Community Subacute and Transitional Care Center

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure daily nurse staffing information contained all required information and was posted in a prominent readily accessible place to residents and visitors when:1. Daily nurse staffing information was posted behind nursing station 1 and nursing station 2, which was inaccessible to residents and visitors.2. Daily nurse staffing information did not include the actual hours worked by Registered Nurse (RN)s, Licensed Vocational Nurse (LVN)s, and Certified Nursing Assistant (CNA)s. This failure resulted in restricted public access to posted nurse staffing information for 99 out of 99 residents admitted within the facility which had the potential to result in residents not knowing how many total or actual direct care hours were provided. During an observation on 12/19/25 at 11:26 a.m. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to establish and maintain a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable (contagious) diseases and infections for four of ten sampled residents (residents 107,7, 39, and 42) when:1. A dignity bag was not correctly put on Resident 107's urine catheter bag and the urine catheter bag was touching the floor. This failure placed Resident 107 at risk to develop a Catheter-Associated Urinary Tract Infection (CAUTI -a serious infection occurring when germs enter the urinary system through a urinary catheter).2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain the dignity and privacy for one of 11 sampled residents (Resident 50) when Resident 50 was observed from the hallway of his room without any clothing on two occasions. This failure violated Resident 50's right to maintain his privacy.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one of nine sampled residents (Resident 5) received personal privacy and confidentiality of his personal and medical records when Licensed Vocational Nurse (LVN) 4 left Resident 5's Medication Administration Record (MAR) computer screen visible in the hallway while administering medications. This failure resulted in Resident 5's personal and medical records being visible to staff, residents and visitors, which could lead to unauthorized access to confidential personal and medical records. During an observation on 12/17/25 at 12:18 p.m. Medication Cart 3 (MC 3) was observed next to Resident 5's room with the drawers and computer screen facing out toward the facility hallway. Licensed Vocational Nurse (LVN) 4 was observed removing medication from MC 3. [...]

Inspectors wroteBased on interview, and record review the facility failed to ensure two out of 22 residents (Resident 38 and Resident 87) received a level II Pre-admission Screening and Resident Review (PASRR- evaluation for individuals suspected of having a Serious Mental Illness (SMI) or Intellectual/Developmental Disability (I/DD)/Related Condition (RC), triggered by a positive Level I screen, to determine if they need specialized services, ensuring placement in the least restrictive setting) evaluation by the designated entity to determine if SMI, ID/DD/RC conditions were present when: 1. Resident 38 had a PASRR level I screening result positive for SMI, and the facility did not ensure a PASRR level II screening was completed. 2. Resident 87 had a PASRR level I screening result positive for SMI, and the facility did not ensure a PASRR level II screening was completed. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents had a well-balanced diet that meets their daily nutritional and special dietary needs when the facility's approved therapeutic diet manual:1. Was not based on current standard of practice or nationally recognized diet for residents with diabetes when the facility had a Reduced Concentrated Sweets (RCS) diet order for nutrition care with diabetes for one sampled resident (Resident 107); and 2. Did not contain a small portion diet or menu for one sampled resident (Resident 29) when the physician's diet order was for a small portion diet. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to prepare, distribute and serve food in accordance with professional standards for food service safety when two of three kitchen staff (Dietary aid 1 and 2) did not have hair and facial hair fully restrained or covered during meal preparation and service. This failure had the potential to compromise food sanitation and resident safety. During an observation of lunch meal service on 12/16/25 at 12:35 pm, in the kitchen, Dietary Aid (DA)1 was wearing a baseball cap with longer hair in back and hair was not fully covered. DA 1 was not wearing hairnet. DA 1 was calling out trays, checking out meal tickets and meal trays with food, putting cold beverages on meal trays and placing meal trays into food carts. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety when: 1. The cook failed to follow the diet order for three of three residents (Residents 56, 69, and 88). 2. The facility failed to have an air gap (an unobstructed vertical space between the water outlet and the flood level of a fixture), under the food preparation sink. These failures had the potential to result in residents being exposed to contaminated food which could lead to food born illness for all residents who receive food prepared in the kitchen and had the potential for Resident 56, Resident 69 and Resident 88 to have weight gain or loss by diet orders not being followed.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were treated with dignity and respect for three of 11 sampled residents (Resident 37, Resident 43, Resident 69) when: 1. Registered Nurse (RN) 1 administered medication to Resident 37's and did not provide privacy. This failure resulted in Resident 37 not being provided with respect and dignity while taking her medication. 2. RN 1 checked Resident 69's blood pressure (B/P-measures the pressure of circulating blood against the walls of blood vessels [channels that carry blood throughout the body]) and did not provide privacy. This failure resulted in Resident 69 not being provided with respect and dignity while her B/P was checked. 3. Resident 43's privacy curtain was tied in a knot. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain medical records which were complete, and accurately documented in accordance with accepted professional standards and practices for three of seven sampled residents (Resident 6, Resident 55 and Resident 41) when Resident 6, Resident 41 and Resident 55's copy of Physician Orders for Life-Sustaining Treatment (POLST-a medical document which outlines a patient's preferences for end-of-life care) were incomplete and not readily available as part of Resident 6 and 55's current medical records. These failures had the potential risk for Resident 6, Resident 41 and 55's decision regarding their healthcare treatment options not being honored.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set assessment (MDS-assessment of physical and psychological functions and needs) accurately reflected resident's health and functional status for one of three sampled residents (Resident 6) when Resident 6's antipsychotic medication (used to treat severe mental disorder in which a person loses the ability to recognize reality or relate to others) use was inaccurately coded in the MDS assessment. This failure had the potential to result in Resident 6's care needs not met.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure drugs and biologicals were labeled in accordance with current accepted professional principles and facility policy and procedures for one of two medication carts in Transitional Unit when medication cart contained Resident 53's (Fluticasone Propionate brand name- used to relieve allergic and non-allergic nasal symptoms) 50 mcg (microgram-unit of measurement) was found to not have an open date and beyond use date (BUD-the last date you can safely use a medication). This failure had the potential for Resident 53's medication to be administered past the discard date which could result in loss of effectiveness of medication leading to poor management of Resident 53's condition.

Inspectors wroteBased on observation, interview and record review the facility failed provide one of 11 residents an accessible call system when Resident 43's call light (a device that is used by a resident to call staff for assistance) was out of reach and wrapped around the television arm behind the resident's bed. This failure resulted in Resident 43 being unable to call for assistance and had the potential to delay care during an emergency and cause adverse outcomes. Findings; During a review of Resident 43's admission Record (AR), dated 8/29/24, the AR indicated Resident 43 had been admitted on [DATE]. Resident 43's admitting diagnoses included: [...]