Corona Post Acute Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) drainage bag (connected to the urinary catheter to collect urine) were covered with dignity bag (a discreet cover or holder designed to conceal a Foley catheter drainage bag [which holds urine] and its connecting tube out of public view) for two of four residents reviewed with urinary catheters (Resident 2 and Resident 3). This failure had the potential to compromise the residents' dignity and privacy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure call lights were within reach for two out of four residents reviewed (Resident 2 and Resident 3). This failure had the potential to delay residents' ability to obtain assistance for care needs, increase the risk of falls, and result in unmet needs or injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection prevention practices were maintained when the urinary catheter drainage bag, (connected to the urinary catheter - a hollow tube inserted into the bladder to drain or collect urine), was observed touching the floor for one of four residents reviewed, (Resident 3). This failure had the potential to contaminate the urinary drainage system and increase the risk of contamination of the urinary drainage system, and the development of a catheter associated urinary tract infection (CAUTI - happens when germs (usually bacteria) enter the urinary tract through a medical catheter that is placed into the bladder).

Inspectors wroteBased on interview and record review, the facility failed to ensure, 13 of 15 residents reviewed for Advance Directive (AD - written statement of a person's wishes regarding medical treatment) (Residents 17, 20, 25, 10, 55, 6, 97, 110, 117, 119, 126, 155, and 159) the resident or their resident representative (RP) had been provided follow up information regarding the formulation of an AD and have an AD available for review in the medical record. These failures had the potential to result in the ADs for Residents (17, 20, 25, 10, 55, 6, 97, 110, 117, 119, 126, 155, and 159) not being readily accessible to staff and physicians, which could lead to the residents' wishes regarding medical treatment being unknown and ultimately not honored.

Inspectors wroteBased on interview and record review, the facility failed to ensure five of five sampled residents (Residents 2, 16, 45, 119, 159) were free from unnecessary psychotropic (drugs that affects brain activities associated with mental processes and behavior) medications when: 1. Resident 16 was administered quetiapine (an antipsychotic medication for bipolar disorder, depression, and schizophrenia) for diagnosis of schizophrenia without documentation to support the diagnosis per The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR, globally recognized standard classification system for diagnosing mental disorders by the American Psychiatric Association); and manufacturer specified monitoring were not done during use of quetiapine;2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure for five of 32 residents reviewed for quality of care (Residents 4, 19, 101, 178, and 180) when:1. For Resident 4, the intravenous (IV- specific location on the body where a small, flexible tube (catheter) is inserted into a vein to deliver medication) medications Meropenem (type of antibiotic) and Linezolid (type of antibiotic) were not documented as administered according to the physician orders. This failure had the potential to result in ineffective treatment of infection, worsening of the resident's condition, and development of antibiotic resistance; and2. For Resident 19, the IV medication Ceftriaxone (type of antibiotic) was not documented as administered according to the physician orders. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nutritional care and services were provided, for two of three residents reviewed for nutrition (Residents 117 and 101), when:1. a. The facility failed to follow its policy Oral Nutritional Supplement (ONS) Use for monitoring the effectiveness of nutrition interventions for Resident 117. This failure had the potential to result in delay in identifying and evaluating the necessity of an alternative nutrition approach.b. The facility failed to follow physician diet ordered providing Fortified diet for Resident 117 during lunch on April 7, 2026, and April 9, 2026. This failure resulted in Resident 117 did not get extra calories to help improve her weight and wounds. (Cross reference 803) c. The facility failed to ensure Resident 117's food preference was honored during lunch on April 9, 2026. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dietary staff were trained and competent to carry out the functions of the department safely and effectively when1. Food and Nutrition Specialist 1 did not know the right concentration of the Dish machine sanitizer. 2. Food and Nutrition Specialist 1 did not know the right location to check dish machine sanitizer.3. Several dietary staff did not follow manufacturer's guideline time length dipping the test strip into sanitizer (sanitizing solution used for sanitizing food contact surfaces) for testing the concentration of the sanitizer. This failure resulted in false reading of the concentration of sanitizer. Failure to have right concentration of sanitizer may result in ineffective sanitizer food contact surface which could cause foodborne illnesses.4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure1. The Fortified diet received melted margarine per Therapeutic Spreadsheets during lunch on 4/7/2026. (cross reference 692)2. The Food and Nutrition Department had recipes for alternate meals.3. One dietary staff used right scoop served pureed dessert during lunch on 4/7/2026.4. [NAME] 2 used right scoop served Mince and Moist meat during lunch on 4/7/2026. These failures had the potential to negatively impact on the residents' nutritional status and further compromising residents' medical status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to:1. Follow its policy titled Point of Service Food Temperature Guide to provide appetizing food at appropriate temperatures according to residents' preferences for five of 146 sampled residents (Resident 8, 10, 21, 84 and126). This failure placed residents at potential risk to decrease nutritional intake and affect the resident's nutrition status.2. Ensure that 11 of 11 residents receiving a pureed diet (a type of diet where all foods are blended until they are smooth, soft, and lump free) were provided foods that were prepared in a manner which preserved nutritional value. This failure placed residents receiving a pureed diet at risk for compromised nutritional status.1. On April 6, 2026, at 9:52 a.m., an interview was conducted with Resident 84 in her room. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure the appropriate food textures was provided when1. 11 out of 11 sampled Residents on pureed texture received grainy pureed beef and pureed bread during lunch on 4/7/2026.2. 13 out of 13 sample Residents on soft and bite sized received wrong texture for green bean and beef during lunch on 4/7/2026. These failure had the potential to place the residents at risk of choking.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents' food preference was honored for two of 146 sampled residents (Resident 10 and Resident 117) when1. Resident 10 had food preferences for double protein and dislikes included carrots on the meal ticket but Resident 10 did not receive double protein and received carrots during lunch service on April 6, 2026.2. Resident 117 had food preference as soup on the meal ticket but Resident 117 did not receive soup during lunch on April 9, 2026. (Cross reference 692)This failure had the potential to result in decreased food intake, and could result in unplanned weight loss, further compromising Resident 10 and 117's nutritional and medical status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure beverages were served in accordance with residents' meal tickets for four out of seven sampled residents (Resident 90, 102, 139, 146) during lunch service. This failure had the potential to result in decreased fluid intake, which may lead to dehydration and compromise residents' hydration and overall medical status.

Inspectors wroteBased on dietary observations, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen when:1. A food preparation sink in Prep area did not have an air gap (refers to a fixture that provides back-flow prevention.)2. Two dietary staff did not know cooling process for egg and tuna salad. 3. Ice machine in kitchen found brown grime buildup on ice maker.4. [NAME] splash spots found on the wall and ceiling in dishwashing area and food Prep area.5. Cooking pans did not air dried before stacked and stored.6. Four broken plastic containers and covers found in kitchen.7. Trash found on floor in several area in kitchen.8. Grease buildup on hood.9. Grime buildup found on several pieces of equipment.10. Several dietary staff had exposed facial hair during meal preparation.11. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to dispose of garbage and refuse properly when trash were found outside surrounding the compactor dumpster. This failure had the potential to attract pests and rodents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the proper maintenance of essential equipment when:1. One walk-in refrigerator was maintained in good working condition.2. Walk-in freezer was maintained in good working condition with ice condensation buildup.3. The dish machine wash temperature was not maintained per manufacturer guideline. These failures had the potential to cause food borne illnesses and poor quality of food served to a population of 146 of 150 residents who received food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program to ensure the facility remained free of pests when drain flies and a house fly were found in the kitchen. This failure had the potential to lead to food borne illnesses (illness caused by food contaminated with bacteria, viruses, parasites or toxins) for 146 out of 146 sample residents who eat food prepared in the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Interdisciplinary Team ( IDT- a collaborative group of healthcare professionals who work together to develop and implement a comprehensive care plan tailored to a resident's specific physical, mental, and psychosocial needs) determined that self-administration of medications was clinically appropriate and safe before allowing a resident to keep a prescribed Ciclesonide inhaler (inhaled medication used to prevent asthma [lung disease that cause airway inflammation] at the bedside for self-administration for one of one residents reviewed for self-administration of medications (Resident 177). This failure had the potential to result in medication mismanagement by the resident which could compromise asthma control and delay needed medical intervention.

Inspectors wroteBased on interview and record review, the facility failed to ensure the PASRR (Preadmission Screening and Resident Review - a federal requirement to determine whether or not an individual who has an active diagnosis of mental illness or intellectual disability meets the criteria for admission to a nursing facility and identify what specialized services an individual needs) was accurately updated when the resident's Level 1 screening was not corrected to reflect the resident's diagnoses of psychosis (symptom involving the distortion or loss of contact with reality) and anxiety (a strong feeling of worry, fear, or nervousness that is hard to control and can affect how you think, feel, and act in everyday life), for one of two residents reviewed for PASRR (Resident 145). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a comprehensive care plan (specific interventions to provide effective and person-centered care to meet the resident's needs) for one of five sampled residents (Resident 45) had adequate interventions in accordance with facility policy when Resident 45 was prescribed a psychotropic (drugs that affects brain activities associated with mental processes and behavior) medication. This failure had the potential to result in delays in treatment and care for Residents 45.

Inspectors wroteBased on observation, interview, and record review, the facility failed to revise the comprehensive care plan to reflect the resident's ongoing poor oral intake and ordered nutritional interventions, for one of six residents reviewed for nutrition (Resident 101). This failure had the potential to delay implementation of appropriate, person-centered interventions and placed the resident at risk for nutritional decline.

Inspectors wroteBased on observation and interview, the facility failed to ensure good oral hygiene for one of three residents reviewed for Activities of Daily Living (ADL) (Resident 180) when the resident was observed with poor oral hygiene. This failure had the potential to contribute to poor nutrition, infection, and unplanned weight loss for Resident 180.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the ordered side rail (a device used to assist with in-bed mobility) was evaluated, care planned, and installed for one of three residents reviewed for mobility needs (Resident 175). This failure had the potential to cause further decline in limited mobility and loss of independence for Resident 175, who required services, equipment, assistance to maintain or improve mobility with the maximum practicable independence.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure intravenous (IV - a small, flexible tube inserted into a vein to deliver medication) sites were maintained in accordance with professional standards of practice, including proper labeling (dating, timing, and identification) and ongoing monitoring for one of two residents reviewed for IV (Resident 19). Resident 19's IV site was unlabeled, and there was no monitoring for signs and symptoms of complications. These failures had the potential to place the resident at risk for catheter-related bloodstream infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure provision of pharmacy services met the needs of the residents when one IV (intravenous, into the vein) Medication Emergency Kit (E-kit; a sealed kit/box containing medications and supplies for immediate use during a medical emergency) was stored open and unsealed, medications were used without documentation on the E-kit logbook, and the E-kit was not replaced timely after being opened in accordance with facility policy. These failures resulted in the potential for emergency medications to be unavailable when needed, and the potential for not meeting the residents' therapeutic needs or worsening of their medical conditions.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported irregularities during the monthly medication regimen review (MRR) for two of five sampled residents (Residents 16 and 45) when: 1. Resident 16 was administered quetiapine (an antipsychotic medication for bipolar disorder, depression, and schizophrenia) without manufacturer's specified monitoring during use of quetiapine; and 2. Resident 45 was administered Xanax (or alprazolam, used to treat anxiety) without adequate documentation of behavioral monitoring and without adequate monitoring for signs and symptoms of adverse effects during use of Xanax. This failure had the potential for medications not being optimized for best possible health outcome, and increased risk for adverse effects for Resident 16 and 45.

Inspectors wroteBased on observation, interview, and record review, the facility had a medication error rate of 12% when three (3) medication errors occurred out of 25 opportunities during the medication administration for one out of three residents (Resident 179). The errors resulted in one medication given without a physician's order and two medications given not in accordance with manufacturer's instructions and had the potential for Resident 179 not receiving the full therapeutic effects of medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper medication storage and labeling of medications in one of three medication carts inspected and one of two medication rooms inspected when:1a. Medication cart D in South Station contained one (1) expired medication vial; and1b. Medication room in South Station contained one (1) refrigerated medication vial opened without an open date label. The deficient practices had the potential for residents to receive unsafe and ineffective medications (reduced potency) from being used past their discard (expiration) date and not being removed from active stock.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its infection prevention and control program to ensure that linens and environmental surfaces such as shower and privacy curtains, were maintained clean and free of visible soil. These failures had the potential to result in cross-contamination and spread of infection among residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure the accuracy of the medical records for one of four sampled residents (Resident 1) when Resident 1's care plan (a personalized guide to support the individual healthcare needs of a resident) inaccurately listed neurogenic bladder (occurs when the nerves that control the bladder are damaged causing problems with storing or emptying urine) as a diagnosis related to the use of a Foley catheter (a flexible tube used to continuously drain urine). This failure resulted in an inaccurate care plan and had the potential to affect clinical decision-making, lead to inappropriate interventions, and compromise the resident's care and safety.

Inspectors wroteBased on interview and record review, the facility failed to provide timely access to medical records for one of one sampled resident (Resident A). This failure had the potential to delay Resident A's ability to obtain personal health information needed for continuity of care after discharge.

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician documented the clinical rationale for the discharge for one of three sampled residents (Resident 1). This failure had the potential to result in an inappropriate discharge without medical justification, compromising the resident's health, safety, and continuity of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were implemented for two of three sampled residents (Residents 1 and 2) when Licensed Vocational Nurses (LVN 1 and 2) did not wear personal protective equipment (PPE- equipment, such as gloves and gown, used to protect against infection or illness) while administering medications via G-tube (a feeding tube inserted through the abdominal wall directly into the stomach) to residents on Enhanced Barrier Protection (EBP-an infection control intervention to reduce transmission of multidrug-resistant organisms [MDRO- bacteria that have become resistant to multiple antibiotics). This failure had the potential to expose vulnerable residents to cross-contamination and increase the risk of developing infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an environment free of accident hazards was provided for one of three sampled residents (Resident 1) when Resident 1 was served a hot beverage by a Certified Nursing Assistant (CNA 1) without checking the safe serving temperature on April 10. 2025. This failure resulted in the hot beverage spilling on Resident 1 causing burn injuries, second degree burn [partial thickness burn - affects both the outer layer and part of the underlying layer of the skin] to third degree burn [most severe type of burn that damages all layers of the skin] on her right breast and shoulder that required medical intervention.

Inspectors wroteBased on observation, interview, and record review, for three of three sampled residents (Residents 1, 4, and 6), the facility failed to ensure appropriate assessment, monitoring, and a follow-up evaluation of skin conditions and injuries were conducted when: 1. For Resident 1, the treatment for a burn injury was not initiated or monitored upon return from the hospital on April 10, 2025. In addition, a follow-up appointment for evaluation of the burn injury was not arranged; 2. For Resident 4, a new skin injury (bruising [skin discoloration] to the left and right hands) identified by the Certified Nursing Assistant (CNA) on April 27, 2025, was not addressed or referred to the physician for appropriate care and treatment. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure telephone calls for the resident were answered by the facility staff for one of three residents reviewed (Resident A). This failure had the potential to to lead to physical and psychosocial distress for Resident A.

Inspectors wroteBased on interview and record review, the facility failed to ensure to ensure that Hydrocodone (a strong pain medicine) was reordered in a timely manner for one of three sampled residents (Resident A), resulting in the medication not available when needed. This failure had the potential for Resident A's pain to be uncontrolled and not following the physician-ordered pain management regimen.

Inspectors wroteBased on interview and record review, the facility failed to provide the resident's medical records within the required 48-hour time frame for one of four sampled residents (Resident 7). This failure had the potential to deny the resident representative access to review records and delay critical legal or medical decision making for the resident.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure pressure ulcer treatment was provided as ordered by the physician for 3 (Resident #57, #63, and #160) of 5 residents reviewed for pressure ulcers.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to provide equipment in good condition for 1 (Resident #125) of 5 residents reviewed for environmental hazards.

Inspectors wroteBased on the interview, record review, and facility policy review, the facility failed to ensure 1 (Resident #72) of 4 residents reviewed for Preadmission Screening and Resident Review (PASRR) was referred for a Level II screening. Specifically, Resident #72 was admitted to the facility with a negative Level I screening; however, the resident had a diagnosis of bipolar disorder, a serious mental illness (SMI). The facility failed to identify the SMI and subsequently failed to refer the resident for a Level II PASRR screening.

Inspectors wroteBased on observation, interview, record review, facility document review, and facility policy review, the facility failed to provide residents with activities of daily living that included fingernail care for 1 (Resident #69) of 3 residents reviewed for activities of daily living.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to provide respiratory breathing treatments as ordered by the physician for 1 (Resident #15) of 2 residents reviewed for respiratory services.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure staff performed hand hygiene and glove changes during wound and peri-care for 2 (Resident #57 and Resident #63) of 5 residents reviewed for pressure ulcers.

Inspectors wroteBased on interview and record review, the facility failed to reassess the vital signs, including blood pressure, for one of three sampled residents (Resident 1). This failure had the potential to delay the staff from acting promptly if the blood pressure remained persistently low which could lead to complications such as confusion, fainting, and organ damage.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement infection control practices when disposable equipment, including a stethoscope (a medical instrument) and sphygmomanometer (blood pressure machine), was not readily available for one of one sampled resident (Resident 1) with Clostridium Difficile (C. diff - a highly contagious bacteria). This failure increased the risk of spreading infection to other residents and staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide assistance with meals for one of four residents, (Resident 1). This failure had the potential to negatively affect Resident 1 ' s psychosocial wellbeing.

Inspectors wroteBased on interview and record review, the facility failed to provide requested medical records for four of four residents, within 48 hours in accordance with the facility policy and procedure. This failure could led to missed opportunity for potential claims and other legal consequences for the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light was within reach for one of the three sampled residents (Resident 3). This failure has the potential to result in unmet needs.

Inspectors wroteBased on interview, and record review, the facility failed to provide a safe and comfortable environment for one of three sampled residents (Resident 3), when pest treatment was conducted while the resident was inside the room. This failure has the potential for the resident to inhale pesticide vapor placing the resident at risk for an allergic reactions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 3) were repositioned at least every two hours, in accordance with the resident ' s written care plan. This failure had the potential to result in Resident 3 ' s pressure injury (the breakdown of skin integrity due to pressure) to worsen.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide clean and sanitary resident's room, when two of four resident's rooms (rooms [ROOM NUMBERS]) had trash, food, and dried blood on the floors. This failure had the potential to expose residents to germs and pests.

Inspectors wroteBased on interview and record review, the facility failed for one of three residents reviewed for discharges (Resident 1) to provide a written notice of transfer/discharge to the resident and or resident representative (RR). This failure had the potential in resident not being protected from inappropriate transfers or discharges.

Inspectors wroteBased on interview and record review, the facility failed to protect Resident 1's personal space when a staff (Certified Nursing Assistant [CNA1]) touched Resident 1 on the shoulder near her breast without her consent, making her uncomfortable. This failure resulted in the violation of Resident 1's right to respect and dignity, potentially causing psychosocial harm including low self-esteem, irritation, sadness, and anxiety.

Inspectors wroteBased on interviews and record reviews, the facility failed for one of three sampled residents (Resident A), to ensure Resident A's discharge plan to an assisted living facility (provides support with daily activities but does not offer extensive medical care) was re-evaluated and modified when the resident developed a Stage 4 pressure injury (bed sore with severe tissue damage with exposed bone, tendon [tissue that connects the muscle to the bone], and muscle). This failure resulted in Resident A being transferred to a lower level of care facility (designed for residents who did not require specialized medical attention) leading to the worsening of the Stage 4 pressure ulcer and requiring acute hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to properly manage and account for the personal belongings, of one of three sampled residents, Resident A. This failure had the potential to make Resident A feel disrespected and undignified due to lack of protection of her personal property.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services for activities of daily living (ADLs), for one of three sampled residents (Resident 1), when feeding assistance was not provided according to the physician's orders and plan of care. This failure had the potential to negatively affect the resident's physical well-being and lead to continued weight loss.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Monitor blood glucose (blood sugar) levels, as ordered by the physician for Residents 1, 2 and 3. This failure has the potential to result in complications due to delayed provision of treatment. 2. Monitor indwelling catheter (a tube inserted into the urinary tract to help decrease urinary retention) for signs and symptoms of Urinary Tract Infection (UTI), and provide catheter care, every shift, as ordered by the physician for Resident 2. This failure has the potential to result in infection. 3. Provide wound care treatments, as ordered by the physician for Residents 1 and 2. This failure has the potential to result in delayed healing or worsening of the pressure injury.

Inspectors wroteBased on interview and record review, the facility failed to provide accurate, and consistent assessments of Resident 1 ' s skin conditions. These failures had the potential to delay treatment for Resident 1 ' s skin conditions.

Inspectors wroteBased on interview and record review, the facility failed to accurately document the reporting and the physician ' s response to the laboratory (lab) abnormal result the abdominal wound culture & sensitivity ({C&S}- A test to determine the types of germs in a wound, and their sensitivity, to certain drugs for treatment) for Resident 4. This failure resulted in the resident's record not to reflect accurate communication between staff regarding treatment and services needed by Resident 4.

Inspectors wroteBased on observation, interview, and record review, the facility failed, for three of five sampled employees, to ensure infection control policy and procedures for Covid-19 (a highly infectious respiratory illness) were implemented when: 1. One Certified Nursing Assistant (CNA 1) did not perform hand hygiene upon exiting Covid-19 positive (residents infected with Covid-19) isolation rooms and entering a contact isolation room (room for resident who could spread a disease by contact). In addition, CNA 1 did not perform hand hygiene upon donning (putting on) and doffing (taking off) the isolation gown (protective apparel used by medical personnel to avoid exposure to blood, body fluids, and infectious droplets); and 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure for one of six residents reviewed (Resident 1) the resident's use of a foley catheter (a plastic flexible tube inserted into the bladder to collect urine) had a physician's order, was assessed and monitored by licensed staff, and a plan of care (POC) was developed. This failure had the potential for Resident 1 to develop catheter associated urinary tract infections, skin irritations from faulty equipment, and for Resident 1's use and need of the catheter to go unassessed.

Inspectors wroteBased on observation, interview, and record review, for one of three residents (Resident 1) with pressure ulcer (PU-injury to skin and underlying tissue resulting from prolonged pressure on the skin), the facility failed to ensure an informed consent for wound treatment was secured for Resident 1 on seven separate occasions on November 2, 9, 16, 23, 2022; and January 5, 12, and 19, 2023. The facility failure resulted to seven separate invasive debridement (removal of damage tissue from a wound) procedures performed on a dependent vulnerable resident. The resident ' s representative (RR) was bypassed and was not included in the decision-making to the discussion of risks and benefits of the procedure.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure bilateral floor mats were in place for one of four residents, (Resident 3), reviewed for fall, when only one floor mat was in place. This failure had the potential to result in injury if Resident 3 fell from her bed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dietary staff was able to safely and effectively carry out the functions of food and nutrition services when: 1. The dietary staff did not perform testing of sanitizing solution properly; 2. The dietary staff did not use the designated scoop for the ice; and 3. The dietary staff entered the kitchen without performing handwashing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide written information on advance directive (AD - a written instruction related to the provision of health care when the resident is no longer able to make decisions) for four of 10 residents reviewed for AD (Residents 39, 69, 110 and 122). This failure had the potential for the residents requests not be honored in the event of a medical emergency.

Inspectors wroteBased on observation, interview, and record review, the facility failed to conduct a self-administration assessment for one of 30 residents reviewed for self-administration of medication (Resident 501). This failure had the potential to result in an unsafe administration of medication for Resident 501.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call lights were within reach for two of five residents reviewed for environment (Residents 254 and 132). This failure had the potential to result in the residents to not be able to call for staff assistance when needed.

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician was notified when the resident had episodes of vomiting for one of one resident reviewed for notification of change of condition (Resident 146). This failure had the potential to result in the delay in treatment which could lead to worsening of the resident's condition.

Inspectors wroteBased on observation, interview, and record review, the facility did not provide a safe, homelike environment by not protecting personal belongings from loss for two of three residents reviewed for personal property (Residents 114 and 306).

Inspectors wroteBased on interview and record review, the facility failed to ensure notification of transfer/discharge was provided to the office of the state long-term care Ombudsman (a representative that helps families and residents by investigating and resolving complaints and serving as an advocate) for two of seven residents reviewed for hospitalizations (Resident 123 and 255). This failure increased the potential for the Ombudsman to not be aware or involved of facility practices and activities related to the resident's transfer and discharge.

Inspectors wroteBased on interview and record review, the facility failed to provide a written notice to the resident or Resident's Representative (RR) of the bed-hold policy (reserving a resident's bed while the resident is out of the facility for therapeutic leave or hospitalization) for one of seven residents reviewed for hospitalization (Resident 84). This failure had resulted in the resident (Resident 18) or the RR not knowing their right to hold the bed while out of the facility and the right to be readmitted back to the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet professional standards of nursing care for three of 30 residents reviewed for quality of care (Residents 39, 253, and 257) when: 1. Resident 253's IV (intravenous - administered through the vein) tubing for Cefepime (an antibiotic) was observed to be undated. In addition, Resident 253's IV tubing for Vancomycin (an antibiotic) was not changed as per physician order and was observed without an end cap (covering for the exposed end of the IV tubing). This failure had the potential to result in an IV catheter-related blood stream infections for Resident 253. 2. Resident 257's yankauer suction tip (oral suctioning tool to allow effective suction without damaging surrounding tissue) was observed used and undated. This failure has the potential for Resident 257 to develop respiratory infection. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure for two of 30 residents reviewed for quality of care (Residents 61 and 84), residents were provided treatment and care when: 1. For Resident 61, an assessment, monitoring were conducted and treatment was provided for resident's change in skin condition; and 2. For Resident 84, an assessment and treatment were conducted during the initial episode of choking. These failures had the potential for delayed services, treatment, and care resulting in deterioration in residents' medical condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident (Resident 34) received the necessary treatment and services consistent with professional standards of practice to prevent infection for one of four residents reviewed for pressure ulcer (bed sores), when the treatment nurse during dressing change did not perform hand washing. This failure had the potential to result in cross contamination affecting the healing process of resident's pressure ulcer.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide respiratory care and treatment in accordance with the facilities policy and procedures for one of one resident (Resident 76) reviewed for oxygen treatment. This failure had the potential to result in ineffective oxygen therapy, respiratory distress, and decline in the resident's health condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident reviewed for medically related social services (Resident 63) when Social Service Director (SSD) did not obtain cardiology consult for Resident 63. This failure had the potential to result in Resident 63 not to receive care and treatment for her heart condition.

Inspectors wroteBased on interview and record review, the facility failed to ensure the pharmacy recommendation was followed up with the physician for one of five residents reviewed for unnecessary medications (Resident 123). This failure had the potential for the resident to receive unnecessary medications.