Cedar Pine Post Acute

Inspectors wroteBased on interview and record review, the facility failed to develop an individualized resident-centered care plan (CP, a document that outlines the facility's plan to provide personalized care to a resident based on the resident's needs)for four (4) of 23 sampled residents (Residents 16, 22, 35 and 73) in accordance with the facility's policy and procedure (P&P) by failing to have a care plan for:Resident 22's use of Montelukast (Singulair, a medication used to treat lung inflammation which has potentially dangerous side effects)Resident 73's use of a low air loss mattress (LALM, mattress overlay used to relieve pressure from a resident's back and help wounds heal). Resident 35 to have activities in accordance with the resident's activity assessment. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure three (3) of three sampled residents (Residents 57, 76 and 82) reviewed for Activities of Daily Living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) were provided care and services to maintain independence, functional status, good grooming and personal hygiene by failing to:1. Provide feeding assistance to Resident 57 on 6/24/2026, during lunch meal. 2. Ensure Resident 76's fingernails on both hands were not long.3. Ensure Resident 82's fingernails on both hands were not long, jagged, and dirty. These deficient practices have the potential for Residents 57, 76 and 82 to develop skin issues/complications and had the potential to result in a negative effect on residents' quality of life and wellbeing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the low air loss mattress (LALM- a specialized medical mattress designed to prevent and treat pressure ulcer [wound that occurs as a result of prolonged pressure on a specific area of the body] by maintaining a cool, dry environment through constant airflow, which helps regulate temperature and moisture) was on the correct setting for two (2) of four (4) sampled residents (Resident 5 and 35) in accordance with the physician's orders and LALM operator's manual instructions. This deficient practice placed Residents 5 and 35 at risk of development of new pressure ulcers, poor wound healing and deterioration (something once in good condition is now weakened, worn out, or otherwise in decline) of current pressure ulcers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary proper care and services for two (2) of two sampled residents (Resident 7 and Resident 48) reviewed for indwelling catheter (a tube that allows urine to continuously drain from the bladder) as indicated in the facility's policy and procedure (P&P) by failing to ensure:Resident 7's indwelling catheter drainage tubing (connects a flexible tube inside the body to an external collection bag) has no sediments (a build-up of waste that collect in the urine tube or drainage bag) and catheter care was provided in accordance with the physician's order. Indwelling catheter care was provided for Resident 48 for 12 days in accordance with the resident's care plan and physician's order. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure three (3) of 3 sampled residents (Resident 6, 16 and 18) reviewed for dialysis (a lifesaving treatment for residents with a kidney failure), who were receiving hemodialysis (process of removing waste products and excess fluid from the body) treatment were provided dialysis care and services in accordance with the facility policy by failing to ensure: Resident 6's dialysis arteriovenous (AV) fistula (vascular access in patients receiving regular hemodialysis) was assessed on 6/10/2026, 6/12/2026, 6/17/2026, and 6/19/2026 (4 days). Resident 16's urine output was monitored and recorded every shift. Resident 18's output was monitored and recorded every shift and the resident's weekly laboratory test was completed as ordered by the physician. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote dignity and respect for two (2) of 23 sampled residents (Resident 71 and 72) reviewed for dignity, in accordance with the facility's policy when: On 6/23/2026 and 6/24/2026, facility staff did not ensure Resident 71 was not drooling while in the dining room and hallway, where the resident was visible to the visitors and other residents while the resident is in the dining room and in the hallway. 2. On 6/24/2026 and 6/25/2026, facility staff did not ensure Resident 72's meal trays were served within the facility's scheduled mealtimes. These deficient practices have the potential to affect Residents 71 and 72 sense of self-worth and self-esteem, which could negatively impact their emotional and mental well being

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light (device used by residents to call staff for assistance) was within reach for one (1) of three (3) sampled residents (Resident 43) reviewed for environment in accordance with the facility's policy and procedure (P&P). This deficient practice has the potential to place Resident 43 at risk of not having his needs met and not receiving medical care in an emergency.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a clean, comfortable, sanitary, and homelike environment for one (1) of three (3) sampled residents (Resident 57) reviewed for environment. On 6/23/2026, Resident 57's room was observed with a pillow and clothes on the floor near the trash can, a used/soiled diaper on the floor in front of Resident 57, and a green hairbrush on the resident's lunch tray. This deficient practice caused an unsanitary and unsafe environment and had the potential for Resident 57 to be placed at risk of infection and/ or injury.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide podiatry (prevention, diagnosis, and treatment of disorders affecting the foot, ankle, and lower limb) services for one (1) of 1 sampled resident (Resident 82) as indicated in the physician's order and facility's policy and procedure. This deficient practice had the potential for Resident 82 to develop foot and skin issues/complications and had the potential to negatively affect the resident's quality of life and self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide oxygen therapy (treatment that provides supplemental, or extra oxygen) as indicated in the physician's order for one (1) of one sampled residents (Resident 5) reviewed for respiratory and oxygen in accordance with the facility's policy and procedures (P&P). This deficient practice had the potential to place Resident 5 at risk for shortness of breath (SOB) or hyperoxia (breathing excess oxygen) which could trigger oxygen toxicity (or poisoning, is damage to the lungs that happens from breathing in too much oxygen. It can cause coughing, trouble breathing, and even death in severe cases) that can lead to irreversible damages of health and/or death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet the needs of two (2) of six (6) sampled residents (Resident 23 and 2) observed during medication administration as indicated on the physician's order and facility policy and procedure (P&P) when:1. Licensed Vocational Nurse 3 (LVN) 3 failed to administer Resident 23's levetiracetam (Keppra, medication used to prevent seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness]), metformin (medication used to control blood sugar levels), and escitalopram (Lexapro; medication used to treat depression [a mood disorder that causes a persistent feeling of sadness and loss of interest]) on time. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a Medication Regimen Review (MRR, also known as a Drug Regimen Review-is a structured, comprehensive evaluation of all medications a resident is taking, conducted typically by a pharmacist to ensure medications are appropriate, safe, effective, and used correctly) to identify and follow up on an irregularity (includes, but is not limited to, use of medications without adequate indication, without adequate monitoring, in excessive doses, and/or in the presence of adverse consequences, as well as the identification of conditions that may warrant initiation of medication therapy) for two (2) of five (5) sampled residents (Resident 22 and Resident 57) reviewed for unnecessary medications in accordance with the facility's policy and procedure (P&P) by failing to ensure: 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one (1) of five (5) sampled residents (Resident 57) were free from unnecessary drug (any drug when used without adequate indications for its use by failing to have accurate indication for the use of donepezil hydrochloride (prescription medication used to treat the symptoms of dementia [a progressive state of decline in mental abilities]). This deficient practice had the potential to place Residents 57 at risk for significant adverse (harmful) consequences from the use of unnecessary drug.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure its medication error rate was less than five (5) percent (%). Four (4) medication errors (the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order/ manufacturer's specifications / accepted professional standards and principles) out of 27 total opportunities (observed administered medications) for error, to yield an overall medication error rate of 14.81 % for two (2) of six (6) sampled residents (Resident 2 and Resident 23) observed for medication administration.1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow its policy and procedure (P&P) to ensure two (2) of six (6) sampled residents (Resident 23 and 2) observed during medication administration were free from significant medication errors (the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order/ manufacturer's specifications / accepted professional standards and principles, which may have cause the resident discomfort or jeopardize health and safety) when:1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an accurate and complete medical records for one (1) of 23 sampled residents (Resident 73) in accordance with the facility's policy and procedures (P&P) by failing to document Resident 73's use of low air loss mattress (LALM, designed to distribute the resident's body weight over a broad surface area and help prevent skin breakdown). This deficient practice has the potential to cause Resident 73 to receive inappropriate care.

Inspectors wroteBased on interview and record review, the facility failed to ensure infection prevention measures (a set of practices that prevent or stop the spread of infections and or diseases in the healthcare setting) were followed for two (2) of 23 sampled residents (Residents 9 and 43) by failing to:1. Ensure Certified Nurse Assistant 3 (CNA 3) performed hand hygiene (cleaning hands with the use of alcohol-based hand rubs containing 60%-95% alcohol or hand washing with soap and water) during meal assistance with Resident 43.2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain clinical records in accordance professional standards and practices and facility's Policy and Procedure (P&P) for one (1) of six (6) sampled residents (Resident 1) by failing to accurately document the administration of narcotics (drug or controlled substance that affects the mood or behavior and if consumed for nonmedical purposes or not prescribed by the doctor can cause serious harm) count in the narcotic drug record (narcotic count sheet is a document used to document and track the administration of controlled substance to ensure accurate dispensing and administration of medications, as well as to provide a record of how much of a controlled substance has been used and when). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to reconcile the General Acute Care Hospital's (GACH) Discharge Medications List and carry out a physician's order to administer long-acting insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) for one (1) of two (2) sampled residents (Resident 2) as indicated on the facility policy and procedure (P&P). [...]

Inspectors wroteBased on interview, and record review, the facility failed to administer the intravenous (IV, administering fluids or medications directly into a vein using a needle or tube, allowing for immediate entry into the bloodstream) hydration (the process of supplying water to maintain adequate fluid levels in the body) for one (1) of two (2) sampled residents (Resident 1) on 4/10/2026, in accordance with the physician's order, care plan, and facility policy. This failure had the potential to put Resident 1 at risk for dehydration (a condition occurs when the body loses more fluids than it takes in, leading to an insufficient amount of water for normal bodily functions) and complications that can lead to hospitalization and death.

Inspectors wroteBased on interview and record review, the facility failed to maintain an accurate and complete record for two (2) of 2 sampled residents (Resident 1 and 2) as indicated in the facility's policy and procedure (P&P) when: The facility failed to complete and accurately document Resident 1's neurological evaluation flow sheet (a standardized clinical documentation tool used to frequently monitor, record, and assess a patient's neurological status). The facility failed to complete Resident 1's fall risk assessment on 4/8/2026. The facility failed to accurately document Resident 2's neurological evaluation flow sheet. This deficient practice had the potential to result in miscommunication and improper delivery of care and inaccurate information of the care provided to Resident 1 and 2.

Inspectors wroteBased on interview and record review, the facility failed to provide an accurate report detailing suspected presence of contraband (any item that is illegal to possess) for one (1) resident (Resident 1) as indicated in the facility's policy and procedure. This deficient practice had the potential to compromise or impede the protection of all the residents which could affect residents' physical, emotional, mental wellbeing and lead to irreversible results or death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate administering of all drugs and biologicals) to meet the needs for two (2) of 2 sampled residents (Resident 1 and Resident 2) in accordance with the facility policy by failing to:1. Administer Resident 1's morning medications timely on 12/23/25.2. Administer Resident 2's morning medications timely on 12/23/25. This deficient practice had the potential to result in ineffectively managing Resident 1 and Resident 2's medical condition, which could result to harm, hospitalization and death.3. Leaving Resident 2's Medication unattended at bedside. This deficient practice had the potential for other residents to take the medications, which could result in harm to the other residents if ingested.

Inspectors wroteBased on interview and record review, the facility failed to prevent sexual abuse (non-consensual sexual contact of any type with a resident) for two (2) of 2 sampled residents (Resident 1 and 2) on 12 /18/2025 in the facility's hallway. On 12/18/2025, Orientee of Dietary (OD) and Certified Nursing Assistant (CNA 1) witnessed Resident 1 pulled down his (Resident 1) pants and pulled out his (Resident 1) penis. Resident 2 then performed oral sex (one partner uses the tongue, mouth or throat to excite the other partner's sex organs) to Resident 1. This failure resulted in Resident 1 and 2 to sexual abuse potentially risking emotional trauma (response to deeply distressing or disturbing event) or psychological trauma (damage to the mind that occurs as a result of a severely distressing event) placing other residents in the facility at risk for sexual abuse.

Inspectors wroteBased on an interview and record review, the facility failed to ensure that the resident's anti-anxiety (medications that reduce feelings of fear, dread, and tension by calming the nervous system) medication ordered as needed (PRN- a medication or treatment to be administered only when the patient exhibits specific symptoms or the situation requires it, rather than on a fixed, routine schedule) had a stop date and was reevaluated by the physician after 14 days of the order date for the appropriateness of use in accordance with facility policy, for one (1) of one two sampled resident (Resident 1). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one (1) of three (3) sampled residents (Resident 1) was free from physical abuse (any intentional act causing injury or trauma to another person through bodily contact). Resident 1 had a change of behavior of screaming towards Resident 3 on 11/11/2025 and the facility did not have documented evidence the behavior was addressed. This resulted in Resident 2 hitting Resident 1 on the face on 11/12/2025.and Resident 1 sustained a scratch under the resident's right eye and redness on the right side of the nose.

Inspectors wroteBased on interview and record review, the facility failed to provide the appropriate treatment and service to prevent urinary tract infection (UTI- infection of the urinary tract) to one (1) of two (2) sampled residents (Resident 1) who was admitted at the facility with indwelling urinary catheter (a thin, flexible tube inserted into the bladder to drain urine when a person is unable to urinate on their own) by failing to: 1. Monitor and document Resident 1's change of condition (COC) that was observed by facility staff on 8/14/2025 and on 8/21/2025 of dark/ brown colored urine (normal urine color is clear and yellow) in the indwelling catheter bag. 2. Notify Resident 1's physician (MD 1) of the resident's (COC) of dark/ brown colored urine noted on 8/14/2025 and 8/21/2025 in accordance with the resident's Care Plan for at risk for UTI. [...]

Inspectors wroteBased on observation, interview and record review, the facility staff failed to implement fall interventions in accordance with the care plan to frequently observe and place one of two Residents (Resident 1) who was assessed as high risk for fall in a supervised area while out of bed. This deficient practice resulted in a fall (unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force) on 5/10/2025, which placed Resident 1 at risk for serious injury like fractures (break in the bone) and head injury (injury that damages your head, including the skull [bony framework of the head, enclosing the brain and supporting the face] and brain), hospitalization and even death.

Inspectors wroteBased on interview and record review, the facility failed to create and implement a comprehensive person-centered care plan for one (1) of two (2) sampled residents (Resident 1) to address Resident's 1's diagnosis of alcohol dependence (also known as alcohol use disorder [[NAME]], a chronic disease characterized by a compulsive need to drink alcohol despite negative consequences). This failure resulted in Resident 1 going out on pass (OOP - a non-medical visit outside of the facility most commonly used for visits with family or friends) from the facility on 7/15/2025 at 11:45 AM and not returning. The facility was notified by the local police on 7/15/2025 at 10:51 PM that Resident 1 was found at the general acute care hospital (GACH) emergency department.

Inspectors wroteBased on interview, observation, and record review, the facility failed to promote dignity and respect for two of three sampled residents (Resident 35 and Resident 5) for dignity and respect as indicated on the facility's policy by failing to ensure: 1. Resident 35 wore the resident's personal clothing. 2. Resident 5 was kept clean and without white colored food debris around the resident's mouth and a brown stain on the left upper should of the resident's gown. These deficient practices had the potential to negatively affect Resident 35 and Resident 5's self-worth, self-esteem and psychosocial (pertaining to the influence of social factors on an individual's mind or behavior) well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive resident centered care plan (a formal process that correctly identifies existing needs and recognizes a resident's potential needs or risks to achieve healthcare outcomes) in accordance with the facility's care plan policy for two (2) of 2 sampled resident (Residents 41 and 51) by failing to ensure: 1. Resident 41 had a care plan to address the resident's central venous catheter (a type of access used for hemodialysis [a procedure removing metabolic waste products or toxic substances from the bloodstream]). This deficient practice had the potential to not be able to provide the specific interventions such as monitoring Resident 41's access site for bleeding and infection, which could result in harm. 2. Resident 51 had a care plan to address use of a heart monitor. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure its medication error (the observed or identified preparation or administration of medications or biologicals which are not in accordance with the prescriber's order; manufacturers specifications / accepted professional standards and principles) rate was less than five (5) percent (%). Two (2) medication errors out of 30 total opportunities for error, to yield an overall medication error rate of 6.67 % for two (2) of seven (7) sampled residents (Residents 50 and 51) observed for medication administration. This deficient practice had the potential to result in Residents 50 and 51 experiencing adverse medication effects (unwanted, uncomfortable, or dangerous effects that a medication may have) that could negatively affect the residents' health and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the facility's policy and procedure on disposal of discontinued medications when three (3) unidentified pills were observed on the floor of the medication storage room. This deficient practice increased the risk for residents to accidentally receive the medication that had become ineffective or toxic due to improper storage possibly leading to health complications, which may result to harm and hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper food handling practices in accordance with its policy and procedure by failing to label food items in the refrigerators, and freezers in the kitchen with item name, date opened and used by date and discard one (1) expired food items. These deficient practices had the potential to result in pathogen (germ) exposure to residents, which could place the residents at risk for developing foodborne illness (example food poisoning with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever) and can lead to other serious medical complications and hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow up on a resident's request on [DATE] to formulate an Advance Directive (legal document that provide instructions for medical care and only go into effect if you cannot communicate your own wishes) for one of three sampled residents (Resident 16). This failure resulted in a delay of seven (7) years in addressing Resident 16's request and had the potential for the staff not to carry out the resident's wishes regarding health care decisions during an emergency.

Inspectors wroteBased on interview and record review, the facility failed to notify the physician of significant changes in condition (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) for one of two sampled resident (Resident 51), who experienced eight (8) episodes of hypotension (low blood pressure when blood pressure is much lower than normal and varies from one person to another. This condition occurs when a person's blood pressure drops as little as 20 mmHg (millimeters of mercury- a unit of measurement to quantify the pressure exerted by blood against the walls of the arteries) reducing blood flow to the heart, brain, and other parts of the body) related to the use of Losartan Potassium-HCTZ (medication to treat high blood pressure). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure an accurate range of motion (ROM, means how far and in what direction you can move a joint or muscle) assessment on the Minimum Data Set (MDS, a resident assessment tool) for one (1) of 2 sampled residents (Resident 50) as indicated in the facility's policy. This deficient practice had the potential to result in an incorrect plan of care which could negatively affect the delivery of necessary care and services to Resident 50.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assist one of one sampled resident (Resident 46) who were unable to carry out activities of daily living (ADL) to maintain good grooming, and personal and oral hygiene by failing to assist Resident 46 with oral care. This failure placed Resident 46 at risk to develop dental caries (or tooth decay- a progressive destruction of bone or tooth), teeth and gum infections and/ or lung infection, that could lead to hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet the needs of two (2) of seven (7) sampled residents (Resident 50 and 51) as indicated on the facility policy and physician's order by failing to: 1. Administer Resident 50's carvedilol (a medicine used to treat hypertension [high blood pressure]) with food on 5/23/2025. 2. Administer Resident 51's sevelamer (a medicine to treat hyperphosphatemia [too much phosphate in the blood]) with food on 5/23/2025. This deficient practice had the potential to result in Residents 50 and 51 not obtaining the therapeutic level (medicine levels in your blood are in a range that is medically helpful but not dangerous) of the medication, which could lead to complications and harm to the residents.

Inspectors wroteBased on interview and record review, the facility failed to assist one of one sampled resident (Resident 42) in obtaining dental services when the Social Service Director (SSD) did not follow up with the dental office regarding Resident 42 ' s eligibility for dental services. This failure resulted in Resident 42 feeling frustrated at not having his dental needs met and having difficulty chewing food.

Inspectors wroteBased on observation, interview and record review the facility failed to provide food that is palatable and attractive for one (1) out of 22 residents (Resident 19) based on the facility's policy. This deficiency has resulted Resident 19 being served his disliked foods which had the potential to negatively affect Resident 19's psychosocial (pertaining to the influence of social factors on an individual's mind or behavior) well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 22 sampled resident (Resident 1) who required adaptive feeding equipment (modified utensils, accessories, glasses, and plates to help improve residents' comfort and independence) utilize a weighted spoon (specialized utensil with built up handle designed to assist residents with limited or weakened grasping strength) and plate guard (unique spill guard which prevents food from accidentally being pushed off the plate) during meal, as indicated on the physician's order. This deficient practice placed Resident 1 at risk for further decline in physical functioning and decline to perform self-feeding skills.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement its policy and procedure on infection control for four (1) of 22 sampled residents (Resident 30) when staff did not use personal protective equipment (PPE, used to prevent or minimize exposure and to protect from potential transmission of biological agents that can be transferred from person to person by direct and indirect contact) while rendering wound care to Resident 30 who was on enhanced barrier precaution (EBP, use of PPE beyond anticipated blood and body fluid exposures) on 5/23/2025. This deficient practice had the potential to result in a widespread infection in the facility that could compromise the health of the residents, visitors, and staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 22 sampled residents (Resident 42) had a call light (a device used to call for assistance) within reach. This failure had the potential to result in Resident 42 being unable to call for assistance resulting to unmet needs and possibly being injured when trying to reach the call light.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one (1) of 1 sampled resident (Resident 1) who was assessed at risk for elopement (a resident who is incapable of adequately protecting himself, and who departs the health care facility unsupervised and undetected) did not elope after going out- on- pass (OOP, temporary permission of a resident to leave the facility in a specified time) on 4/15/2025 at 6 PM by failing to: 1. Develop a care plan and interventions to address Resident 1's risk for elopement. 2. Implement procedures based on the facility's Elopement Risk policy to search for Resident 1 when Resident 1 did not return to the facility while OOP. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two samples residents (Resident 1) received appropriate treatment and services to correct the assessed problem and provided behavioral health services for Resident 1, whose primary diagnosis includes alcohol use, unspecified with unspecified alcohol-induced disorder (alcohol use without specific details about the extent or nature of the related disorder), other psychoactive (a drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) substance abuse, uncomplicated (many illegal drugs and substances including alcohol, caffeine, nicotine, marijuana, and certain pain medicines), imprisonment and other incarceration (confinement to a jail, prison or other penal institution or correctional facility) by failing to: 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 2) were free from physical abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish), when Resident 1 allegedly scratched Resident 2's face on 3/18/2025. This deficient practice resulted in Resident 1 had a scratch to his nose and had the potential to negatively affect Resident 1's comfort and psychosocial (having to do with the mental, emotional, social, and spiritual effects of a disease) well-being which can lead to hospitalization and/ or death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure standard infection prevention control practices (a set of practices that prevent or stop the spread of infections and or diseases in the healthcare setting) were followed in accordance with the facility's Enhanced Barrier Precaution (EBP- infection control practices in nursing homes that focuses on reducing the spread of multi drug resistant organisms [MDRO - bacteria that have become resistant to certain antibiotics, and these antibiotics can no longer be used to control or kill the bacteria] by using targeted gown and gloves use during high-contact resident care activities [activities involving a lot of physical touching or close interaction with the resident, potentially increasing the risk of spreading germs or infections], rather than isolating residents) policy when: 1. [...]

Inspectors wroteBased on interview and record review, the facility (Facility 1) failed to maintain complete and accurate medical records in accordance with the accepted professional standards (a set of guidelines and expectations that define the competent level of care a healthcare professional should deliver) and practices and follow facility's Policy and Procedures (P&P) for one of one sampled resident (Resident 1) by failing to document resident-initiated discharge (when a nursing home resident or their representative gives notice that they want to leave the facility) coordination of Resident 1 to Facility 3 on 1/20/2025. This deficient practice had the potential to confuse members of the health care team and negatively impact the delivery of services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to report an allegation of abuse (any intentional or unintentional actions that cause harm or distress to a patient or person in their care) within two hours to local police department, state survey agency and ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities) after the allegation of physical abuse (inflicting physical injury such as hitting and slapping) was made by one of one sampled resident (Resident 1). This deficient practice resulted in delayed reporting which could have resulted in ongoing abuse, leading to worsening physical, emotional, or psychological (mental or emotional) harm for Resident 1.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure accurate assessment of oxygen (O2) use for three of three sampled residents (Residents 4, 5 and 6) on the Minimum Data Set (MDS- a resident assessment tool) as indicated on the facility policy. This deficient practice had the potential for the facility to not develop and implement an individualized care plan for Residents 4, 5, and 6, which could negatively affect the resident's overall wellbeing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary respiratory care services for three (3) of 3 sampled residents (Residents 4, 5, and 6) by failing to: a. Ensure oxygen (O2, a colorless, odorless gas necessary for most living organisms to breathe and function properly) was administered to the residents via nasal cannula (NC- a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) according to the physician's orders. b. Label the humidifier (medical devices that increase the humidity in your oxygen while using supplemental oxygen. These devices look like water bottles and have a special cap with a wing nut on top used for attaching the humidifier to an oxygen concentrator.) with resident's name and date as indicated in the facility's oxygen policy and procedure (P&P). [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain an accurate resident medical records for one of two sampled Residents (Resident 1) by failing to ensure vital signs (measurements of the body's most basic functions that include body temperature, blood pressure, pulse rate, breaths per minute, and the amount of oxygen circulating in blood, also known as oxygen saturation [level of oxygen in the blood]) were not documented on 12/22/2024, 12/23/2024, 12/24/2024 and 12/25/2024 while Resident 1 was in the General Acute Hospital (GACH, a health facility having a duly constituted governing body with overall administrative and professional responsibility and an organized medical staff that provides 24-hour inpatient care.) This deficient practice had the potential for staff to not know the resident's actual condition resulting to necessary services and care not provided to [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure staff followed the facility's isolation (separation of residents with an infection from residents without an infection) and enhanced barrier precautions (EBP- refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs] that employs targeted gown and glove use during high contact resident care activities) policies for two of two sampled residents (Residents 4 and 7) and four of eight rooms (Rooms 3, 7, 9, and 11) with residents on EBP by: 1. Resident 4 did not have isolation signage posted outside the room door or wall. 2. Staff did not wear personal protective equipment (PPE-equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide padded side rails (metal or plastic bars positioned along the side of a bed) as indicated on the physician's order for one of two sampled Residents (Resident 3) who has a diagnosis of seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness). This failure had the potential for Resident 3 to sustain an injury or harm in an event of a seizure episode.

Inspectors wroteBased on interview, and record review, the facility failed to provide Occupational Therapy (OT, improving the patient's ability to perform activities of daily living) and Physical therapy (PT, treatment that helps you improve how your body performs physical movements) for one (1) of two (2) sampled residents (Resident 2) as indicated on the Physician's order, care plan, and facility assessment tool. This deficient practice placed Resident 2 at risk for decline in physical functions and developing contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints), which could negatively affect the resident's overall wellbeing.

Inspectors wroteBased on interview and record review, the facility failed to provide reasonable accommodation to meet the choices of two of two sampled residents (Resident 37 and Resident 38) by failing to assign female Certified Nursing Assistants (CNA) as per the residents' request. This deficient practice had the potential to affect Resident 37 and Resident 38's quality of life and negatively impact their psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to provide a safe and homelike environment (having qualities associated with home; comfortable, familiar, cozy) for two (2) of 23 sampled resident (Resident 31 and 64) by: 1. Facility failed to provide protection of Resident 64's personal property from theft or loss, when Resident 64's responsible party (RP) reported missing personal belongings. 2. Facility failed to provide a bathroom to Resident 31 that did not have four missing tiles on the wall. These deficient practices resulted in the violation of the Resident 64 and 31's right of having a safe and clean environment and had the potential to cause emotional distress to the resident.

Inspectors wroteBased on interview and record review, facility failed to develop care plans (a document that outlines the facility's plan to provide personalized care to a resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs) for three of four residents (Resident 21, 32, and 52) per facility policy, facility failed to: 1. Develop a care plan for Resident 21 after having 4 incidents of falling. 2. Develop a care plan for Resident 32's compromised oral condition. 3. Resident 52 did not have an individualized care plan for limited range of motion on the resident's left side of body. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to update and revise the care plans for two of 23 sampled residents in accordance with the facility policy by failing to ensure: 1. Resident 64's care plan was revised when the diet was changed. 2. Resident 63's dialysis (a lifesaving treatment for residents with kidney failure) care plan was updated and revised to address intake and output (I & O) monitoring. These deficient practices have the potential to negatively affect the provisions of care and services for the residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure three of four sampled residents (Resident 37, 48, and 60) were provided necessary treatment and services to prevent formation of and promote healing of pressure injury (pressure ulcers- injury to the skin and underlying tissue resulting from prolonged pressure on the skin) in accordance with the facility's policy and procedure (P&P) and physician's order by: 1. Facility failed to ensure Resident 37's low air loss mattress (LALM/ LAL mattress- an air mattress covered in tiny holes designed to let out air very slowly which helps keep the skin dry and [NAME] away any moisture) was set up according to the resident's weight. Resident 37 was observed with the LALM set at approximately 200 pounds ([lbs]- unit of measurement) and Resident 37 weighed 121 lbs. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide two of two sampled residents (Resident 63 and 60) safe and appropriate care for the provision of dialysis (a lifesaving treatment for residents with kidney failure) consistent with professional standards of practice by: 1.a. Facility failed to assess Resident 60's left upper chest dialysis catheter (a catheter [thin tube] that is placed under the skin in a vein, allowing long-term access to the vein) on 5/14/2024 and 6/1/2024, in accordance with the facility's policy. 1.b. Facility failed to revise Resident 60's dialysis care plan when the resident's left upper arm Antero ventricular shunt (AV shunt, (vascular access in patients receiving regular hemodialysis) vascular access in patients receiving regular hemodialysis) was placed on 5/29/2024. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess risk for entrapment (an event in which a resident is caught, trapped, or entangled in the space in or about) and attempt alternatives prior to the use of side rails (adjustable metal or rigid plastic bars that attach to the bed) for two (2) of three (3) sampled Residents (Resident 32 & 61) as indicated on the facility policy. 1. Resident 32 did not have a reassessment for the use of side rails 2. Resident 61 did not have an assessment for the use of side rails. This failure had the potential to result in the inappropriate use of side rails for Resident 32 and 61, which could pose a safety risk and result in injury or harm.

Inspectors wroteCross reference F759 Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet the needs of one of seven sampled residents (Resident 50) in accordance with the facility policy by: 1. Failing to administer Dexamethasone (medication that provides relief for inflamed areas of the body) two milligrams (mg, unit of measurement) tablet timely as ordered on 6/14/2024. 2. Failing to administer the following 9 AM due medications on 6/14/2024: a. Cozaar (medication to lower blood pressure) oral tablet 50 mg b. Lasix (medication to treat fluid retention and swelling) oral tablet 20 mg c. Norvasc (medication to lower blood pressure) oral tablet 5 mg d. Docusate Sodium (stool softener) oral Capsule 100 mg e. Levetiracetam (medication to treat seizures [a sudden, uncontrolled burst of electrical activity in the brain]) oral tablet 750 mg f. [...]

Inspectors wroteBased on interview and record review, the facility failed to report to the resident's primary physician the irregularities (includes, but is not limited to, use of medications without adequate indication, without adequate monitoring, in excessive doses, and/or in the presence of adverse consequences, as well as the identification of conditions that may warrant initiation of medication therapy) on the medication regimen review (MRR, or Drug Regimen Review, 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), dated 5/28/2024, for two (2) of five (5) sampled residents (Resident 12 and Resident 61) in accordance with the facility policy. 1. [...]

Inspectors wroteCross reference: F755 Based on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five (5) percent (%). There were seven (7) medication errors out of 25 total opportunities for error, to yield an overall medication error rate of 28 % for one (1) of seven (7) residents observed for medication administration (Residents 50). The medication errors were as follows: 1. During a Medication Pass observation, Licensed Vocational Nurse 1 (LVN 1) failed to administer Dexamethasone (medication that provides relief for inflamed areas of the body) two milligrams (mg, unit of measurement) tablet timely as ordered on 6/14/2024. 2. During a Medication Pass observation, LVN 1 failed to administer the following 9 AM due medications on 6/14/2024: a. Cozaar (medication to lower blood pressure) oral tablet 50 mg b. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to follow its Medication Storage policy by failing to: 1. Remove a box of expired eye gel from medication storage room [ROOM NUMBER] (MSR 1). 2. Remove a box of expired eye drops from MSR 1 This deficient practice increased the risk for Residents on insulin to receive medication that had become ineffective or toxic due to improper storage possibly leading to health complications, which may result to harm and hospitalization. 3. Store four (4) unopened Basaglar Kwik Pen (a medication used to control high blood sugar) in the refrigerator. 4. Store 4 unopened Trulicity (a medication used to lower blood sugar) in the refrigerator. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper food handling practices in accordance with its policy and procedure by failing to: a. Label foods in the kitchen with item 'use by' date (the last date recommended for the use of the product) or open date. b. Discard expired food in the kitchen. c. Store dishes in the kitchen in a sanitary manner. d. Ensure water filter line had an air gap and did not touch the drain on the floor. e. Ensure plunger was stored in accordance with professional standards. These deficient practices had the potential to result in pathogen (germ) exposure to residents and placed residents at risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever and can lead to other serious medical complications and hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policy to monitor the refrigerator and freezer's temperature containing residents' food brought from home to ensure that it was within acceptable temperatures for four of five sampled residents (Residents 18, 31, 47, and 50). This deficient practice had the potential to result in food-borne illnesses (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea and fever, other serious medical complications, and hospitalization.

Inspectors wroteBased on interview and record review, facility failed to ensure the arbitration agreement (a contract in which the right to bring certain claims to court for resolution is given up) included for the selection of a venue that is convenient (a location in which to carry out arbitration proceedings which should be agreed upon and suitable to both parties (facility and residents) for two of three sampled residents (Resident 3 and 21). This failure resulted in violation of Residents 3 and 21's right to be informed of all information related to an arbitration agreement.

Inspectors wroteBased on interview and record review, the facility failed to ensure a coordination of care between the facility and hospice (care designed to give supportive care to people in the final phase of a terminal illness and focus on comfort and quality of life, rather than cure) staff for three of three sampled residents (Residents 61, 52, and 64) in accordance with the facility's hospice policy and hospice agreement by failing to ensure: 1. Hospice staff visited Resident 61 per Hospice calendar. 2. and 3. Residents 52 and 64 had a hospice comprehensive assessment to include the frequency of hospice staff visits This deficient practice had the potential for Resident's 61, 52, and 64 not to receive the hospice care and services necessary to promote comfort and quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement appropriate infection control practices for one of two sampled residents (Resident 62) as indicated on the facility's policy and procedure (P&P) by failing to ensure availability and use of EPA (Environmental Protection Agency) approved disinfectant solution in cleaning a contact isolation (used when a resident has an infectious disease that may be spread by touching either the resident of other objects the resident has handled) room with Clostridium difficile (C. diff- a bacteria that causes diarrhea), This deficient practice placed the residents, staff, and visitors at higher risk for cross-contamination, and increased spread of C. diff infection in the facility and the community.

Inspectors wroteBased on observation and interview, the facility staff failed to provide a safe environment in the kitchen by failing to: 1. Ensure the portable air conditioner unit was safely plugged into the wall outlet. 2. Ensure the wall outlet was free of tape covering the plug and outlet when the generator was plugged into the wall outlet. This deficient practice had the potential to result in a fire which placed residents, staff, and visitors at risk.

Inspectors wroteBased on observation, interview and record review, facility failed to treat one of three sampled residents (Resident 8) dignity and respect by failing to secure the privacy curtain during resident care as indicated in facility's policy and procedure (P&P). This failure resulted in the violation of Resident 8's rights, with the potential for Resident 8 to experience negative feelings (including disrespect).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light device (a device used by a resident to signal his or her need for assistance) was within reach for one of 23 sampled residents (Resident 56) who had a history of cerebrovascular accident (CVA, stroke- loss of blood flow to a part of the brain) and left-side hemiparesis (weakness or the inability to move on one side of the body), in accordance with the facility policy. This deficient practice had the potential to result in delayed provision of care and services for Resident 56.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents' medical records were updated to show documentation that advance directives (legal written instructions of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) were discussed and written information were provided to the residents and/or responsible parties (RP) for three of the seven sampled residents (Resident 5, 47 and 43). This deficient practice violated the Residents 5, 47 and 43 and/or the representatives' right to be fully informed of the option to formulate their advance directives and had the potential to cause conflict with the residents' wishes regarding health care.

Inspectors wroteBased on interview and record review, the facility failed to ensure the preadmission screening and annual resident review assessment (PASARR, preventing individuals with mental illness, developmental disability, intellectual disability, or related conditions from being inappropriately placed in nursing homes for long term care) form was accurately completed for a resident who had a mental illness for one of four sampled residents (Resident 52). This deficient practice led Resident 52 to not receive the necessary and appropriate psychiatric level of treatment and evaluation in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an activity based on resident's preference and activity assessment for two of two sampled residents (Residents 52 and 29) in accordance with the facility policy. This deficient practice had the potential not to meet Residents 52 and 29's interests and activity needs, which could affect the physical, mental, and psychosocial well-being of each resident.

Inspectors wroteBased on interview and record review, the facility failed to assist one (1) of two sampled residents (Resident 12) in making appointment of vision services as ordered by the physician. This deficient practice resulted in Resident 12 not having his vision examined to maintain and/or improve his vision.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary respiratory care services for one of two sampled resident (Resident 26) by failing to ensure Resident 26's nebulizer mask (a drug delivery device used to deliver drugs in the form of atomized inhalation into the lungs) and tubing were changed weekly per facility's policy. This deficient practice had the potential for Resident 26 to develop a respiratory infection.

Inspectors wroteBased on interview, and record review, the facility failed to ensure one (1) of five (5) sampled residents (Resident 61) was free from an unnecessary psychotropic drug (any medication capable of affecting the mind, emotions, and behavior) in accordance with the facility policy and procedure by failing to ensure Resident 61 had a specific target behavior for the use of Zyprexa (medication used to treat certain mental/mood disorders). This deficient practice had the potential to place Resident 61 at risk for significant adverse (harmful) consequences from the use of unnecessary psychotropic drug.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 23 sampled resident (Resident 22) who required adaptive feeding equipment (modified utensils, accessories, glasses, and plates to help improve residents' comfort and independence) utilize a plate guard (unique spill guard which prevents food from accidentally being pushed off the plate) during meal, as indicated on the physician's order. This deficient practice placed Resident 22 at risk for further decline in physical functioning and decline to perform self-feeding skills.

Inspectors wroteBased on interview and record review, facility failed to conduct a monthly Quality Assessment and Assurance (QAA, process to evaluate activities under the Quality Assurance and Performance Improvement [QAPI, process used to ensure services are meeting quality standards and assuring care reaches a certain level) program, such as identifying issues with respect to which QAA activities, including PI projects required under the QAPI program, are necessary) meeting as indicated in the facility policy and procedure (P&P). This failure had the potential to result in inadequate, incomplete provision of care and services provided to residents throughout the facility, decreasing their quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision to a resident assessed as high risk for fall by not providing a one-to-one sitter (1:1, staff who provides constant observation to ensure the safety of a resident who may be suffering from cognitive [thought process and ability to reason or make decisions] impairment or may be at risk for falls or of causing harm to themselves or others) for one of three sampled residents (Resident 1), in accordance with the resident ' s physician ' s order. This deficient practice resulted in Resident 1 ' s unwitnessed fall on 12/22/23 and resulted in the following: 1. A six (6) centimeter (cm, unit of measurement) laceration (a deep cut or tear in the skin) to Resident 1 ' s posterior occiput (back of the head) requiring 12 staples 2. [...]

Inspectors wroteBased observation, interview, and record review, the facility failed to accurately assess the resident's functional abilities for one (1) of five (5) sampled residents (Resident 1) on the Minimum Data Set (MDS- an assessment and care screening tool) as indicated on the facility policy. This deficient practice had the potential to not develop and implement an individualized care plan for Resident 1, which could result in injury/harm and negatively affect the resident's overall wellbeing.

Inspectors wroteBased observation, interview, and record review, the facility failed to develop a resident centered care plan for one (1) of five (5) sampled residents (Resident 1) to address resident's specific functional abilities during activities of daily living as indicated on the facility policy. This deficient practice had the potential to not develop and implement an individualized care plan for Resident 1, which could result in injury/harm and negatively affect the resident's overall wellbeing.

Inspectors wroteBased on interview and record review, the facility failed to promote dignity and respect for one of five sampled residents (Resident 2) as indicated on the facility policy. This deficient practice had the potential to cause a decline in Resident 2's individuality, self-esteem, and self-worth.

Inspectors wroteBased on interview and record review, the facility failed to ensure one out of one sampled resident (Resident 1) received proper services to maintain the resident's vision by failing to arrange the resident's appointment with an ophthalmologist (are eye doctors who perform medical and surgical treatments for eye condition). This deficient practice resulted in Resident 1 not receiving his vision services by not making his ophthalmologist appointment to maintain his vision.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide supervision to prevent accidents for three of five sampled smoking residents (Resident 1, 2, and 3) in accordance with the facility's Smoking Policy and guidelines. a. Residents 1, 2 and 3 had a lighter and cigarette in their possession and not kept at the designated locked storage cabinet for smoking paraphernalia. b. Resident 3 was observed smoking outside the designated smoking area without staff supervision and threw a lighted cigarette butt (end of cigarette) on the regular trash can on 10/24/2023. This deficient practice had the potential to result in an accidental fire in the facility, which could lead to harm and injury to the residents and staff.