased on record review and interview, the facility failed to maintain inventory sheets of personal belongings upon entry to the facility, and a laundry process that would track unclaimed laundry or claims of missing clothes for 4 (R #'s 5, 13, 55, & 81) of 4 (R #'s 5, 13, 55, & 81) residents reviewed for personal property. This deficient practice could likely result in residents experiencing frustration due to missing clothes when sent out for laundering and when personal items have gone missing.

Inspectors wroteBased on record review, observation and interview the facility failed to develop and implement a comprehensive person-centered care plan for 6 (R #'s 31, 36, 49, 56, 68, and 103) of 6 (R #'s 31, 36, 49, 56, 68, and 103) residents. 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 decline in abilities and a failure to thrive.

Inspectors wroteBased on observation, record review and interview, the facility failed to provide an ongoing activity program for 4 (R #7, 31, 68, and 91) of 4 (R #7, 31, 68, and 91) residents reviewed for activities. If the facility is not ensuring that all residents are receiving an ongoing activity program, documenting resident refusals, making in room activity accommodations, and completing an activity assessment (a questionnaire designed to collect information about resident likes, interests, and capabilities); then residents are likely to demonstrate an increase in isolation and depression.

Inspectors wroteBased on record review and interview, the facility failed to follow physician orders related to nutritional needs for 2 (R #'s 18 and 96) of 3 (R #'s 18, 96, and 104) residents reviewed for dialysis care and weight management. This deficient practice could likely result in residents not receiving the required nutritional support needed.

Inspectors wroteBased on observation, record review, and interview, the facility failed to maintain oxygen equipment according to the professional standards for 6 (R#'s 23, 24, 25, 36, 64, and 103) of 6 (R#'s 23, 24, 25, 36, 64, and 103) residents reviewed for respiratory care. This deficient practice could likely result in oxygen tubing not being changed according to the date of install or previous replacement, and not ensuring the resident is wearing oxygen as per the physician's order.

Inspectors wroteBased on record review and interview, the facility failed to maintain a process to monitor resident behavior after prescribing psychotropic medication (a medication that alters the chemical makeup of the brain and nervous system) to determine effectiveness for 4 (R#25, R #36, R #40, and R #89) out of 4 # R (R #25, R #36, R #40, and R #89) residents reviewed for unnecessary medications. This deficient practice could likely result in residents being administered psychotropic medications they do not need, experience potential unnecessary drug and/or adverse side effects.

Inspectors wroteBased on record review and interview the facility failed to ensure residents the correct notification(s) for 1 (R #21) of 1 (R #s 21) resident reviewed for timely and specific Beneficiary Protection Notification. This deficient practice can likely result in confusion for the resident or their representative as to what services they receive or do not have financial coverage for under Medicare.

Inspectors wroteBased on record review and interview, the facility failed to develop and implement a baseline care plan within 48 hours of a resident's admission for 1 (R #106) of 1 (R #106) resident. If the facility is not developing a care plan for newly admitted residents, then residents are likely to not get the specific care and assistance they need.

Inspectors wroteBased on record review and interview, the facility failed to ensure good communication was in place for care coordination between the hospice company and the facility staff for 1 resident (R #'s 56) of 1 (R #56) reviewed for hospice services. This deficient practice is likely to result in staff uncertainty over resident care needs and affected residents not receiving appropriate care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide podiatry services for 1 (R #43) of 1 (R #43) residents reviewed for diabetic nail care. This deficient practice could likely result in residents feeling uncomfortable with the feel and appearance of their toenails and/or result in medical complications.

Inspectors wroteBased on observation and interview, the facility failed to provide a safe environment that was free of hazards for 1 (R #158) of 1 (R #158) resident looked at during the initial pool sample. This deficient practice has the potential to cause an accident when there is no light in the bathroom.

Inspectors wroteBased on observation, interview and record review, the facility failed to properly maintain records of controlled substances (drugs that are subject to strict government control because they may cause addiction) on each cart medication cart. This deficient practice could cause the likelihood of controlled substances being diverted (a medical and legal concept involving the transfer of any illegal prescribed controlled substances from the individual for whom it was prescribed to another person for any illicit use).

Inspectors wroteBased on record review and interview, the facility failed to ensure medications were administered as ordered by the physician for 1 (R #157) of 3 (R #s 67, 84 and 157) residents reviewed for medications. This deficient practice can result in a resident failing to obtain maximum wellness and/or suffering prolonged illness.