Chestnut Ridge Post Acute LLC

Inspectors wroteBased on interview and record review the facility failed to obtain and administer Rifaximin (a prescription medication used to reduce the risk of recurring brain function issues caused by severe liver failure (a life-threatening state where a large portion of the liver is permanently damaged and stops functioning)) for one of two sampled residents (Resident 5) in accordance with the facility's policy and procedures on Medication Orders and Receipt Record. This failure had the potential to result in rapid recurrence of debilitating neurological symptoms (persistent or intermittent physical and cognitive impairments) such as confusion, lethargy (state of abnormal drowsiness), or coma, which often leads to emergency hospitalization.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide one of five sampled residents (Resident 1), who had functional limitation on both sides of her upper extremities (shoulder, elbow, wrist, and hand), with a soft-touch pad call light (a communication tool in that allows the residents to request help from nursing staff) instead of a standard button call light to accommodate the resident's needs. This failure resulted in Resident 1 not able to call for help when the resident had pain and needed assistance from the nursing staff on 7/2/2026 at 6:48 AM. This failure had the potential to delay medical attention and increased the risk of the resident not able to maintain and/or achieve independent functioning, dignity, and well-being.

Inspectors wroteBased on interview and record review, the facility failed to notify the physician for significant change in condition for two of two sampled residents (Resident 4 and Resident 5) in accordance with the facility's policy and procedures titled Administering Medications and Requesting, Refusing and/or Discontinuing Care or Treatment when: Resident 4 refused bedtime medications for 8 nights in June 2026. Resident 5 was unable to take medications because facility had not received the medications from pharmacy on 6/23/2026 - 6/25/2026. This failure had the potential to worsen residents' condition and not meet their highest potential. In addition, the physician can increase dosage of medications by not knowing the medications were not administered to the residents, leading to hospitalization or death.

Inspectors wroteBased on interview and record review the facility failed to resolve a grievance (any formal or informal, written or verbal expression of dissatisfaction with the operations, activities, or behavior of the facility) for one of six (6) sampled residents (Resident 4), who reported a concern on 6/8/2026 that the resident was not receiving medications correctly from Licensed Vocational Nurse (LVN) 2 by failing to: 1. Replace LVN 2 with another nurse to administer Resident 4's medication as indicated in the recommendation/corrective action for the resident's grievance report. 2. Ensure the Administrator in Training (AIT) followed up to ensure the corrective action was implemented and completed another grievance report form when Resident 4 continued to report her concerns that LVN 2 was not administering her medications correctly. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide activity of daily living (ADL, the basic self-care tasks everyone performs daily to survive, such as like bathing, dressing, and eating) care for one of three sampled dependent residents (Resident 2), in accordance with the facility's Activities of Daily Living policy and Bath/Shower Tub by failing to: 1. Ensure Certified Nurse Assistant (CNA) 1 provided Resident 2 with a shower on her scheduled shower day of 6/30/2026. 2. Ensure CNA 1 reported Resident 2's missed shower to the licensed nurses for appropriate follow up and documentation. These deficient practices had the potential to result in body odor, uncomfortable skin rashes, and an increased risk of fungal or bacterial infections for Resident 2.

Inspectors wroteBased on interview and record review, the facility failed to complete an annual Certified Nursing Assistant (CNA) performance review (a yearly, documented meeting between a nursing assistant and their supervisor to assess the CNA's quality of care, communication, and attendance over the past 12 months) for one of four sampled CNAs (CNA 1). This failure had the potential to result in CNA 1 being unable to provide quality care to the facility's residents, which could negatively impact their dignity, mental health, and physical comfort.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the facility's two out of three shower rooms (SR) were clean and sanitary, in accordance with the facility's policy and procedure titled, Infection Prevention and Control. On 6/2/2026 SR 1 and SR 2 were observed to have brown-colored substances that were smeared on the floor and shower chairs (a specialized, waterproof seat designed to allow individuals to sit while bathing). This deficient practice had the potential to spread infection to all the facility's residents who use the shower rooms. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the water filter was changed at least once a year for the facility kitchen's coffee maker and juice machine. This deficient practice had the potential to affect the residents' appetite and fluid consumption because of the water palatability of the facility-served coffee and juice. During a concurrent observation and interview on 6/2/2026 at 3:11 PM with Dietary Supervisor (DS), the facility's kitchen was inspected. During the inspection, the facility's water filter was observed with a label indicating that the filter was changed on 5/28/2025. DS stated the water filter supplies water to the facility's coffee maker and juice making sure the water, which is served for the residents. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one (1) of three sampled residents (Resident 1) were administered medications, in accordance with the physician's order and facility's policy and procedure (P&P) titled, Administering Medications. This deficient practice placed Resident 1 at risk of complications associated with the possible mismanagement of the resident's diseases process.

Inspectors wroteBased on interview and record review, the facility failed to provide a hazard free environment and device to prevent falls in accordance with the facility's policy and procedure (P&P) titled Falls and Fall Risk, Managing, and Smoking Policy or five of five sampled resident (Resident 2, 5, 6, 7, and 8) by failing to: 1. Supervise and implement intervention for Resident 2 who used a wheelchair instead of a Front Wheeled [NAME] (FWW-a mobility aid featuring two wheels on its front legs and rubber, non-slip tips on the back legs) plan for safety while ambulating. 2. Monitor, supervise compliance with Smoking Policy and implement intervention to promote safety for Resident 5 who smokes and found sharing cigarettes and carrying a lighter. 3. [...]

Inspectors wroteBased on interview and record review the facility failed to provide a hazard free environment, supervision and assistive device to prevent accidents and injuries to one of three sampled resident (Resident 1) in accordance with the resident's care plan, physician order and the facility's policy and procedure titled Assessing Falls and Their Causes. The facility failed to ensure: Resident 1's call light was always within Resident 1's reach. Application of the bed alarm (a pressure sensitive pads with a pad alarm (a device that alarms when pressure is relieved from the pad (by the patient 'getting up' from the chair or bed) the alarm will sound and assistance can be provided) in good functioning condition as ordered by the physician. To complete the Fall Risk Assessment to assess and implement interventions based on the resident's risk factor for fall. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1), who had a stage 4 (Full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone), pressure injury (PI localized damage to the skin and/or underlying tissue usually over a bony prominence) was provided care and services to prevent wound deterioration in accordance with the facility's policy and procedures titled Prevention of Pressure Injuries. This deficient practice placed Resident 1 at risk for delayed wound healing, infection, and negative outcome of Resident 1's prognosis.

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify interventions related to one (1) of three sampled residents (Resident 1's) specific risks and causes to try to prevent the resident from falling by failing to: Ensure that Resident 1 was frequently monitored and checked for safety and not to leave frequently used items unreachable for Resident 1;Ensure that IDT (Interdisciplinary Team- a collaborative group of health professionals working together to manage patient care) identified and evaluated specific factors and causes after Resident 1 fell on [DATE] and 1/21/2026;Ensure that staff obtained physician's order for floor mat and applied as recommended by IDT and as in the Care Plan. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed notify the physician after a change in condition for one of three sampled residents (Resident 1) who was a diabetic (someone whose body cannot properly manage blood sugar levels) and had an episode of hypoglycemia (a condition where blood sugar drops below normal levels, typically under 70 mg/dL( unit of measurement used to show the concentration of a substance) on 3/6/2026 This deficient practice had the potential for Resident 1's hypoglycemic episode to recur resulting in weakness, confusion or even coma (unconsciousness) that could negatively affect Resident 1's quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide care and services to ensure one of three sample residents (Resident 1) with blisters (a painful skin condition filled with fluid fills a space between layers of skin) due to shingles (an infection caused painful rash) was assessed, monitored and documented weekly for two weeks the skin condition in accordance with the facility's policy and procedures (P&P) titled, Wound Care. This deficient practice had the potential for Resident 1's to receive delayed care or no care when the resident's skin condition with blisters due to shingles to worsen, become infected, and could also spread to other vulnerable residents in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure proper and effective Basic Life Support (BLS-the level of care provided to victims of life-threatening illnesses or injuries until full medical care is available, including recognition of cardiac arrest and activation of the emergency response system), that included cardiopulmonary resuscitation (CPR, an emergency procedure combining chest compressions and rescue breaths to circulate blood and oxygen when the heart stops or breathing ceases). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a physician's order for a resident's code status preference that included the resident's Provider Orders for Life-sustaining Treatment (POLST-a set of portable medical orders that communicate a patient's wishes for end-of-life intervention to health care facilities and providers) was readily retrievable and placed in the residents' current medical chart for 11 out of 100 sampled residents (Resident 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 and 11), in case of an emergency and in accordance to the facility's Policy and Procedure (P&P) titled, Advance Directive. This deficient practice had the potential to delay life sustaining measures during a medical emergency.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that direct care staff were qualified to respond and perform cardiopulmonary resuscitation (CPR) for one out of 66 identified full code (a resident who wants all possible life-saving measures used if their heart stops or they stop breathing, including CPR residents) (Resident 1). After further investigation, it was determined the facility failed to ensure that: 1. On [DATE], CNA 1, Registered Nurse (RN) 1, LVN 1, LVN 2, and LVN 5 did not call a code blue immediately when Resident 1 was found unresponsive on [DATE] between 3:05 PM to 3:10 PM. 2. On [DATE], LVN 1 and CNA 2 did not place Resident 1 on a firm, flat surface while performing CPR. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the necessary respiratory care and interventions in accordance with the resident's respiratory care needs, care plan, facility policy and professional standards of practice, the physician's order and facility's policy and procedure for one of two sampled residents (Resident 1) diagnosed of respiratory failure (a condition where the lungs cannot supply enough oxygen or remove carbon dioxide from the blood) with hypoxia (a life-threatening condition where the lungs fail to deliver enough oxygen to the blood, leading to dangerously low oxygen levels in the body), chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty breathing), emphysema (a lung disease where the air sacs [alveoli] in the lungs are damaged, making breathing difficult) and recurrent pneumonia (an infection/inflammation in [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure four out of five facility staff members, Registered Nurses (RNs) 1 and 2, and Certified Nursing Assistants (CNAs) 1 and 2, demonstrated competencies and skill sets necessary to provide emergency response and perform cardiopulmonary resuscitation (CPR-CPR is an emergency, life saving procedure performed when the heart stops beating and involves chest compressions at a rate of 100-120 beats per minute (bpm) and rescue breaths to maintain blood flow and oxygenation) as indicated in the facilities policy and procedure (PP) for Emergency Procedure - Cardiopulmonary Resuscitation and the American Red Cross CPR guidance as evidence by: 1. CNA 1 stated it took two (2) minutes to check for an unresponsive resident's pulse and breathing prior to performing CPR. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from significant medication errors for one of two sampled residents (Resident 1). Licensed nurses did not administer prescribed respiratory medications to Resident 1, who had chronic obstructive pulmonary disease (COPD-a chronic lung disease causing breathing difficulty) and was oxygen-dependent. Missed doses included: Acetylcysteine Inhalation Solution 20% (used to thin mucus in the lungs): 25 scheduled doses between September and November 2025 Budesonide Inhalation Suspension (reduces airway inflammation): 31 scheduled doses between September and November 2025 Ipratropium-Albuterol Inhalation Solution (relaxes and opens airways): [...]

Inspectors wroteBased on interview and record review, the facility failed to verify received or follow up with the attending physician (Medical Doctor [MD] 1) and/or the Nurse Practitioner (NP) 1 of the abnormal laboratory and diagnostic results for one of two sampled residents (Resident 1) with abnormal laboratory and diagnostic results. Resident 1 had an elevated white blood cell (WBC - a blood cell that helps attack infection or injury in the body) count of 16.85 x10*3/ul (thousands of cells per microliter- a unit of measurement [Normal range 4.0-11.0 x10*3/ul]) and abnormal chest x-ray (a type of imaging that uses electromagnetic radiation to view internal structures of the body) results indicating mild patchy opacity (an area that appears white or dense on an x-ray) in the left lower lung which represented a potential indicator of lung infection. [...]

Inspectors wroteFindings: During a review of Resident 1's admission Record, the record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing), emphysema (a lung disease where the air sacs [alveoli] in the lungs are damaged, making breathing difficult), respiratory failure (a condition where the lungs cannot supply enough oxygen or remove carbon dioxide from the blood) with hypoxia (a condition in which body tissues do not receive enough oxygen to function properly), and recurrent pneumonia (an infection/inflammation in the lungs). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the resident's rights to be free from physical abuse for two of three sampled residents (Resident 2 and 3) by failing to protect Residents 2 and 3 from physical abuse. On 11/24/25, Resident 1 was observed by facility staff to be agitated, pacing back and forth in the room and swinging two metal wheelchair footrests in the air. Facility staff (Certified Nurse Assistant 1) failed to redirect and remove Resident 1 from the room leaving two other residents (Residents 2 and 3) in the room with Resident 1. As a result, Resident 1 hit Resident 2 several times in the head with the metal wheelchair footrests while Resident 2 was in bed. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide medically related social services for one of three sampled residents (Resident 3) by not ensuring the resident attained or maintained his/her highest practicable physical, mental, or psychosocial well-being. Specifically, facility staff did not identify or address factors negatively affecting Resident 3's psychosocial functioning after the resident witnessed and was exposed to a violent incident (physical abuse) involving another resident (Residents 1 and 2). No nursing or facility staff checked or followed up on Resident 3 following the incident. This deficient practice had the potential to result in long-term psychosocial harm as resident 3 verbalized experiencing fear, anxiety, and emotional distress after witnessing and being threatened during a violent incident. [...]

Inspectors wroteBased on observations, interview, and record reviews, the facility failed to ensure timely implementation of physician-ordered Passive Range of Motion (PROM) services and splint application for 1 of 2 sampled resident (Resident 88) reviewed for Restorative Nursing Assistant (RNA) services. This deficient practice resulted in a 22-day delay in PROM exercises and splint use, which placed Resident 88 at risk for increased joint stiffness, reduced mobility, and progression of contractures (the permanent shortening of a muscle or a joint, leading to a deformity and restricted range of motion). During a review of Resident 88's admission Record [AR], the AR indicated Resident 88 was originally admitted to the facility on [DATE], with diagnoses that included contracture right elbow and contracture right hand. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide a safe and hazard free environment to ensure electrical and extension cord devices were safely used for one of 1 of 8 sampled residents (Resident 75). This deficient practice has the potential to result in fire at the facility, electrical shock, and burns that could lead to residents' hospitalization and deaths. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to implement the facility's policies and procedures, titled storage of Food and Supplies, Procedures for Refrigerated Storage, and Preventing Foodborne illness- Employee Hygiene and Sanitary Practices, professional standards of practice on food storage, food service safety, sanitation and handling practices to prevent the outbreak of foodborne illness (food poisoning) by failing to ensure: 1. Discard one jar of turmeric powder, two (2) jars of curry powder, one jar of ground cumin, two (2) jars of ground Italian seasoning, one jar of ground paprika, one jar of steak sauce, one jar of dry basil leaves, one jar of chili powder, two bags of dried shredded coconut, one bag of pancake mix, one bag of brown rice; a bag of cornflakes, one bag of pepperoni slices when expired. 2. [...]

Inspectors wroteBased on interview, and record review, the facility failed to complete an informed consent (a process of communication between a person and the health care provider that often leads to agreement or permission for care, treatment, or services) for psychotropic/psychotherapeutic (any drug that affects behavior, mood, thoughts, or perception) drug for one of two sampled resident (Resident 101) who was prescribed Ativan (a psychotropic medication used for anxiety). This deficient practice had the potential for Resident 101's rights to be violated by not being providing a complete and accurate explanation of care and treatment provided to Resident 101, in which Resident 101 fully understood the risk, benefits, and expected outcomes. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure one of four sampled resident (Resident 65) and her representative was assisted to formulate an Advance Directives (AD-a written statement 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) upon admission and to complete an Advance Directive Acknowledgement (ADA a document where a person confirms they have received information about their right to create an advance directive and understand their options for future medical decisions) form timely. This deficient practice had the potential to cause conflict with Resident 65's wishes regarding health care treatment especially in an event of emergency. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a base line comprehensive person-centered care plan for one of three residents (Resident 61), who was identified as having dental problems and required change in texture of to be able to chew food effectively. This deficient practice had the potential to delay care and services to Resident 61 and could negatively impact Resident 61's health and lead to nutritional problems.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide medically-related social service in accordance with the facility's policy and procedure titled Social Services for one of three sampled residents (Resident 61), who had missing teeth and had requested new dentures (removable oral appliances that replace missing teeth). The Social Service Designee (SSD) failed to follow up with the dentist's recommendation to have a dental hygiene prior to obtaining new dentures for Resident 61. As a result of this deficient practice, Resident 61 did not receive new dentures and leaving Resident 61 to remain with difficulty chewing with the remaining teeth.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary dental care services to one of one sampled resident (Resident 61) who was not assisted to receive dental care as recommended by the dentist due to missing teeth and dental cavities and difficulty chewing food. As a result of these deficient practices Resident 61 had the potential for nutrition deficit, weight loss, choking due to difficulty chewing and pain due to untreated dental cavities.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to implement infection control measures for two of eight sampled residents (Resident 75 and Resident 83) by failing to: 1. Ensure Resident 75's respiratory equipment was properly labeled and stored in a plastic bag with the resident's name and the date the tubing was changed. 2. Ensure Resident 83's Peripherally inserted Central Catheter ICC a long, thin tube inserted into a vein in the upper arm that extends to a large vein near the heart.)) site was labeled with the date of the last dressing (typically a transparent, secure, and often antimicrobial dressing that protects the insertion site from infection) change. These deficient practices had the potential to place Resident 75 and Resident 83 at risk for infection. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to maintain a safe and sanitary environment for one of three sampled residents (Resident 74); by failing to ensure Resident 74's room was clean and free from stains and dust. 1. Resident 74's room was observed with more than one brown stains on the wall in 2. Resident 74's exhaust vent (a mechanical device designed to pull stale or polluted indoor air out of a room and expel it outdoors) was observed covered in dust. These deficient practices had the potential to result in Residents' discomfort. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident who displayed behaviors of refusing medications received treatment and services to correct the assessed problem, was provided behavioral health services for one of three sampled residents ( Resident 1) whose primary diagnosis was schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly) and bipolar disorder (a brain disorder that causes changes in a person's mood, energy, and ability to function) by failing to: 1. Notify the physician when Resident 1 refused Haloperidol (a medicine used to treat and manage various mental health and behavioral condition, including schizophrenia and bipolar disorder) 10 milligram (MG, a unit of measurement) one tablet by mouth two times a day for a total of 35 doses. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that a comprehensive, person-centered care plan was developed for one of two sampled resident (Resident 1) who was assessed to be at risk of elopement (the act of leaving a facility unsupervised and without prior authorization) and wandering. This deficient practice had the potential for Resident 1 to not receive care that would prevent the resident from wandering into other resident ' s rooms, which could be a violation of other resident ' s privacy and rights, and/or elope from the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the facility have sufficient and competent nursing staff to address, and provide necessary services (behavior monitoring and management) and implement person centered care plans for the behavioral healthcare needs of one of three sampled residents (Resident 1) diagnosed with schizoaffective disorder- bipolar type (a mental illness that combines symptoms of schizophrenia [a serious mental health condition that affects how people think, feel and behave] with those of bipolar disorder (a mood disorder characterized by extreme mood swings)], and psychotic disorder (severe mental disorders that cause abnormal thinking and perceptions), in accordance with the facility ' s policy and procedures on Behavioral Assessment, Intervention and Monitoring and Care Planning - Interdisciplinary Team. The facility failed to: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to report immediately and/or no later than two hours if the alleged allegation involves abuse, the verbal and physical altercation that happened with two of two sampled residents (Resident 1 and Resident 6) on 5/3/2025. Resident 6 reported that on 5/3/2025 around 9AM, Resident 1 stopped him in the hallway in his wheelchair, and yelled profanity (offensive or vulgar language, often considered impolite, rude, or disrespectful) at him and while in his wheelchair, he was pushed fast, spun around and grabbed his shirt prior to the staff separating them. As a result, Resident 6 verbalized feeling upset, sad and discouraged, which negatively affected his quality of life. Also, it had the potential for a recurrence resulting in harm to other residents and staff in the facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide sufficient nursing staff who have the knowledge, training, and skills sets to address behavioral healthcare needs for one of four sampled residents (Resident 1), who was diagnosed with dementia and assessed at high risk for elopement, in accordance with the resident ' s care plan, the facility ' s policy and procedure on Behavioral Health Services, Dementia Care, and the Facility Assessment. The facility staff failed to intervene when Resident 1, who was visibly agitated and refused to come back inside the facility upon returning from an out-on-pass with the family [FM 1] on 11/27/2024. Registered Nurse [RN] 1 failed to implement Resident 1 ' s care plan on Behavioral Problem. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide adequate monitoring and supervision to ensure one of two sampled resident (Resident 1), who had severely impaired cognition and memory and was assessed at risk for elopement with diagnoses of dementia (a term used to describe a group of symptoms affecting memory, thinking and social abilities) did not elope from the facility on 11/14/2024. The deficient practice had resulted in Resident 1 eloping from the facility on 11/14/2024. As of 11/15/2024, Resident 1 had not been found by the facility staff. Resident 1 had the potential for fall and injury from being struck by motor vehicles. Resident 1 also had the potential to be exposed to extreme weather and malnutrition (lack of proper nutrition.

Inspectors wroteBased on interview and record review, the facility failed to provide the resident with access to personal and medical records pertaining to him or herself, upon an oral or written request, in the form and format requested by one of two sampled residents (Resident 1), or in a readable hard copy form or such other form and format as agreed to by the facility and the resident, within 24 hours (excluding weekends and holidays), in accordance with the facility ' s Policy and procedure [P&P] titled Resident Rights and Release of Information. This deficient practice violated the rights of Resident 1 to access personal and medical records pertaining to him or herself.

Inspectors wroteBased on interview, observation and record review, the facility failed to ensure the facility ' s recent (last survey was on 10/5/2023) survey binder with past survey result (outcome of the survey that were conducted to protect residents and to ensure that all residents receive the quality of care) were accessible and available for all the residents, including Resident 27, 102 and 106 who attended the facility ' s resident council meeting on 10/2/2024. This deficient practice had the potential for the residents and their legal representatives to not fully informed of the facility's deficient practices and how they were corrected.

Inspectors wroteBased on interview and record review, the facility failed to ensure the quarterly Minimum Data Sets (MDS - a federally mandated resident assessment tool) were completed within the required time frame for four out of four sampled residents (Residents 2, 30, 60, and 77). This deficient practice had the potential to negatively affect the provision of necessary care and services for Residents 2, 30, 60, and 77.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a document that outlines the facility's plan to provide personalized care to a resident based on the resident's needs) for four of five sampled residents (Resident 58, 3, 70 and 63) by failing to: 1. Develop a care plan for dementia Resident 58 with dementia (a progressive state of decline in mental abilities) 2. Develop a plan of care for Resident 3 and Resident 70 while receiving psychoactive medications ( medications that affects mood and behavior). 3. Develop a plan of care for Resident 63 who refused to have the nasal canula (a device used to deliver supplemental oxygen placed directly on a resident's nostrils) placed in a bag when not in use. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who needs respiratory care were provided such care, consistent with professional standards of practice, care plan goals, and facility's policy and procedure for four of four sampled residents (Resident 258, 63, 26 and 55) by failing to ensure: 1. Resident 258, 63 who uses and was receiving oxygen in the room had an oxygen in use warning sign was posted on the resident's doorway. 2. Resident 258 does not receive oxygen therapy since 9/16/2024 without a physician ' s order. 3. Resident 26 and Resident 55 nebulizers (a small machine that turns liquid medicine into a mist that can be easily inhaled) were stored in a sanitary manner and changed according to facility's policy and procedure. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the food were stored prepared and distributed of food under sanitary conditions to all the residents in the facility by failing to: 1. Ensuring to store food with label and open date. 2. Ensure expired food was not stored in the kitchen. 3. Monitoring and documenting Sanitization Bucket Log. 4. Monitoring and documenting Ice Machine cleaning log. 5. Monitoring and documenting cleaning and maintenance schedule log. These deficient practices placed the residents at risk for foodborne illnesses (refers to illness caused by the ingestion of contaminated food or beverages).

Inspectors wrote2. During a review of Resident 86's admission Record indicated the facility initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that include dementia (a group of thinking and social symptoms that interferes with daily functioning) and dysphagia (difficulty swallowing foods or liquids). During a review of a Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 9/2/24, indicated Resident 86 had severely impaired cognition (ability to understand and make decisions) skills for daily decision making. The MDS indicated Resident 86 required substantial/maximal assistance with eating, and was dependent with oral hygiene, toilet hygiene and personal hygiene. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain an informed consent for psychotropic (any drug that affects behavior, mood, thoughts, or perception) drug for one of one sampled resident (Resident 99) who was prescribed Quetiapine (medication used to treat a mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions), and Zolpidem (medication used for used to treat insomnia (trouble sleeping) . This deficient practice had violated Resident 99's rights to be informed when choosing the type of care or treatment to be received, make decisions on alternative measures the resident or responsible party preferred, which could negatively affect Resident 99 ' s quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide communication board (a sheet of symbols, pictures, or photos that one can use by point to, to help people who have limited spoken language ability to communicate with others.) to facilitate and help residents express and have their needs met for one of twenty-three sampled residents (Resident 23). This failure had a potential to result in Resident 23's needs not met, feeling upset, potential decline in quality of care provided to her and her overall quality of life.

Inspectors wroteBased on interview and record review, the facility failed to implement facility's written abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish) policy and procedure for two of three sampled residents (Resident 106 and Resident 29) by not conducting a thorough investigation when the two residents were involved in a resident-to-resident altercation. Resident 106 allegedly physically abused by Resident 29 during a resident -to-resident altercation on 9/26/24. Resident 29 poured a cup of water on Resident 106, who was sleeping on his bed around 7:30 PM on 9/26/24. Resident 29 walked out the room with Resident 106 following behind him. Resident 29 and Resident 106 stopped and stood face to face about one foot away from each other in front of the nursing station #1. [...]

Inspectors wroteBased on interview and record review, the facility failed to report immediately and within two hours an allegation or suspicion of physical abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish) to the Administrator (the facility ' s Abuse Coordinator), state agency, responsible party, police department and ombudsman (state personnel that advocates for the residents in the facility) for one of three sampled residents (Resident 106) in accordance with the facility ' s policy Abuse Reporting and Investigation. LVN 4 witnessed the confrontation between Resident 106 and Resident 29 in front of the nursing station #1 after Resident 106 allegedly poured water on Resident 29 while the resident was asleep, and did not report the incident to the Abuse Coordinator or designee within two hours. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure assistance was provided ADLS (Activities of Daily Living- (routine tasks, activities such as eating, that a person performs daily to care for themselves) during mealtimes for one of twenty-three sampled residents (Resident 23). This failure resulted in Resident 23's feeling upset, not able to eat her chicken during lunch on 10/1/2024, and a potential risk for malnutrition and weight loss. In addition, could result in a decline in the resident ' s ability to perform ADLS.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents provide necessary care and services for skin breakdown and pressure injuries (localized damage to the skin and underlying soft tissue, usually occurring over a bony prominence or related to medical devices) to prevent skin breakdown for one of three sampled residents (Resident 4) by failing to ensure Resident 4 who uses a low air loss mattress (LAL Mattress -air filled mattress used to relieve pressure) was set according to resident's weight. As a result of this deficient practice placed Resident 4 at additional risk for developing pressure injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate device and appropriate rehabilitation services (assessment and evaluation of the residents to determine exercises or devices needed to improve or maintain mobility) to maintain or improve mobility for one of two sampled residents (Resident 58). with limited mobility and contractures (a permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff) on both arms was observed with towel between the arms. This failure practice had a potential to result in Resident 58's worsened elbow contractures that could lead to pain, discomfort and high risk for fractures (broken bones).

Inspectors wrote2. During a review of Resident 63's admission Record (Face Sheet), dated 2/18/2022, the face sheet indicated the facility admitted Resident 63 on 2/18/2022, and readmitted on [DATE] with diagnoses including Chronic Obstructive Pulmonary disease (COPD - lung disease which makes breathing difficult), and bronchiectasis (a condition where your airways widen or develop pouches). During a review of Resident 63's History and Physical (H&P), dated 3/3/2024, indicated, Resident 63 had the mental capacity to make medical decisions. During a review of Resident 63's Smoker's Risk Assessment, dated 7/21/2024, indicated Resident 63 was an independent smoker (no supervision needed). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to verify one of seven sampled residents (Resident 89)'s identity before medication was administered to the resident in accordance with the facility's policy and procedure. The deficient practice had put Resident 89 at risk of receiving the wrong and unnecessary medications that could cause the adverse effects (an undesired effect of a drug or other type of treatment).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of five sampled residents (Resident 58 and 4) were free of unnecessary psychotropic medications (any medication capable of affecting the mind, emotions, and behavior) in accordance with the facility's policy and procedureby [NAME] to ensure: (any medication capable of affecting the mind, emotions, and behavior) in accordance with the facility policy and procedure. Resident 58 1. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure drugs and biologicals used in the facility were, stored under proper temperature, are labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable in accordance with the facility's policy and procedures. The facility failed to: 1. Ensure the medication room [ROOM NUMBER] ' s thermometer readings were monitored and recorded in the Daily Room Temperature Log to assure a safe temperature range for medication storage. 2. Label Resident 257's opened multi-dose medication bottles (a bottle of medication in the forms of liquid, tablet, or capsule, that contains more than one dose of medication) with the name in the Medication Cart #1 for: a. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food prepared in a form designed to meet individual needs for one of twenty-three sampled residents (Resident 23) with dysphagia (difficulty swallowing) and was ordered by the physician to be served Regular diet (diet that does not include any restrictions) with mechanical soft texture (any foods that can be blended, mashed, pureed, or chopped using a kitchen tool such as a knife, a grinder, a blender, or a food processor) since 7/16/2024. This failure resulted in Resident 23 received regular texture instead of mechanical soft texture as ordered from 7/16/2024 to 10/3/2024, which could place her at risk for aspiration (happens when food, liquid, or other material enters a person ' s airway by accident. It can happen as a person swallows) and choking.

Inspectors wroteBased on interview and record review, the facility failed to screen for the need of pneumococcal (PNA) vaccine (an administration of vaccine that stimulate the body's own immune system to protect the person against infection or disease) and offer the vaccine to one of five sampled residents (Resident 160) when the resident was initially admitted to the facility as indicated in the facility's policy and procedure titled, Pneumococcal Vaccine The deficient practice had the potential to result in Resident 160 did not receive the PNA vaccine as recommended by the Department of Public Health and Centers of Disease Control and Prevention (CDC), which out the resident at risk for contracting pneumonia (a severe lung infection).

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe and sanitary environment for one of three sampled residents (Resident 160) who was observed with stained and soiled both upper bed siderails (one of the long narrow members connecting the headboard and footboard of a bed). This deficient practice had the potential to result in Resident 160's discomfort and the spread of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate supervision for one of three sampled residents (Resident 1) by not escalating the process of finding Resident 1 ' s whereabout by not informing the Medical Doctor (MD), Director of Nurses (DON)] or the Social Worker (SW) for guidance when Resident 1 went out on pass (OOP) (temporary permission of a patient to leave the hospital in a specified time) on 5/23/2024 at 8:30 AM, and did not return to the facility the same day at 12:00 PM (which was Resident 1 ' s estimated time of return). This incident delayed the notification of law enforcement and other appropriate agencies, who were notified more than 24 hours from the time of the incident. [...]

Inspectors wroteBased on observations, interview, and record review, the facility failed to provide adequate supervision for one of five residents (Resident 1) based on the resident ' s individual and assessed needs. This lack of supervision has increased risk for falls and injuries due to resident ' s wandering (Going one location to another aimlessly, usually without a plan or definitive purpose). This deficient practice had the potential for Resident 1 to sustain injuries and increases the risk of altercations with other residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to comprehensively assess the root cause of behavioral symptoms and develop measurable goals and interventions to address care and treatment of a resident with dementia (a disorder of mental processes caused by brain disease or injury and marked by memory disorder, personality changes, and impaired reasoning) for one of five sampled residents (Resident 1) with diagnosis of dementia with behaviors. This deficient practice had the potential to negatively affect the safety, wellbeing, and the delivery of services.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide the resident's call light (device used to alert facility staff assistance as needed by residents) within reaxh as indicated in the care plan, for one out of three sampled residents (Resident 2). This deficient practice had the potential in a delay in meeting the resident ' s needs for assistance and can lead to frustration, unavoidable falls and accidents.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care in a manner that maintained or enhanced a resident's dignity and respect in full recognition of his individuality for one (1) of seven sampled residents (Resident 5). The facility staff was observed removing Resident 5's shirt and exposing Resident 5's upper body in the facility's Activity Room, in the presence of Resident 6, Resident 7, and Resident 6's Family Member (FAM 1). This deficient practice had the potential to affect Resident 5 's self-esteem and self-worth.

Inspectors wroteBased on interview and record review, the facility failed to ensure Resident 1 was free from physical restraints by allowing emergency medical technicians (EMT) to apply physical restraints attached in a gurney to Resident 1 ' s wrists and ankle on 11/15/2023 from 9:30 AM to 10:45 AM (one hour and 15 minutes) while waiting for Resident 1 to be evaluated by the Psychiatric Evaluation Team (PET), without a physician ' s order, on-going assessments and monitoring of the resident while on physical restraints, in accordance with the facility policy and procedure on Physical Restraint Application. This failure resulted in Resident 1 ' s restriction of freedom of movement and had the potential to result in the resident ' s increased anxiety, agitation, and loss of dignity.

Inspectors wrote4. A review of Resident 46's admission Record indicated the resident was initially admitted to the facility on [DATE] with the diagnosis of paranoid schizophrenia (a severe mental health condition that can involve delusions and paranoia) and encephalopathy (damage or disease that affects the brain). A review of Resident 46's Minimum Data Set (MDS a standardized assessment and care screening tool), dated 8/30/2023, indicated that Resident 46 had moderate impaired cognition (the ability or mental action or process of acquiring knowledge and understanding). During a concurrent interview and record review of Resident 46's Care Plan, with the Director of Nursing (DON), on 10/4/2023, at 11:35 AM, the DON stated there was no care plan in Resident 46's medical records for elopement. The DON stated Resident 46 had a history of elopement on 3/17/2022 from the facility. [...]

Inspectors wroteBased on observation and interview and record review the facility failed to follow its policy and procedure on food storage, preparation, distribution and serving food in accordance with professional standards for food service safety by failing to: 1. Label the cut-up cantaloupe, ham slices and cheese sandwiches with the date of when the food were prepared and when to be consumed by. 2. Remove an egg carton with white liquid from the storage refrigerator. 3. Store two uncracked eggs with other uncracked eggs in the same egg carton. These deficient practices had the potential to result in food contamination, growth of microorganisms (disease causing organism) that could cause foodborne illness (food poisoning or food illness due to pathogens (harmful organism that cause illness such as bacteria, viruses, or parasites) and toxins that contaminate food.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement the facility's policy and procedure for infection control practices by failing to: 1. Implement the facility's policy and procedure titled Departmental (Respiratory Therapy) Prevention of Infection by ensuring the oxygen nasal cannula (NC) tubing (a device used to deliver supplemental oxygen placed directly on a resident's nostrils) was labeled when first used for one of 3 sampled residents (Resident 67). 2. [...]

Inspectors wrote2. A review of Resident 38's Face Sheet (admission record) indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including dysphagia following cerebral infarct (difficulty swallowing), polyneuropathy (when multiple peripheral nerves symptoms include problems with sensation, coordination, or other body functions), and depression (constant feeling of sadness). A review of Resident 38's History and Physical (H&P) dated 8/24/23, indicated Resident 38 had fluctuating capacity to understand and make decision. A review of Resident 38's Minimum Data Set (MDS, a standardized resident assessment and care screening tool) dated 7/12/23, indicated Resident 38 had severe cognitive impairment. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment by not repairing a leaking flushometer of a toilet (a metal water-diverter that uses an inline handle to flush tankless toilets or urinals) for one of four residents (Resident 17). The failure had the potential to result in Resident 17 falling and sustaining an injury from the slipping on the wet restroom floor.

Inspectors wroteBased on interview and record review, the facility failed to receive care consistent with professional standards of practice (specialty practice guidelines or protocols of care for specific populations) to prevent worsening of pressure injury/ulcers (a skin injury resulting from prolonged unrelieved pressure or being in one position in the bony areas of the body) and/or does not develop new pressure ulcers that were unavoidable by ensuring one of three sampled residents (Resident 21) received and documented the skin treatment as ordered by the physician for skin redness on both heels on 10/1/23. This deficient practice had the potential for the Resident 21 and other potential residents with pressure ulcer to develop worsened pressure injury/ulcer.

Inspectors wroteBased on interview, observation, and record review, the facility failed to follow its policy and procedure on Oxygen Administration for one of 3 sampled residents (Resident 67) who had a was receiving oxygen therapy (a supplemental delivery of oxygen) without a physician's order. This deficient practice had the potential for Resident 67 and other residents receiving oxygen therapy to develop complications associated with oxygen therapy such as oxygen toxicity (also called oxygen poisoning is a lung damage due to receiving too much (supplemental) oxygen that can cause coughing, trouble breathing and in severe cases leads to death).

Inspectors wroteBased on interview, and record review, the facility failed to monitor and review their hospice communication binder for 2 of 2 sampled residents (Resident 63 and Resident 342) which contains hospice nurse sign-in sheet, weekly calendar visits and hospice nurses notes that include treatment recommendations. This deficient practice had the potential to negatively affect the delivery of care and services related to the resident's change of health (including but not limited to pain, shortness of breath, spiritual and psychosocial needs related to dying) and may put at risk the personal needs that are particular to end of life issues not being met.