Community Care Center

Inspectors wroteBased on observation, interview, and record review the facility failed to provide safe discharge teaching and caregiver training, including return demonstration and evaluation of the caregiver's ability to assist with activities of daily living (ADL- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves), for one of three sampled residents (Resident 1) reviewed for discharge planning. As a result, the facility discharged Resident 1 to a hotel with a son identified as the primary caregiver despite concerns related to unstable housing, reported intoxication, lack of caregiver training, and failure to evaluate caregiver competency to safely meet Resident 1's 24-hour care needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure safe and effective pharmaceutical services when:Random controlled medication (medications with a high abuse potential) use audit for three of four sampled residents (Residents 73, 4, and 50) indicated medications were signed out of the controlled drug record (CDR, count sheet used to track controlled medications), but were not documented on the Medication Administration Record (MAR, section of the medical record where all medications given to the resident are recorded to ensure patient safety) to indicate they were administered to the residents. In addition, for Resident 50, an administration was documented on the MAR, but not signed out on the CDR. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure one of one sampled resident (17) reviewed for dignity had sufficient personal clothing of choice and footwear. This failure resulted in Resident 17 remaining in a hospital gown instead of personal clothing and without available footwear, with the potential to diminish the resident's sense of self-worth. Resident 17 was admitted to the facility on [DATE] with a diagnosis of cachexia (severe weight loss and muscle wasting caused by serious illness) per the facility admission record. During an observation and interview on 4/29/26 at 9:50 A.M., Resident 17 sat in bed wearing a hospital gown. Resident 17 stated she was in her hospital gown because she did not have enough personal clothing and wanted to purchase clothing of her choice. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (17) had access to personal funds when the resident requested money to purchase clothing of choice. As a result, Resident 17 was unable to purchase desired clothing and continued to wear a hospital gown. Resident 17 was admitted to the facility on [DATE] with a diagnosis of cachexia (severe weight loss and muscle wasting caused by serious illness) per the facility admission record. During an observation and interview on 4/29/26 at 9:50 A.M., Resident 17 sat in bed wearing a hospital gown. Resident 17 stated she wore the hospital gown because she did not have enough personal clothing. Resident 17 stated she wanted to buy clothing of her choosing and had requested access to her money, but the facility had not provided access to her money. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to record and document fluid intake for one resident (118) on intravenous (IV - a medical method of delivering fluids, medication, or blood directly into a vein using a small tube and needle) therapy. This failure had the potential for fluid mismanagement that can lead to fluid overload (when the body retains too much water, causing it to build up in blood vessels and tissues) or dehydration (when the body loses more fluids than it takes in, causing it to lack enough water to function normally) to Resident 118. Per the facility's admission sheet, Resident 118 was admitted to the facility on [DATE] with diagnoses that included dysphagia (trouble swallowing). On 4/27/26 at 8:10 A.M., an observation was conducted of Resident 118 in his room. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not monitor for and treat signs of pain for one of one clients (23) reviewed. This failure caused Client 23 to experience avoidable discomfort.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate was less than five percent. The facility's medication error rate was 11.54% when three medication errors occurred out of 26 opportunities during the medication administration for three of five randomly observed residents (Residents 53, 85, and 106). These failures had the potential for the residents not to get the full therapeutic benefit of their medications or to experience negative health outcomes, such as harm from exposure to medication errors.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free of significant medication errors when one of five residents sampled for unnecessary medications (Resident 93) and two of four sampled residents for controlled medication use audits (Residents 73 and 4) received pain medications that were not in accordance with the prescribers' orders. This failure had the potential for diversion (unlawful distribution or use), as well as the potential for Residents 93, 73 and 4 to experience physical dependence (unpleasant symptoms if a medication is suddenly stopped) and adverse effects, such as sedation (sleepiness), dizziness and respiratory depression (slowed or shallow breathing).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and effective prescription labeling when a portion of both a prescription label and the handwritten date opened were missing on a medication in one of four inspected Medication Carts for Resident 38. This failure had the potential to negatively alter the drug's stability and effectiveness and for Resident 38 to experience adverse health outcomes.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain sanitary food storage and food service practices when individual size milk cartons were stored in boxes saturated in standing water inside a refrigerator, and when resident meals were cooked and plated for service without verifying cooking and holding temperatures. This failure had the potential to expose residents to foodborne illness from consuming contaminated beverage cartons and serving food to residents without a verified safe cooking temperature. During an observation and interview on 4/27/26 at 9:30 A.M., the kitchen's dairy refrigerator was inspected with the dietary supervisor (DS). The three-door reach-in refrigerator had approximately one inch of standing water that extended across the entire bottom shelf of the refrigerator. [...]

Inspectors wroteBased on interview and record review, the facility's nursing staff failed to maintain the dignity of one sampled resident (Resident 1) when Resident 1 arrived to the dialysis center (a facility where patients undergo a procedure to remove toxins from the blood) wearing only briefs and a blanket. This failure had the potential to cause the resident embarrassment and had the potential to lower self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent and treat three of five residents (Residents 99, 11 and 12) who were identified as being at risk of pressure injuries (localized damage to the skin and underlying soft tissue, usually occurring over a bony prominence) when: 1a. Resident 99 was not turned and repositioned every two hours; 1b. Resident 99 had missing entries on his daily wound treatment log; and 2. Resident 11 had missing entries on her daily wound treatment log; and 3. Resident 12 had missing entries on her daily wound treatment log. These failures had the potential for additional or worsening skin injuries to occur. 1a. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food safety and sanitation practices were met in the kitchen according to standards of practice, when two green cutting boards with deep cuts and food stains were stored in the clean area. In addition, one red cutting board and one brown cutting board with deep cuts were also stored in the clean area, when reviewed for food sanitation. This failure exposed residents to contaminated food surfaces and unsanitary practices, which had the potential to place them at risk of developing foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer the correct amount of oxygen, according to the physician's order for one of two residents (Resident 99), reviewed for oxygen therapy. This failure had the potential for too much carbon dioxide to accumulate in the blood, affecting the body's blood pH, respiratory drive, and the blood cells affinity for oxygen.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the kitchen staff competently performed and carried out the functions of the Food and Nutrition Service department when [NAME] 1 could not properly demonstrate how to calibrate a food thermometer, when reviewed for competency. This failure had the potential for food contamination, resulting in food borne illnesses for all residents who consumed food from the kitchen.

Inspectors wroteBased on observation, interview, ad record review, the facility failed to accurately document antibiotic (drugs which treat infections) administration in one of two residents (Resident 88) clinical record, when reviewed for Antibiotic Therapy. This failure had the potential for Resident 88's clinical record to be incomplete and inaccurate.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents was free from unnecessary drugs when 1) Resident 1 did not have an appropriate diagnosis for a psychotropic medication. 2) An anti-anxiety medication was administered to Resident 1 past the 14 day limit without reassessment from the physician. These failures had the potential to harm Resident 1 when an unnecessary psychotropic medications was administered.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement infection control measure when three of nine Subacute resident rooms were reviewed. 1) A housekeeper was observed removing Personal Based onProtective Equipment (PPE-gown, gloves, masks) in the hallway outside of an Enhanced Barrier Precaution (EBP--a type of infection control strategy where PPE is worn when providing high-contact care to residents) resident room. 2) A visitor was in an Enhanced Barrier Precaution room providing care without wearing PPE. These failures had the potential to spread infection among staff and visitors.

Inspectors wroteBased on interview and record review, the facility failed to follow the physician plan of care related to weekly weights and notification of the physician when the vital signs (blood pressure, heart rate, respiratory rate, and temperature) were outside of the parameters set (a measurable limit), for one of three residents (Resident 1), reviewed for care plans. This failure had the potential for the physician to be uninformed of changes, which could have negative consequences on Resident 1's overall health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a care plan for one of three residents (Resident 1) reviewed for foley catheters. This failure placed Resident 1 at risk for complications related to the foley catheter, including infection.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to ensure a Minimum Data Set (MDS) assessment was accurate for 1 (Resident #93) of 5 residents reviewed for unnecessary medications. Specifically, the facility failed to ensure Resident #93's MDS reflected the resident's diagnosis of schizophrenia.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to ensure the accuracy of a Preadmission Screening and Resident Review (PASRR) Level I Screening for 1 (Resident #93) of 3 sampled residents reviewed for PASRR requirements. Specifically, the facility failed to ensure Resident #93's PASRR Level I Screening reflected the resident had diagnosed mental disorders, including depression, anxiety disorder, and schizophrenia.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to document and monitor the implementation of physician prescribed fluid restrictions for 1 (Resident #162) of 1 sampled resident reviewed for dialysis and with a prescribed fluid restriction. Specifically, Resident #162, who received renal dialysis, had a physician's order for a 1500 milliliter (mL) fluid restriction each day, and the facility failed to document and monitor the amount of fluids Resident #162 consumed.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to ensure 2 (Resident #54 and Resident #85) of 2 residents observed receiving medications via feeding tubes (gastrostomy or G-tube) received appropriate treatment and services to prevent feeding tube complications. Specifically, the facility failed to follow physician's orders to flush Resident #54 and Resident #85's G-tube between administration of medications.

Inspectors wroteBased on record review, interview, and document and policy review, the facility failed to ensure the attending physician documented adequate response to pharmacy monthly medication review irregularities for 1 (Resident #53) of 5 residents reviewed for unnecessary medications.

Inspectors wroteBased on record review, interviews, and facility policy review, the facility failed to ensure orders for as-needed (pro re nata, PRN) psychotropic medications were limited to 14 days and failed to document a rationale for continued use and the intended duration when the medication extended beyond 14 days for 2 (Resident #2 and Resident #53) of 6 sampled residents reviewed for psychotropic medications.

Inspectors wroteBased on interview and record review, the facility staff failed to communicate and collaborate with hospice (end of life care) staff about Resident 1's, recent fall, and increased level of pain, for one of three residents (Resident 1), reviewed for Falls. This failure resulted in inconsistent nursing services, which put Resident 1 at risk for diminished care and increased pain.