Catered Manor Care Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate treatments and services to prevent decline in range of motion ([ROM], full movement potential of a joint [where two bones meet]) on two of six sampled residents (Resident 13, and Resident 70). The facility failed to:1. Ensure Restorative Nursing Aide ([RNA] an advanced nursing assistant who helps residents maintain their function and mobility) notify licensed nurses of Resident 13's inability to tolerate application of handroll ( soft, cylindrical cushions placed in the palm to jeep joints flexible and stop the hand from curling tightly into a fist) and Resident 13's complained of pain on resident's right hand during application of a handroll.2. Ensure appropriate handroll was used on Resident 13's right hand consistently as ordered.3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow appropriate isolation precautions and observe infection control measures for three of 19 sampled residents (Resident 31, Resident 47 and Resident 58) by failing to:1. Ensure Resident 31 with active shingles (a painful viral infection that causes a blistering skin rash) and immunocompromised (the body's defense system is weakened or not working properly) was placed in airborne precaution isolations (used to prevent the spread of germs that can float in the air) to prevent the potential transmission of shingles to other residents and staff. 2. Offer and provide hand hygiene (simple practice of cleaning your hands to remove dirt, grease and germs) to Resident 47 and Resident 58 before mealtime. [...]

Inspectors wroteBased on interview and record review, the facility failed to accurately assess the mental capacity (the ability to understand information and make decisions) of one of four sampled residents (Resident 6) before obtaining informed consent (a voluntary agreement to accept treatment or procedures after receiving information about the risks, benefits, and alternatives) for a psychotropic medication (a drug that affects brain activity related to mental processes and behavior). Resident 6 had fluctuating capacity to make medical decisions. This failure had the potential to violate Resident 6's right to receive adequate information about the risks and benefits of taking psychotropic.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were provided accurate information necessary to make informed choices regarding their smoking preferences. The facility failed to:1. Provide consistent and accurate information during the admission process regarding whether the facility was a smoking or non smoking facility.2. Ensure staff, including the Administrator and admission Coordinator, understood and communicated the facility's smoking policy correctly.3. Ensure the admission Packet and written policies aligned with the information provided verbally to residents.4. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 6) was free of chemical restraints (use of medication to control a patient's behavior or restrict patient's movement and not required to treat the medical symptom). The facility failed to:1. Assess appropriateness of Resident 6's psychotropic medicines (drugs that affect the mind, emotions and behavior) who has a diagnosis of dementia (a progressive state of decline in mental abilities) after being admitted to the facility on [DATE]. Resident was receiving Buspirone (medication that treats anxiety) 0.5 milligram (mg.- unit of measurement) by mouth two times a day for anxiety, Quetiapine Fumarate (generic name of Seroquel- antipsychotic [a type of medication prescribed to treat mental health problem])100 mgs. [...]

Inspectors wroteDuring an interview and record review the facility failed to ensure two of three sampled residents (Resident 3 and Resident 6) had a PASRR level II (a federal assessment requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care) completed to reflect Resident 3 and Resident 6's medical conditions. This deficient practice had the potential to result in inappropriate placement and unidentified specialized services for Resident 3 and Resident 6.

Inspectors wroteBased on interview, and record review, the facility staff failed to ensure one of one sampled resident (Resident 65) received proper assistive devices to maintain hearing abilities by not assisting Resident 65 in arranging for an audiologist (a licensed healthcare professional who diagnoses, treats, and manages hearing loss) referral consult. This deficient practice resulted in Resident 65 not being able to hear adequately during a conversation, not being able to effectively communicate with staff and understand care and services being given.

Inspectors wroteBased on interview and record review the facility failed to ensure one of three sampled residents (Resident 7) received necessary care and services to prevent the development and progression of avoidable pressure injuries (localized damage to the skin and/or underlying tissue usually over a bony prominence). The facility failed to:1. Provide consistent, accurate, and timely skin assessments and wound management for Resident 7. Inconsistent documentation in Shower Day Skin Inspections between 3/5/2026 and 3/18/2026 showing skin intact/clear despite the resident's known Stage III pressure ulcers (a severe, full-thickness skin loss extending down to the subcutaneous fat).2. Perform and document weekly skin assessments for Resident 7 as required by the facility's policy3. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure employees' personnel files contained documentation of completed performance evaluations for four of eight employees (Certified Nurse Assistant [CNA] 1, CNA 3, Treatment Nurse [TN] 1, and Registered Nurse [RN] 1 ). This failure had the potential to result in unassessed staff performance, competency and training needs which may result in unsafe and ineffective care for residents. During concurrent interview and record review on 5/12/2026 at 10:20 a.m., with the Director of Staff Development (DSD), employee files were reviewed. The DSD stated CNA 1, CNA 3, TN 1, and RN 1 did not have documentation of their employee performance evaluations. The DSD stated that annual performance evaluations were important to assess whether employees can fulfill their roles and responsibilities for residents in their care. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure proper documentation of the destruction of controlled substances (Schedules II, III, or IV drug, chemical where possession, and use are strictly regulated by the government) as required for six medications in the month of 4/2026 when the pharmacist's signature was not co-signed by a registered nurse. This failure had the potential to result in mismanagement or diversion of controlled substances.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food service staff was competent in testing the chlorine (deep cleaning and sanitizing agent) of the dishwashing machine for one of two dietary aides (DA)1. This failure had the potential to put residents at risk for food borne illness (any illness resulting from eating contaminated/spoiled foods) due to inability to read and know what the proper range of sanitizer solution for the dishwashing machine.

Inspectors wroteBased on observation, interviews and record review the facility failed to identify and honor cultural food preferences for one of one sampled resident (Resident 76). This failure had the potential to result in weight loss for Resident 76.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the quaternary sanitizer solution (disinfectant) in the red bucket used to clean kitchen surfaces was at the 200 parts per million (PPM- unit of measurement) to ensure kitchen surfaces were sanitized properly. This failure had the potential to expose all residents to food borne illnesses (any illness resulting from ingestion of food contaminated with bacteria, viruses, or parasites).

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain complete and accurate clinical records for one of three sampled residents (Resident 11) by not documenting restorative nursing services ([RNA] nursing aide program that helps residents to maintain their function and joint mobility) as ordered. The facility failed to:1 Accurately document restorative nursing services, including passive range of motion ([PROM] movement at a given joint with full assistance from another person) to the bilateral lower extremities and active assistive range of motion ([AAROM]- movement at a given joint with a person's own effort and assistance from an external force or another person) to the bilateral upper extremities, as ordered five times per week.2. [...]

Inspectors wroteBased on interview, and record review, the facility failed to develop and implement comprehensive plan for one of one sample residents (Residents 1) when Resident 1 fell on 7/3/2025 from the wheelchair. This deficient practice increased Resident 1's risk of further falls and injuries.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident environment was free of potential hazard for one of one sample residents (Resident 1). Resident 1 who had an unwitnessed fall from her wheelchair on 7/3/2025. The facility failed to: 1. Ensure Resident 1's wheelchair was locked upon Resident 1's return from dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) machine to filter their blood ) treatment on 7/3/2025. This deficient practice resulted in Resident 1 falling from her wheelchair on 7/3/2025 with no injury and had the potential for increased risk for further falls and injury.

Inspectors wroteBased on interview and record review, the facility failed to ensure that licensed nurses monitored the blood sugar (b/s) levels for one of four sampled residents (Resident 1) who had diagnosis of diabetes mellitus ([DM] disease characterized by elevated levels of blood sugar) and was receiving Prednisone (medication used to treat a wide range of conditions that raises b/s levels and can induce hyperglycemia (a condition where there's too much sugar in the bloodstream). The facility failed to:1. Ensure licensed nurses clarified with Resident 1's physician, instructions from the admitting GACH to check Resident 1's b/s levels every day before meals and at bedtime and to take diabetic medication or insulin (a medication used to manage b/s levels in people with DM) as prescribed. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the physician when one of four sampled resident's (Resident 1) laboratory (lab) result dated 5/22/2025 indicated a high blood glucose (sugar) level, a low sodium (the electrolyte in the body crucial for maintaining fluid balance, nerve and muscle function, and blood pressure) level, and a low chloride (an essential electrolyte that plays a crucial role in body fluids, including blood, sweat and urine) level. This deficient practice resulted in Resident 1's physician being unaware of Resident 1's abnormal lab results and a delay in care and treatment.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Care Plan was created one of four sampled residents (Resident 1) who was administered Prednisone (medication used to treat a wide range of conditions that raises b/s levels and can induce hyperglycemia [a condition where there's too much sugar in the bloodstream]) with intervention to monitor Resident 1 for risk, side effects, and adverse reactions related to the use of Prednisone due to this medications ability to increase blood sugar (b/s) levels. This deficient practice resulted in Resident 1's b/s level not being monitored from 4/11/2025 through 5/16/2025 to ensure it was within an acceptable range in order to provide care and treatment accordingly. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) who had an order for Prednisone (medication used to treat a wide range of conditions that raises b/s levels and can induce hyperglycemia (a condition where there's too much sugar in the bloodstream) 20 milligrams ([mg] a metric unit of measurement, used for medication dosage and/or amount) 2 tablets, twice a day (80 mg), had a stop date and/or duration of administration. This deficient practice resulted in Resident 1 taking Prednisone 20 mg., 2 tablets twice a day (for a total of 80 mg daily), from 4/12/2025 until 6/22/2025. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a Medication Regimen Review (MRR) for one of four sampled residents (Resident 1) was conducted in 6/2025. They failed to ensure a MRR conducted in 5/2025 with a recommendation by the facility's Pharmacist Consultant (PC) to add a duration of time for the use of Prednisone (medication used to treat a wide range of conditions[b/s] levels) was followed, by notifying Resident 1's physician of the PC's recommendation and ensuring Resident 1's physician responded. This deficient practice resulted in Resident 1's use and dosage of Prednisone not being evaluated per the PC's recommendation from 4/12/2025 until 6/22/2025. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who was dependent (helper does all the effort, resident does none of the effort to complete the activity, or the assistance of two or more helpers is required for the resident to complete the activity) on nursing staff for toileting hygiene, and rolling to the left and right side while lying on his back in bed, was provided assistance by two people when receiving incontinent (loss of control of bowel and/or bladder) care. The facility failed to: 1. Ensure Certified Nursing Assistant (CNA) 1 did not turn and reposition Resident 1 during incontinent care without the assistance of an additional staff member, per the Minimum Data Set ([MDS] a resident assessment tool) assessment. [...]

Inspectors wroteBased on interview and record review, the facility failed ensure they documented interventions needed to prevent falls and injuries for one of three sampled residents (Resident 1), per the Minimum Data Set ([MDS] a resident assessment tool) assessment. This deficient practice resulted in an incomplete care plan and staff not being aware that Resident 1 was dependent (helper does all the effort, resident does none of the effort to complete the activity, or the assistance of two or more helpers is required for the resident to complete the activity) on nursing staff for toileting hygiene and rolling to the left and right side while lying on his back in bed during care.

Inspectors wroteBased on interview and record review the facility failed to involve one of one resident (Resident 1) and/or responsible party in the Interdisciplinary team (IDT) conference after Resident 1 fell on 4/3/2025. This deficient practice had the potential to result in poor quality of care and a delay of care and services.

Inspectors wroteBased on interview and record review the facility failed to provide one of one family member (FM)1 medical records of Resident 1 within the required time frame. This deficient practice had the potential to result in poor quality of care and a delay of care and services.

Inspectors wroteBased on interview and record review the facility failed to recheck one of one ' s resident (Resident 1) blood glucose (sugar) levels after insulin (a hormone that removes excess sugar from the blood can be produced by the body or given artificially via medication) was administered as indicated in Resident 1 ' s care plan. This deficient practice had the potential to result in poor quality of care and a delay of care and services.

Inspectors wroteBased on observations, interviews, and records review, the facility failed to ensure there were competent staff (Cook) was able to carry out position related duties when: 1. Cook prepared pumpkin pie, without following the recipe. This deficient practice had the potential to result in decreased puree food quality and had the potential to result in wrong meal preparation.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff prepared puree diet (composed of food of a pasty consistency: smooth, with no lumps or pips) was prepared according to the menus and standardized recipes when: 1. Cook added milk to pumpkin pie without following the recipe. This deficient practice had the potential to result in choking for Resident's that has swallowing problem.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the assessment entries on the Minimum Data Set (MDS- an assessment and a care screening tool) related to the legal name of Resident 59 was accurately documented and not 120 days overdue. This failure had the potential to negatively affect Resident 59's plan of care and delivery of necessary care and services.

Inspectors wroteBased on interview and record review the facility failed to ensure one of one sampled resident (Resident 21) level 1 Preadmission and Resident Review (PASRR- a federal regulation to prevent inappropriate placement of individuals with mental illness, intellectual disability, or developmental disabilities in Medicaid-certified nursing facilities) was documented correctly. This failure had the potential to result in Resident 21 not receiving the necessary care and services.

Inspectors wroteBased on interview and record review the facility failed to ensure a comprehensive care plan and a change of condition ([COC] a sudden, clinically important deviation from a patient's baseline in physical, cognitive (ability to think, understand, learn, and remember) behavioral, or functional status which without immediate intervention, may result in complications or death)) was completed for two of 15 sampled residents ( Resident 49 and 22). The facility failed to: a. Ensure Resident 22 had a COC and plan of care when Resident 22 passed out with unknown cause and regain consciousness on 01/01/2025. b. Ensure Resident 49 had a COC and care plan in place for Resident 49's left big toe infection. These deficient practices had the potential to negatively affect the delivery of necessary care and services to Resident 22 and 49.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one of one sampled resident (Resident 3) referral, appointment and recommendation for ophthalmology (medical specialty focusing on diagnosis and treatment of eye disorders) was arranged to maintain vision. This failure had the potential to result in worsening vision for Resident 3.

Inspectors wroteBased on interview and record review the facility failed to ensure one of 15 sampled residents (Resident 49) was seen by a podiatrist (a medical specialty focused on the care and treatment of the foot, ankle, and lower leg) for her left big toe infection. This failure placed Resident 49 at risk for complications related to her left big toe infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that a resident received continuous oxygen (a medical treatment to help resident breathe better) as ordered by the physician for one of twenty sampled residents (Resident 19) by: a. Failing to ensure Resident 19 received oxygen at eight liters per minute (lpm unit of measurement) via re-breathable mask (a medical oxygen delivery device where the patient inhales a mixture of oxygen and exhaled air, rather than pure oxygen) as ordered by the physician. This deficient practice had the potential to result in Resident 19 receiving inaccurate amount of oxygen and cause complications associated with oxygen therapy.

Inspectors wroteBased on interview and record review, the facility failed to ensure an annual performance evaluation (a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics in performing that an individual need to perform work roles or occupational functions successfully) was performed every year for Certified Nursing Assistant (CNA 3). This deficient practice had the potential for the facility not be able to assess the skills necessary for CNA 3 to provide nursing services to assure resident safety and to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident.

Inspectors wroteBased on interview and record review the facility failed to ensure the McGeers criteria (a set of guidelines used to define and classify healthcare-associated infections (HAIs) in long-term care facilities) was used for one of 15 sampled residents, when (Resident 49) was prescribed bacitracin (topical antibiotic) ointment for a left big toe infection. This failure had the potential to result in Resident 49 developing antibiotic resistance (not effective to treat infection) from unnecessary or inappropriate antibiotic use.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Infection Preventionist ([IP]) term used for the person(s) designated by the facility to be responsible for the infection prevention and control program) had specialized training in infection prevention and control. This failure had the potential to lead to inadequate oversight and potential spread of infections within the facility due to poor infection control education training.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident, who had a change in condition (COC a sudden, clinically important deviation from a patient's baseline in physical, cognitive (ability to think, understand, learn, and remember) behavioral, or functional status which without immediate intervention, may result in complications or death) manifested by oxygen (O2) saturation ( the amount of oxygen circulating in the blood) of 86 percent ([%] a reference range for O2 saturation is 95% to 100%) on room air on [DATE], was transferred to a general acute care hospital (GACH) without a delay for one of four sampled residents (Resident 1). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three out of 38 sampled residents (Resident 16, 34, and 3) with limited range of motion (ROM - the extent of movement of a joint) and/or limited mobility, received restorative nursing (a program available in nursing homes that helps residents maintain any progress they have made during therapy treatments, enabling them to function at a high capacity) care per Physical Therapist (PT-(a healthcare professional who specializes in helping patients improve their physical function) and Occupational Therapist (OT-a healthcare professional who specializes in helping patient improve ability to perform daily tasks) recommendation and follow through the progress of the residents who received restorative nursing care by : 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two cartridges (container) of morphine (controlled medicine used to relieve pain) tablets were stored in the cubex machine (automated medication dispensing system) after delivery by pharmacy to the facility. This failure had a potential to result in the inability to identify drug diversion (illegal distribution or abuse of prescription drugs or their use for purposes not intended by the prescriber) and theft.

Inspectors wroteBased on interview and record review the facility failed to ensure five of 14 sampled residents (Resident 35, Resident 24, Resident 5, Resident 49, Resident 1 and Resident 3) were informed of the right to develop an advance directive (a legal document prepared by you that expresses what kind of medical care you want, or who was authorized to make decisions for you should you be unable to make or communicate your wishes). This failure resulted in Resident 35, Resident 24, Resident 5, Resident 49, Resident 1, and Resident 3's rights being violated to be fully informed of the option to formulate their advance directives.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of 14 sampled residents (Resident 24 and Resident 5) had a Preadmission Screening and Resident Review (PASARR-a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) assessment done when diagnosed with a mental illness prior to admission. This failure had the potential for Resident 24 and Resident 5 not receiving the necessary services and appropriate psychiatric level of treatment and evaluation in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure two of 14 sampled residents (Resident 24 and 3): 1. Received Restorative Nursing Aide (RNA- helps tide rehabilitative care for residents) services as recommended by the physical therapist (a healthcare professional who specializes in helping patients improve their physical function). This failure had the potential to result in Resident 24 developing contractures (shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) and decreased mobility. 2. Provide a communication tools or system to Resident 3 who had aphasia (loss of ability to understand or express speech due by brain damage) to be able to communicate requests and needs. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure the consultant pharmacist's recommendation in the Medication Regime Review (MRR- a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication), were communicated to the physician for two of 14 sampled residents (Resident 2, 56, 24, and Resident 1) for unnecessary medications review. This failure resulted in Resident 2, 56, 24, and Resident 1 receiving an unnecessary medication that can lead to adverse side effects and the potential to result in harm.

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Ensure seven (7) over-the-counter medication were not expired in (1) out of two (2) sampled medication storage rooms. This failure had the potential for harm to residents due to the potential loss of strength of the medications, and the potential for the residents to receive ineffective medication dosages. 2. One of five sample residents' (Resident 22) medicines were not left on the bedside table by a Licensed Vocational Nurse (LVN) 1. This deficient practice had the potential for delay or omission (patient did not receive the medicines that had been ordered) of Resident 22's medications affecting the health of the resident.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe and sanitary food storage practices in the kitchen when: 1. Banana puree with a label of use by date of 3/16/2024, egg puree with a label of use by date of 4/01/2024, lettuce with a label of use by date of 4/7/2024, and eggs with a label of use by date of 4/7/2024 remains in the kitchen. This failure had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (illness caused by food contaminated with bacteria, viruses, and parasites) in 55 out of 55 residents who received food from the facility.

Inspectors wroteBased on interview and record review, the facility failed to assess mental capacity (ability to make decisions) and provide information to two of three sampled residents (Resident 60 and Resident 45) and their responsible parties before signing arbitration agreement (a way of resolving a dispute without filing a lawsuit and going to court). This failure had the potential to result in Resident 60 and Resident 45 not fully understand their right to limit opportunity to initiate judicial proceedings that challenge unfavorable decisions.

Inspectors wroteBased on observation, interview, and record review the facility failed to observe infection control practices and procedures in the facility by failing to: 1. Ensure dietary staff did not store its personal food items in the kitchen refrigerator. This failure had the potential to result in cross contamination (transfer of harmful bacteria from one place to another) of the resident's food and to cause the spread of food borne illnesses (illness caused by food contaminated with bacteria, viruses, and parasites) to residents. 2. Wear personal protective equipment([PPE] specialized clothing or equipment worn by an employee for protection against infectious materials) properly when providing care for Resident 215. This failure had the potential to spread infection among residents, staff, and visitors.

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of five sample residents (Resident 56) and/or responsible party (RP) was informed in advance, of the risks and benefits of psychoactive medication (a drug that changes brain function and results in alterations in perception, mood, consciousness, or behavior). This failure resulted into violating the residents' right to make an informed decision regarding the use of psychoactive medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure call light was within reach for one of three sampled residents (Resident 60). This failure resulted in Resident 60 feeling lack of self-determination to make decisions, loss of dignity, loss of self-esteem and had the potential to result in Resident 60 not being cable to call staff for help when needed and delay in necessary care and services.

Inspectors wroteBased on interview, and record review, the facility failed to accurately assess and code the Minimum Data Set (MDS, a standardized assessment and care-screening tool) assessment for one of 14 sampled residents (Resident 24) by failing to ensure the MDS was coded correctly. This failure had the potential to result in delayed or missed identification of joint range of motion (ROM, full movement potential of a joint) changes, inaccurate care planning, and inadequate provision of services and treatments for Resident 24.

Inspectors wroteBased on interview and record review, the facility failed to ensure care plan interventions for two of three sampled residents (Resident 1's fall on 3/15/2023 and the use of two people during perineal care (cleaning private areas of resident), and repositioning for Resident 2. These deficient Resident 1 and 2) were revised and/or implemented to include the use of floor mats and specifics for visual checks following practices resulted in recommended interventions and interventions that were already in place not being implemented and Resident 2 falling from a bed sustaining abrasions to his face and thumb and had the for additional falls and/or injuries to occur.

Inspectors wroteBased on interview and record review, the facility failed to notify the physician when one of three sampled residents (Resident 2) continued to refuse to have restorative nurse aide ([RNA] a nurse who provides rehabilitative care to individuals recovering from illnesses or injuries) therapy exercises provided to him because of pain to his left knee. This deficient practice resulted in and had the potential to cause a delay in Resident 2' s assessment and treatment which could lead to a decline in Resident 1's range of motion ([ROM].

Inspectors wroteBased on interview and record review, the facility failed to ensure a physician's order for Ivermectin (a drug used to treat parasitic (an organism [an individual animal, plan, or single-celled life form] that lives on or in a host organism and gets its food from or at the expense of its host) infections such as scabies [a parasitic infestation caused by tiny mites that burrow into the skin and lay eggs, causing intense itching and a rash]) was transcribed and administered to one of three sampled residents (Resident 1). This deficient practice resulted in Resident 1 not receiving Ivermectin as ordered by the physician and had the potential for further itching and discomfort to occur.

Inspectors wroteBased on interview and record review, the facility's Interdisciplinary Team (IDT) failed to meet, following one of three sampled residents (Resident 2) fall with injury on 1/13/2024 to determine the cause of Resident 2's fall and recommend interventions to put in place in order to prevent other falls and/or injuries from occurring. This deficient practice resulted in the facility not exploring the root cause of Resident 2 ' s fall and had the potential for other falls to occur.

Inspectors wroteBased on interview and record review, the facility failed to ensure the treatment of one sampled resident (Resident 1) with Permethrin (a medication used to kill scabies) was reported to the Infection Preventionist Nurse ([IPN] a person who is responsible for identifying, investigating, monitoring, and reporting healthcare associated infections) in order to ensure methods such as isolation, monitoring of rashes and proper cleaning and disinfection of linens and equipment used by Resident 1 was implemented. This deficient practice resulted in the IPN nurse being unaware of a possible scabies diagnosis, a delay in implementing infection control methods and had the potential for acquiring and spreading scabies throughout the facility and to the community.

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of three sampled residents, (Resident 1) remained free from verbal abuse by Licensed Vocational Nurse (LVN) 3. This deficient practice had the potential for Resident 1 to experience a decline in psychosocial well-being and degraded self-esteem.

Inspectors wroteBased on interview and record review, the facility failed to create a care plan for skin integrity for one of three residents (Resident 1) who had a moisture-associated skin damage (MASD- inflammation of the skin) on the sacrum (tail bone). This deficient practice had the potential to place Resident 1 at risk for further skin breakdown. Findings During a review of Resident 1 ' s admission Record, the record indicated Resident 1 was admitted to the facility on [DATE] with the diagnosis including multiple sclerosis (a nervous system disease that affects the brain and spinal cord). During a review of Resident 1 ' s Minimum Data Set ([MDS]- a standardized assessment and care screening tool) dated 10/9/2023, the MDS indicated Resident 1 ' s cognition (thinking and reasoning) was intact, and Resident 1 is dependent on two staff members when repositioning. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow the facility ' s medication administration policy for one of one resident (Resident 2) when Licensed Vocational Nurse 2 (LVN 2) left three medication pills in a medicine cup on Resident 2 ' s bedside table unattended. This deficient practice had the potential for Resident 2 to have missed medication doses and had the potential to result in other residents getting access to Resident 2 ' s medication which can cause harm when inadvertently consumed.