Cornerstone Care Center

Inspectors wroteBased on interview and record review, the facility failed to document the condition of one of two residents (Resident 2) upon discharge from the facility. This failure resulted in Resident 2's clinical record not containing details of his emergency discharge from the facility and events leading to why he was sent out by ambulance with police also being called to the facility. During a review of Resident 2's admission Record (AR), dated 1/21/26, the AR indicted Resident 2 was admitted to the facility on [DATE] and was discharged on 6/25/25. During a review of Resident 2's Progress Notes (PN), dated 6/25/26, the PN indicated, Resident was very aggressive to CNA [Certified Nursing Assistant] during care and hurt CNA wrist. DON [Director of Nursing] witness and called police. Resident was sent out approx. (approximately). 1030 am on gurney via emergency transportation. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a specialized mattress to two of four sampled residents (Resident 1, Resident 4) who required them, due to both residents having significant pressure injuries (a severe wound, involving full-thickness tissue loss where skin, fat, muscle, tendon, or bone is exposed, also known as a pressure ulcer) to their sacrum (tailbone area), and failed to include the intervention of using a specialized mattress in the care plan for Resident 1. These failures had the potential for delayed healing to the pressure injuries, and an increase in the risk of the pressure injuries worsening, including further tissue loss, pain, and infection, to the two residents. During a concurrent interview and record review on 12/30/25, at 11:30 a.m., with the Assistant Director of Nursing (ADON), Resident 1's clinical record was reviewed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare food in accordance with professional standards for food service safety when: 1. The food preparation sink's air gap (a vertical space between the end of a pipe and the top of a nearby sink that prevents the backflow of contaminated water) was not appropriate for use in a nursing facility. This failure had the potential for contaminated water to flow back into the sink and result in pathogenic (viruses, bacteria and other types of germs that can cause disease) microorganism (an organism that is so small it can only be viewed under a microscope) growth that could inadvertently (accidentally) be transferred to food and served to 93 residents in the facility, causing foodborne illness. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy and procedure, Garbage and Rubbish Disposal for three of three outside trash bins when the garbage was filled over the top of the bin not allowing the lids of the bins to be closed. This failure had the potential to attract animals, insects and pests which could lead to infestation (large number of pests), and the spread of disease.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate was less than five percent when the facility's medication error rate was 15.38 percent. There were 27 opportunities for errors and four medication errors occurred for three of ten sampled residents (Resident 80, Resident 146, and Resident 294) when: 1. Resident 80's blood glucose (simple sugar - the body's primary source of energy from food) was assessed after Resident 80 began eating lunch and not before meals, according to the prescriber order. 2. Resident 146's blood glucose was assessed after Resident 146 began eating lunch and not before meals, and medication Calphron (medication used to control phosphate levels to keep them from getting too high) was not administered with meals, according to the prescriber orders. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper storage and disposal of medication and biologics in accordance with facility policy and procedures when: 1. A partially used Lantus insulin pen (medication used to control high blood sugar) for Resident 17 was discarded in a container labeled, Medications to be destroyed in the medication room. This failure had the potential for a medication error, and increased risk of injury and contamination, by not following facility policy. 2. The red container, Medication to be destroyed, was observed to be overflowing with medication. This failure had the potential for unauthorized access to medications. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the planned menus were followed when: 1. Two of 10 sampled residents (Resident 50 and Resident 83) received portion sizes that were different from what was prescribed by their Medical Doctor on 4/27/25. This failure had the potential to result in Resident 50 and Resident 83 not meeting their physician's prescribed diet order and their nutritional needs not being met which can result in weight gain or weight loss. 2. Residents on a regular portion diet were served baked chicken portions during the lunch meal on 4/28/25 that were smaller than what was prescribed by their Medical Doctor. This failure had the potential for all residents on a regular portion diet to receive inadequate amounts of protein, potentially leading to weight loss and malnutrition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program to provide a safe and sanitary environment to help prevent infections for three of eight sampled residents (Resident 2, Resident 88 and Resident 145) when: 1. Licensed Vocational Nurses (LVN) 4 did not properly disinfect a glucometer (device used to measure blood sugar) used for multiple residents after providing care for Resident 2. This failure had the potential for the development and the spread of infection to all residents who had their blood sugars checked with the glucometer. 2. Staff did not follow enhanced barrier precaution procedures prior to providing care to Resident 88 and Resident 145. This failures had the potential for the development and the spread of infection to all residents and/or staff in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were treated with dignity and respect for one of nine sampled residents (Resident 88) when Resident 88's urinary catheter (flexible tube inserted into the bladder to drain urine) bag was not covered and was visible to residents and visitors This failure violated Resident 88's right to dignity and privacy and had the potential to lead to psychological harm.

Inspectors wroteBased on interview and record review, the facility failed to complete a Minimum Data Set (MDS-a computerized clinical assessment tool ) Significant Change in Status Assessment (SCSA-a comprehensive assessment that must be completed when the resident meets the significant change guidelines for either major improvement or decline) within 14 days, for one of five sampled residents (Resident 83) when a significant changed had occurred. This failure had the potential to delay identification and implementation of necessary interventions to address Resident 83's care and support needs.

Inspectors wroteBased on interview and record review, the facility failed to meet the required timelines for encoding and transmission of Minimum Data Set (MDS-evaluation of cognition, care needs and functional abilities) assessments for two of five sampled residents (Resident 44 and Resident 68) when the Minimum Data Set Nurse (MDSN) did not complete or transmit discharge MDS assessment for Resident 44 and Resident 68. This deficient practice resulted in the potential of resident's needs upon discharge going unmet.

Inspectors wroteBased on observation, 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 five sampled residents (Resident 57) when Resident 57's pressure ulcer (localized injury to the skin and underlying tissue caused by prolonged pressure) was inaccurately coded on the MDS assessment. This failure had the potential to result in Resident 57's care needs not being met and the potential for pressure ulcer to worsen

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services in accordance with accepted professional standards of quality of care for one of three sampled residents (Resident 147) when Licensed Vocational Nurse (LVN) 5 signed Resident 147's electronic Treatment Administration Record (eTAR-digital version of treatment administered to a resident) indicating Resident 147 was wearing compression stockings on 4/29/25. This failure had the potential for Resident 147 to not receive prescribed care which could result in more serious health conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs for three of seven sampled residents (Resident 30, Resident 70 and Resident 294) when: 1. Residents 30 and 294 did not receive appropriate monitoring for Vitamin D (a nutrient that the body needs for absorption of calcium). This failure had the potential risk for Resident 30 and Resident 294 to result in toxicity or ineffective dosing from a continued and unmonitored Vitamin D administration. 2. Resident 294 was administered Torsemide (a medication used to help treat fluid retention and swelling) and did not have a diagnosis for fluid retention or swelling, and was administered Sevelamer Carbonate (a medication used to control high blood phosphate levels). [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide food in accordance to resident preferences for one of six sampled resident (Resident 295) when Resident 295's preference to receive beverages other than milk was not followed. This failure caused resident 295 to be upset regarding the meal he had been provided and had the potential to cause Resident 295 to not receive the full nutritional benefit of his meal.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a comfortable and homelike environment for two of 16 sampled residents (Residents 15 and 78), when: 1. The wall in Resident 78's bedroom had deep scratches, exposing white chalky building material, and missing paint. This failure resulted in Resident 78 feeling unimportant, and not listened to. 2. The wall in Resident 15's bathroom had an approximate one inch (unit of measure), by one inch hole in the wall. This failure had the potential to affect Resident 15's mental state as well as creating a portal for pests to enter the bathroom.

Inspectors wroteBased on interview and record review, the facility failed to ensure their policy that only English is spoken in resident care areas when three out of six sampled residents (Resident 1, Resident 6, and Resident 7) stated they heard staff speak language(s) other than English to each other while in resident care areas. This failure had the potential to negatively impact the rights and dignity of the three affected residents by causing confusion and the residents being uninformed of their total health status, including their medical condition, in a language they can understand.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the facility was free of accident hazards when: 1. One door at the end of C-Wing hallway (door number one) exiting directly to the exterior of the facility had a working alarm, 2. Sliding door number two that led to an outdoor patio courtyard contained an unlocked gate which opened to the exterior of the facility and did not have a working alarm, and there was no system in place to monitor nine more sliding doors (door number three through 11) that led to the same outdoor patio. These failures had the potential for residents to exit the building via multiple (11) exits without staff knowledge and/or supervision, causing potential harm and injury to those residents.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure two electrical outlets were not overloaded when outlet adapters were used to increase the number of items that could be plugged into them, and when an extension cord was noted plugged into a power strip adapter. These failures violated the facility's policy on Electrical Safety and had the potential to compromise the facility's safety by overloading outlets, potentially causing electrical circuit overload and/or fire.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three shower rooms were clean when the D-Wing Shower room was noted to be unclean. This failure had the potential for residents needing a shower to do so in an area not clean and sanitary.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow professional standards of practice for 10 of 16 sampled residents (Residents 7, 8, 9, 10, 11, 12, 13, 14, 15 and 16) when: 1. Licensed Vocational Nurse 2 failed to administer medications and fingerstick blood sugar testing as prescribed before meals for Residents 7, 8, 9, 10, 11, 12, 13, 14 and 15 according to physician orders. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents receive assistive devices to maintain hearing abilities for one of 28 sampled resident (Resident 75) when Resident 75 who was extremely hard of hearing, was assessed for the use of hearing aid, and was not provided with hearing aid. This failure resulted in Resident 75 not having hearing aid to maintain hearing for communication with staff regarding care needs and treatment, and compromise Resident 75's quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that one of nine sampled residents (Resident 75) were free from unnecessary psychotropic (drugs that affect brain activities associated with mental processes and behavior) medications when: 1. The facility did not attempt or implement resident specific non pharmacological interventions (behavioral intervention not based on medicine) prior to prescribing and administration of alprazolam (an antianxiety medication), Resident 75 was administered alprazolam unnecessarily. 2. The facility did not provide documented clinical rationale for administrating and increasing the dosage of aripiprazole (an antipsychotic mild altering drug to treat mental illness) and quetiapine (antipsychotic medication), and Resident 75 was administered aripiprazole and quetiapine unnecessarily. 3. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to post the most recent survey results in a place readily accessible to residents and their representatives when the facility survey binder did contain the survey results for the year 2022. This failure had the potential to violate the rights of residents and their representatives to be informed of previous survey results.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to prepare food in accordance with professional standards for food service safety when the food preparation sink did not have an air gap (a vertical space between the end of a pipe and the top of a nearby sink that prevents the backflow of contaminated water). This failure had the potential for contaminated water to flow back into the sink and result in pathogenic (viruses, bacteria and other types of germs that can cause disease) microorganism (an organism that is so small it can only be viewed under a microscope) growth that could inadvertently (accidentally) be transferred to food and served to 93 residents in the facility, causing foodborne illness.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a clean and homelike environment was provided for five of 14 sampled residents (Residents 8, 44, 56, 85 and 96) when: 1. The ceiling in Resident 8, 44, and 56's room had a hole with water stains surrounding it and peeling cracked paint. 2. Resident 85's wall mounted light pull string was in dis-repair and Resident 85 was using a plastic bag to control the light. 3. One light bulb on Resident 96's wall mounted light was not working. These failures resulted in an environment that was not homelike for Residents 8, 44, 56, 85 and 96.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive care plan for six of 21 sampled residents (Residents 18, 40, 44, 22, 55, and 74) when: 1. Resident 18 did not have a care plan for the use of anticoagulant (medication used to prevent blood clot) medication. This failure placed Resident 18 at a potential risk for bleeding which could lead to serious health condition. 2. Resident 40 did not have a care plan for her non-compliance to use proper footwear when ambulating. This failure placed Resident 40 at a potential risk for accidents like falling which could lead to injury like fracture (bone break). 3. A floor mat was not placed on the floor next to Resident 44's bed as indicated in the care plan. This Failure had the potential to cause Resident 44 to be injured during a fall. 4. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide foot care and make necessary podiatry appointments for three of six sampled residents (Residents 6, 64 and 81) when Residents' 6, 64 and 81 had long and thick toenails. This failure placed Residents 6, 64 and 81 at a potential risk for painful, ingrown toenails and infections which could affect Residents 6, 64 and 81's mobility.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pharmaceutical services which ensured appropriate administration of medications to meet residents needs and have an adequate system for periodically reconciling controlled drugs (substances that have an accepted medical use and have a potential for abuse and may also lead to physical or psychological dependence), when: 1. The facility's injectable emergency kit (e-kit) did not have insulin medications available for emergency use for residents. 2. Residents 6 and 9's diclofenac (medication used to reduce pain and stiffness) gel 1% (concentration) were administered without the use of dosing stick provided by manufacturer. 3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all medications used in the facility were properly labeled and discarded after the expiration date or discontinued date when: 1. In the C wing IV (intravenous- into the vein) medication cart, three 0.9% Normal Saline (mixture of salt and water used to replenish fluid and electrolytes) 100 ml (milliliter- unit of measure) bags in opened manufacturer overwrap packaging were observed without a use by date labeling. 2. In the D wing medication cart, Resident 76's discontinued nystatin cream (medication used to treat fungal infection) 15 GM (gram- unit of measurement) was observed not separated from medications that were in use for facility residents. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program to provide a safe, sanitary, and comfortable environment to help prevent infections for 5 of 14 sampled residents (Residents 77, 78, 79, 59, and 95) when: 1. Residents 77, 78 and 79's toilet including toilet seat commode in room [ROOM NUMBER] was soiled and splattered with feces (stool). This failure had the potential to result in cross contamination (bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) and transmission of infection between residents. 2. Two bags of dirty linens were found on the floor in a resident room. This failure had the potential to result in cross contamination which could lead to more serious health condition. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were treated with dignity and respect for one of two sampled residents (Resident 52) when Resident 52's urinary catheter (flexible tube inserted into bladder to drain urine) bag was not covered and was visible to residents and visitors to see. This failure had the potential to violate Resident 52's privacy and dignity.

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 of one of five sampled residents (Resident 64) when Resident 64's anxiety (feeling of fear, dread, and uneasiness) diagnosis was not accurately coded on the MDS assessment. This failure had the potential to result in Resident 64's care needs not met.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure accurate documentation of a mental health diagnosis for 1 of 28 sampled residents (Resident 75) based on standards of practice when Resident 75's medical record was marked with schizoaffective disorder (a mental health disorder marked by a major mood episode and a break down between thought, emotion, and behavior) as a diagnosis for use of quetiapine (brand name used- an antipsychotic [mind altering] medication used to treat mental disease) and aripiprazole (brand name used, antipsychotic) with no prior history of such diagnosis. This failure resulted in Resident 75 being inappropriately administered aripiprazole and quetiapine, which resulted in adverse events including weight gain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to comprehensively assess the root cause of behavioral symptoms, develop and implement measurable goals and interventions to address the individualized care plan for 1 of 28 sampled resident (Resident 75), who was diagnosed with dementia (progressive decline in memory that affects the ability to perform everyday activities and interferes with daily functioning). This failure resulted in Resident 75 not receiving the appropriate treatment and services needed to meet his dementia care needs and achieve his highest level of functioning.

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs for one of seven sampled residents (Resident 56) when Resident 56 did not have the appropriate monitoring for the use of levetiracetam (medication used to treat seizure disorders). This failure had the potential for Resident 56's levetiracetam level to be elevated and for Resident 56 to be administered levetiracetam unnecessarily.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program for one of three sampled residents (Resident 85), when two cockroaches were found in the Resident 85's bathroom. This failure resulted in an ineffective pest control program with cockroaches found in Resident 85's bathroom.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their policies and procedures regarding the safe and appropriate prescribing and administering of antipsychotic (used to treat psychosis - conditions that affect the mind, where there had been some loss of contact with reality) medication for four of five residents (Residents 4, 21, 20 and 52) when antipsychotic medications were prescribed and administered prior to determining the appropriate indications for use. The facility did not develop and implement non-pharmacologic (without the use of medications) interventions prior to physicians prescribing the use of anti-psychotic medications. Mental health professionals (psychologists and/or psychiatric providers) were not consistently consulted to accurately diagnose resident mental health illnesses and prior to the use of anti-psychotics. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide pain management services consistent with professional standards of practice for one of five sampled residents (Resident 56) when Licensed Vocational Nurse (LVN) 1 did not assess Resident 56's complaints of pain and report of redness, swelling and warmth to left hip area which started in the morning (8 a.m.) of 2/4/22. This failure resulted in Resident 56 experiencing pain and suffering and not being sent out to the hospital for evaluation until the night (11 p.m.) of 2/4/22.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident rights to formulate an advance directive (legal document that allow one to spell out the decisions about end-of-life care ahead of time) was supported for seven of 19 sampled residents (Residents 6, 13, 44, 54, 61 and 183) when there were no POLST (Physician Orders for Life-Sustaining Treatment) form in the residents' clinical records. This failures placed Residents 6, 13, 44, 54, 61 and 183 at a potential risk for not having their wishes for end of life care upheld.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a person-centered comprehensive care plan for 12 of 24 sampled residents (Residents 185, 183, 184, 182, 5, 44, 54, 58, 29, 4, 20, 60) when: 1. There were no care plans for recreational activities for Residents 185, 183, 184, 182, 5, 44, 54, 58, 29. This failure resulted in Residents 185, 183, 184, 182, 5, 44, 54, 58, 29 not meeting their activity preferences and psychosocial needs. 2. There were no care plans for diagnoses of Anxiety (a mental health illness characterized by a sudden feeling of panic and fear, restlessness, and uneasiness) and Depressions (a persistent feeling of sadness and loss of interest); no non-pharmacological interventions care plan; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to revise and implement a person-centered comprehensive care plan for three of 10 sampled residents (Resident 14, 20, 45) when activity care plans were not updated to reflect the residents current goals and preferences. This failure had the potential for residents activity needs to go unmet.

Inspectors wroteBased on interview and record review, the facility failed to provide services which met professional standards of practice for three of 11 sampled residents (Residents 14, 29 and 52) when: 1. Resident 14's (hydrocodone/acetaminophen brand name [medication used to treat pain]) was administered on 12/3/21 for a pain level of 10/10 ( 1-3 mild pain, 4-6 moderate pain, 7-9 severe pain, 10 excruciating pain on a scale of zero to 10) and acetaminophen (medication used to treat pain) was administered on 1/15/22 for a pain level of 10/10 and Licensed Nurses (LN) did not call the MD (medical doctor) to advise per MD's orders and LN's did not reassess pain within an hour after administering pain medication. 2. [...]

Inspectors wroteBased on interview, and record review, the facility failed to implement its pharmaceutical policies and procedures for two of two controlled substance records reviewed (for Residents 44 and 20) when nursing staff did not ensure accurate controlled substance (medications which can be easily abused and under strict government control) accountability. This failure had the potential for diversion (used illegally) of controlled substance medications.

Inspectors wroteBased on interview, and record review, the facility failed to ensure irregularities in the drug regimen review and resident chart review were addressed for five of six sampled residents (Residents 4, 20, 21, 52 and 60) when: 1. There were no physician-documented resident clinical justification rationale for not conducting the required Gradual Dose Reduction (GDR- tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued) recommendation from the Consultant Pharmacist (CP) for Resident 21 and 52. 2. There was no baseline Abnormal Involuntary Movement Scale (AIMS- a side effect of antipsychotic medication) for Residents 4, 20, 21, 52 and 60 when antipsychotic medications were started. 3. Resident 52 did not have a documented monitoring for A1c (blood sugar measurement). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the facility medication error rate did not exceed five percent or greater when observation of 28 opportunities during the medication pass resulted in six errors. The calculated medication error rate was 19.23 percent. These failures resulted in: 1. Placing Resident 22 at risk for weight gain and increased blood pressure as a result of not taking Furosemide (used to treat in removing extra fluid in the body caused by conditions such as heart failure) and at risk for elevated magnesium blood levels as a result of not taking Magnesium Oxide (used to treat low blood levels of magnesium) at least two hours apart from other medicines. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to safely store, and label drugs and supplies in accordance with acceptable standards of practice when: 1. There were 28 expired intravenous (IV, given through a vein) medications were not removed from the medication room and were available for administration. This failure placed residents at a potential risk of being given expired IV medications which could compromise the health of residents. 2. One of two medication carts stored two expired medications (Docusate Sodium and Nystatin Powder) and were available for administration, and one medication (Nystatin Powder) was stored in the medication cart with no patient identifier. This failure placed residents at a potential risk of being given expired and unlabeled medications. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents rights to participate in resident groups was supported when Resident Council Meetings (meeting with residents designed to give the opportunity to voice any concerns or grievances about the facility) were not held once a month for two out of four months (December 2021 and January 2022). This failure had the potential for residents to not have an opportunity to voice their concerns and grievances to the facility that could lead to residents needs not being met.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide the necessary care and services based on the resident's needs and choices for activities of daily living (ADLs) for one of three sampled residents (Resident 45) when the facility did not assist Resident 45 to get out of bed daily. This failure placed Resident 45 at risk for her abilities in ADL to diminish.

Inspectors wroteBased on interview and record review, the facility failed to ensure dialysis (treatment for people whose kidneys are failing) assessment was completed for one of five sampled resident (Resident 185), when the facility did not perform a post dialysis assessment (contains vital signs and assessment of access site of dialysis catheter [used for connecting to a machine that filters blood during treatment]) on 2/4/22. This failure placed Resident 185 at a potential risk of dialysis complications (low blood pressure, fluid overload, blood clots, muscle cramps, access site infection, itchy skin) to go unnoticed which could lead to harm or death.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from unnecessary medications in their treatment plan for one of 10 sampled residents (Resident 22) when Resident 22 had no appropriate indication and monitoring for the use of magnesium oxide (medication supplement to maintain adequate magnesium in the body). This failure placed Resident 22's at risk of being administered magnesium oxide unnecessarily which could potentially lead to elevated blood magnesium level.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective infection control program when: 1. Resident 34 was not restricted to staying within the yellow zone (an area designated for suspected COVID-19 [Corona Virus- a contagious serious respiratory infection transmitted from person to person] positive residents). Resident 34 was observed seated at the facility main entrance next to Resident 36 in a green zone (residents without exposure, confirmed negative or recovered COVID 19). These failures had the potential to place residents at increased risk for transmission of COVID-19.