Country Manor Healthcare

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignity including the right to be free from physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the resident's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) for three of three sampled residents (Resident 29, 9, and 77) reviewed for physical restraints by failing to: 1. Ensure Residents 29 and 9 did not have wedge pillows (firm, triangular-shaped foam cushion used to elevate parts of the body) tucked under the residents' fitted sheets on the right and left side of the body while in bed. 2. Ensure Resident 77's restraint bilateral wedges tucked under the sheets had a/an: a. Physician's order b. [...]

Inspectors wroteBased on observation, interview, and record review, the facility's licensed nursing staff failed to provide care in accordance with professional standards of care to: 1. One of one sampled resident (Resident 4) reviewed for insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) use by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (sq, beneath the skin) insulin administration sites. The deficient practice had the potential for adverse effect (unwanted, unintended result) of the same site subcutaneous administration of insulin such as excessive bruising, lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin). 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free of any significant medication errors (means the observed or identified preparation or administration of medications or biologicals which are not in accordance with the prescriber's order, manufacturer's specifications, and accepted professional standards) for one of one sampled resident (Resident 4) reviewed for insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) use by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (sq, beneath the skin) insulin administration sites. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to follow the menu and did not meet nutritional needs of 15 of 85 residents on pureed texture diets (diet with pudding like consistency foods used for individuals with difficulty chewing or swallowing) when Cook1 did not follow the recipe for the amount of thickening powder when preparing the pureed vegetables to be served for lunch service as observed on 2/10/2026. This failure had the potential to result in difficulty in eating, chewing, and swallowing to the residents and decreased food and nutrient intake resulting to unintended (not done on purpose) weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen by: 1. Failing to ensure seven (7) clear food storage bins were stacked wet in the storage area next to the dishwashing area. 2. Failing to ensure a container of grated white cheese labeled parmesan cheese was found inside Refrigerator two (2) with a lid was tightly sealed inside Refrigerator 2. 3. Failing to discard two (2) tomatoes with black spots and two (2) tomatoes with white fluffy material inside a clear vegetable bin. 4. Failing to discard one (1) head of lettuce with brown discoloration on the leaves and bottom part inside a vegetable bin. 5. Failing to discard a tub of unopened beef bouillon seasoning with a received date of 9/17/2025 and an expiration of 2/5/2026 and remained in the dry storage room. 6. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure necessary care was provided consistently for one (1) of two (2) sampled residents (Resident 9) reviewed for hospice services (a program designed to provide a caring environment for meeting the physical and emotional needs of the terminally ill) by: 1. Failing to ensure Hospice Aid (HA) visited Resident 9 two (2) times per week as indicated in the Team Care Plan and calendar of visits. 2. Failing to ensure the HA provided visitation notes to the facility from 12/26/2025 to 2/9/2026. These deficient practices had the potential to negatively affect Resident 9's physical comfort and psychosocial well-being resulting in the delay or lack of necessary hospice care and services.

Inspectors wroteBased on interview and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases (an infectious illness caused by germs that can spread from person to person, or from animals to humans), and infections by failing to: 1. Ensure the Certified Nursing Assistants (CNAs) wore a gown while providing direct care to Resident 44, who was on an enhanced barrier precaution (EBP, infection control measures in nursing homes requiring staff to wear gowns and gloves during high-contact care (e.g., bathing, dressing, changing linens) to prevent the spread of germs, specifically antibiotic-resistant bacteria. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep the call light (an alerting device for nurses or other nursing personnel to assist a patient when in need) within reach of one of two sampled residents (Resident 26) reviewed under environment task. The deficient practice had the potential to prevent residents from summoning health care worker for help when needed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to honor the resident's right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and support for daily living safely for one of two sampled residents (Resident 77) reviewed under environment facility task by failing to ensure there were no signs of wear and tear on the resident's floor mat (a cushioned floor pad designed to help prevent injury should a person fall), as evidenced by cracks and holes on Resident 77`s left floor mat. The deficient practice had violated the resident's right to a safe, clean, comfortable, and homelike environment.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive care plan (CP - a plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs) for one of one sampled resident (Resident 37) reviewed for antibiotic (a type of medication used to treat infection) use by failing to develop and implement a CP addressing Resident 37`s use of micafungin (medication used to treat fungal infections) and isavuconazonium sulfate (Cresemba-medication used to treat fungal infections). This deficient practice had the potential to result in delays in the delivery of necessary care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care consistent with professional standards of practice to prevent pressure ulcer/injury (ulcers that happen on areas of the skin that are under pressure from lying in bed, sitting in a wheelchair, or wearing a cast for a long period) for one of one sampled resident (Resident 3) reviewed for pressure ulcers by failing to set the low air loss mattress (LALM, a special type of air mattress that uses a constant, gentle flow of air through microscopic holes to keep the skin dry and prevent pressure wounds) according to the resident's weight. The deficient practice had the potential for development and worsening of pressure ulcers/injuries to residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 22) received appropriate services to prevent a decline (to become lower in amount or less in number) in range of motion (ROM - full movement potential of a joint) by failing to provide a safe and appropriate Restorative Nursing Aide program (RNA - nursing aide program that help residents to maintain their function and joint mobility) for active assistive range of motion exercises (AAROM - use of muscles surrounding the joint to perform the exercise but requires some help from a person or equipment) to Resident 22's left lower extremity (part of the body that includes the hip, knee, ankle, and foot) in accordance with the physician's order and care plan. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment was free of accident hazards for two of five (5) sampled residents (Residents 26 and 77) reviewed for accidents by failing to ensure: 1. Resident 26's call light (a button, cord, or device in a hospital room or nursing home that allows a patient to alert nurses or caregivers to need assistance) was within reach and there were no banana peels on the floor in Resident 26`s room. 2. Resident 77 did not have furniture or equipment on top of the floor mat (a cushioned floor pad designed to help prevent injury should a person fall). The deficient practices increased the risk of accidents such as slips, trips, and falls with injuries for the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received appropriate treatment and services to prevent urinary tract infections (UTI, an infection in the bladder/urinary tract) for one sampled resident (Resident 5) reviewed for UTIs by failing to ensure Resident 5 did not use a urinal labeled for Resident 42, a discharged resident. This deficient practice had the potential to result in UTIs in Resident 5.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of residents by failing to ensure licensed nurses (LN) completed documentation indicating reconciliation (a system of recordkeeping that ensures an accurate inventory of medications that have been received, dispensed, administered, and wasted) of controlled medications (medication considered to have a strong potential for abuse and may also lead to physical or psychological dependence) at every change of shift on the Narcotic Check Sheet form in one of two medication carts (Station 1 Medication Cart) observed during the Medication Storage and Labeling task. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe provision of pharmaceutical services (the procuring, manufacturing, compounding, dispensing, distributing, storing and administering of drugs, biologicals and chemicals) by failing to: 1. Ensure the medication disposition record contained the signature of witnesses when Eliquis (apixaban - an anticoagulant [blood thinner]) medication for Resident 24 was disposed and destroyed reviewed during medication storage task in one of one medication room (Med room [ROOM NUMBER]). This deficient practice had the potential to result in medication diversion (illegal transfer of prescription drugs) and unauthorized use. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement its policy for antibiotic (medication used to treat infection) stewardship (efforts in long-term care facilities to ensure that antibiotics are used only when necessary and appropriate [means prescribing the right drug at the right dose at the right time for the right duration]) program for one of one sampled resident (Resident 37) reviewed for antibiotic use by failing to monitor Resident 37's adverse effects (undesired or harmful effects) of isavuconazonium sulfate (also known as Cresemba - an antifungal medication used to treat fungal infection) and micafungin (an antifungal medication) while receiving the medication. This deficient practice had the potential for Resident 37 to experience unmonitored adverse reactions.

Inspectors wroteBased on interview and record review, the facility failed to report an incident of a physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) for one of three sampled residents (Resident 1). This deficient practice had the potential to result in unidentified abuse in the facility and failure to protect Resident 1 from further abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Attending Physician (AP) visited one of three sampled residents (Resident 1) timely. This deficient practice had the potential to result in an undetected decline in medical, health or psychosocial condition and can lead to a delay in necessary care, treatment and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure therapeutic diets (a customized meal plan designed by a healthcare professional to treat a specific medical condition) were served as prescribed by the physician for one of three sampled residents (Resident 2). This deficient practice can prevent Resident 2 from receiving the benefit of the therapeutic diet.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care in a manner that maintained a resident's dignity for two of two sampled residents (Resident 3 and Resident 52) investigated under the dignity care area and for one of two sampled residents (Resident 94) investigated under the urinary catheter (also known as an indwelling catheter, a hollow tube inserted into the bladder to drain or collect urine) care area when: 1. Certified Nursing Assistant 6 (CNA 6) failed to sit at eye level with Resident 3 while assisting the resident with feeding. 2. Activities Assistant 1 (AA 1) failed to sit at eye level with Resident 52 while assisting the resident with hydration. 3. Treatment Nurse 1 (TN 1) and CNA 2 did not refer to an incontinence brief as a diaper while providing care to Resident 94. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents were treated with respect and dignity including the right to be free from physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the resident's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) for one (1) out of 1 sampled resident (Resident 60) investigated during a review of physical restraints care area by failing to obtain a physician's order, informed consent from the resident and/or resident representative, and complete a restraint assessment prior to use of the pommel cushion (a cushion for wheelchair designed to maintain proper hip and leg alignment, reduce the risk of inward movement of the legs, and prevent the patient from sliding forward in the seat). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for three (3) sampled residents (Residents 60, 17, and 57) investigated under the accidents care area and one (1) out of two (2) sampled residents (Resident 3) investigated under the respiratory care area: 1. By failing to develop a care plan addressing the use of pommel cushion (a cushion for wheelchair designed to maintain proper hip and leg alignment, reduce the risk of inward movement of the legs, and prevent the patient from sliding forward in the seat) for Resident 60. 2. By failing to develop a care plan addressing the use of floor mat (a cushioned floor pad designed to help prevent injury should a person fall) for Resident 17. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide care in accordance with professional standards for four (4) of five (5) sampled residents (Resident 14, 37, 56 and 60) investigated for insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) use by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous ([SQ] -beneath the skin) insulin administration sites. The deficient practice increased the risk that Residents 14, 37, 56 and 60 could experience adverse effects (unwanted, unintended result) from same site subcutaneous administration of insulin such as lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin).

Inspectors wroteBased on interview and record review, the facility failed to implement their policy and procedure on cardiopulmonary resuscitation (CPR, an emergency procedure used to restart a person's heartbeat and breathing after one or both have stopped) by failing to maintain American Red Cross (an organization led by volunteers that provide relief to victims of disasters and help people prevent, prepare for and respond to emergencies) or American Heart Association (AHA, a non-profit organization that aims to reduce disability and death from cardiovascular diseases and stroke) CPR certification for three (3) of five (5) sampled employees (Activity Assistant 1 [AA1], Certified Nursing Assistant 3 [CNA 3], CNA 4) during a review of employee files under Sufficient and Competent Nurse Staffing care area. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment was free of accident hazards for two of four sampled residents (Residents 17 and 57) investigated under accidents by: 1. Failing to ensure Resident 17's floor mat (a cushioned floor pad designed to help prevent injury should a person fall) did not have the wheelchair and overbed table on top of it. 2. Failing to ensure Resident 17's floor mat was placed properly as indicated in the application instructions. 3. Failing to ensure Resident 57's floor mat did not have a medical equipment on top of it observed multiple times. These deficient practices increased the risk of Resident 17 and Resident 57 incurring an injury such as falls with fracture (a break or crack in a bone) and even death.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free of any significant medication errors (means the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order, manufacturer's specifications, and accepted professional standards) for four (4) of five (5) sampled residents (Resident 14, 37, 56 and 60) investigated for insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) use by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous ([SQ] -beneath the skin) insulin administration sites. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the menu and did not meet the nutritional needs of 17 of 96 residents on puree texture diets (diet with pudding-like consistency foods used for individuals with difficulty chewing or swallowing) when: a. Polenta (a grainy dish made from boiled cornmeal) was watery and could not hold its shape on the plate on 11/5/2024 for lunch. b. Puree carrots were runny and could not hold its shape on the plate on 11/6/2024 for lunch. This failure had the potential to result in difficulty in eating, chewing, and swallowing to the residents and decrease food and nutrient intake resulting to unintended (not done on purpose) weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare food by methods that conserved flavor and appearance when: a. The polenta (a grainy dish made from boiled cornmeal) was watery, runny, and touching other foods on the plate for Resident 10. b. Fresh green salad with dressing was served frozen and wilted for Resident 10. These failures had the potential to result in 95 of 96 facility residents getting food from the kitchen, including Resident 10 at risk of unplanned weight loss, a consequence of poor food intake.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices were followed in the kitchen when: a. Garbanzo (chickpea) salad and sherbert were not labeled with product names. b. Three eggs and hash brown (staff food) in a Styrofoam container was sitting on the countertop by the thawing spinach container. c. Staff walked around inside the walk-in refrigerator while drinking from an open coffee tumbler. d. Domes and pans were stacked wet. e. Ice machine internal parts had brown and black slimy dirt when wiped with paper towel. f. Internal parts of the mixer had dry food residues and buildup. g. Staff's cellphone was stored on top of the pot in the clean area. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to enforce its policy and procedures of storing food brought in by family or visitors in a way that it was either separate or easily distinguishable from facility food when there was no designated refrigerator space. This failure had the potential to result in a decrease food intake resulting to unintentional (without trying) weight loss, frustrations, and psychosocial harm to 95 of 96 facility residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections by failing to: 1. Ensure the indwelling catheter (a hollow tube inserted into the bladder to drain or collect urine) drainage bag was not touching the floor for one of five sampled residents (Resident 16) reviewed during the Infection Control task. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide education about the risks and benefits of, obtain consent or refusal for, and/or administer the 2023/2024 coronavirus disease 2019 vaccine (medication used to prevent complications from COVID-19 [a highly contagious viral infection that can trigger respiratory tract infection]) for three of five sampled residents (Resident 16, 57, and 91) reviewed during the Infection Control task by failing to: 1. Ensure informed consent was obtained prior to the administration of the 2024/2025 COVID-19 vaccine to Resident 16. 2. Offer and/or clarify with the physician the appropriateness for the administration of the 2024/2025 COVID-19 vaccine for Resident 57. 3. Ensure vaccine education was provided and documented per the facility policy and procedures prior to the administration of the 2024/2025 COVID-19 for Resident 91. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure services provided by the facility were provided by qualified persons in accordance with the resident's plan of care for one of two sampled residents (Resident 52) investigated under the dignity care area when Activities Assistant (AA) 1 provided hydration to Resident 52. This failure had the potential to result in Resident 52 aspirating (accidental breathing in of food or fluid into the lungs) during the intake of fluid provided by an unqualified staff member.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents receiving enteral feeding (also known as tube feeding, a method of supplying nutrients directly into the gastrointestinal tract) received appropriate care and services to prevent complications of enteral feeding for one of one sampled residents (Resident 90) investigated under the tube feeding care area when the facility failed to replace the tubing on the tube feeding set when replacing the resident's tube feeding formula and water flush bag. This failure had the potential for clogging and harboring bacteria which may result in infection, disrupted delivery of proper nutrition and hydration, and risk for aspiration (happens when food or liquid enters a person's airway by accident when food or liquids come back up from the stomach) if the formula flows improperly.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow professional standards of practice for respiratory care for one of two sampled residents (Resident 13) reviewed under the Respiratory care area by failing to ensure Resident 13 received continuous administration of oxygen as ordered when the resident's oxygen tank (supplemental oxygen) was observed empty. This deficient practice had the potential to place Resident 13 at risk for respiratory distress.

Inspectors wroteBased on observation, interview, and record review the facility failed to assess the medical need, evaluate the risks of entrapment (a state in which a person is trapped by the bed rail [also known as side rails, a type of safety device that can be attached to a bed frame to help prevent falls and provide support for getting in and out of bed] in a position that they cannot move from), and obtain a physician's order and informed consent from the resident or resident representative for one (1) out of 1 sampled resident (Resident 17) investigated under the Accidents care area. This deficient practice placed the resident at risk for potential accidents such as a body part being caught between the rails; falls if a resident attempts to climb over, around, between, or through the rails; restriction of resident's freedom of movement; decline in physical functioning; psychosocial harm; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Residents 22) was free from unnecessary medications by not: 1. Assessing Resident 22's pain level prior to administering Celebrex (a medication referred to as analgesic which is used to decrease pain) on 11/5/2024, 2. Administering Celebrex to Resident 22 daily for a documented pain level of zero (0) (by using a numerical scale used to measure pain with 0 being no pain and 10 being the worst pain) between 11/1/2024 and 11/5/2024, and 3. Following physician orders for non-pharmacological (also known as non-drug, that do not involve medications or drugs) interventions prior to the administration of Celebrex to Resident 22. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to store one insulin (medication used to regulate blood sugar levels) Humalog (rapid-acting insulin) vial (a glass bottle that contains the insulin) for Resident 49, in accordance with manufacturer's requirements in one (1) of two (2) inspected medication carts (Medication Cart 3). This deficient practice increased the risk that Residents 49 could have received insulin that had become ineffective or toxic due to improper storage or labeling, possibly leading to health complications resulting in hospitalization or death.

Inspectors wroteBased on interview and record review, the facility failed to maintain documentation of offering advance directive (a legal document indicating resident preference on end-of-life treatment decisions) information to the resident/resident representative and of reviewing the resident's advance directive annually for one of two sampled residents (Resident 86) per facility's policy and procedure (P&P). This failure had the potential to result in not knowing the resident's wishes regarding end-of-life care and life-sustaining treatments which may lead to unwanted or inappropriate medical interventions.

Inspectors wroteBased on interview and record review, the facility failed to obtain informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) prior to the administration of the pneumococcal vaccine (medication used to prevent pneumonia [serious lung infections caused by streptococcus pneumoniae, a type of bacteria]) and the 2024/2025 influenza vaccine (medication used to prevent a highly contagious respiratory illness, which spreads easily through the air or when people touch contaminated surfaces) for one of five sampled residents (Resident 16) reviewed during the Infection Control task. This deficient practice had the potential to result in adverse reactions (any unexpected or dangerous reaction) from the vaccines and the denial of the resident's right to refuse vaccines.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the physician was notified when one of three sampled residents (Resident 1) had a change in condition. This deficient practice had the potential for delayed medical interventions for Resident 1.

Inspectors wroteBased on observation, interview and record review, the facility failed to secure a resident's urinary indwelling catheter (a flexible plastic tube inserted into the bladder that helps provide continuous urinary drainage) with a securement device (strap free device which locks the catheter in place, stabilizes the catheter and eliminates any chance of sudden pull) for one of one sampled residents. This deficient practice had the potential to result in urinary catheter dislodgement (forcefully pulled out of a secure position) causing urethral (the tube through which urine leaves the body) tearing resulting to possible pain, bleeding, and infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who had three falls at the facility since admission and needed moderate assistance from staff (helper does less than half the effort; helper lifts, hold, or supports trunk or limbs and provides more than half the effort while walking between 10 to 50 feet) when walking, was free of accidents and injury. The facility failed to provide Resident 1 supervision and assistance in accordance with the assessment and plan of care. As a result, on 11/16/2023, Resident 1 sustained an acute fracture (sudden break of a bone) of the femoral component (generally made of metal, and curves around the end of the femur [thigh bone]) of the right total hip arthroplasty (damaged femoral head is removed and replaced with a metal stem that is placed into the hollow center of the femur).

Inspectors wroteBased on interview and record review, the facility failed to ensure an allegation of abuse was reported immediately, but no later than two hours after the allegation was made, to the State Survey Agency (SSA) for one of three sampled residents (Resident 1). On 11/16/2023 Resident 1 reported to Registered Nurse 1 (RN 1) that someone pushed him causing him to fall to the ground. The facility did not investigate and reported the allegation of abuse to the SSA. This deficient practice had the potential to result in harm to residents from uninvestigated allegations of abuse.

Inspectors wroteBased on observation, interview, and record, the facility failed to provide an environment that is restraint-free as indicated in the facility's policy for three (3) of 3 sampled residents (Residents 51, 53, and 55) investigated under the Restraint care area by: 1. Failing to ensure least restrictive measures were attempted prior to use of self-release belt alarm and sensor pad alarm in bed to ensure the alarms were used to treat medical symptoms and not for discipline or convenience, for Resident 51. 2. Failing to ensure least restrictive measures were attempted prior to use of self-release belt alarm and failing to ensure the informed consent was clarified with the physician for the use of self-release belt alarm, to ensure the self-release belt alarm was used to treat medical symptoms and not for discipline or convenience, for Resident 53. 3. [...]

Inspectors wroteBased on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan (a written or electronic record containing all the information the resident needs to effectively manage their own health) for three out of 31 sampled residents (Residents 80, 93, 34, and 20) by failing to ensure: 1. Resident 80 had a care plan addressing the use of an anticoagulant (Eliquis, a drug to treat and prevent dangerous blood clots). 2. Resident 93 had a care plan addressing the resident's discharge to home. 3. Resident 34 had a care plan addressing the use of an anticoagulant (Xarelto, anticoagulant [blood thinner medication] used to lower the risk of stroke [occurs when something blocks blood supply to part of the brain) 4. [...]

Inspectors wroteBased on interview and record review, the facility licensed nursing staff failed to provide care in accordance with professional standards to one out of twenty-four sampled residents (Residents 71) by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) insulin (a hormone that lowers the level of sugar in the blood) administration sites to Resident 71. This deficient practice had the potential to place the resident at increased risk of developing lipodystrophy (a group of conditions characterized by a complete or partial loss of fat tissue) and amyloidosis (when an abnormal protein called amyloid builds up in the tissues and organs).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received adequate supervision and implemented measures to prevent accidents for five of five sampled residents, by failing to: 1. Ensure smoking aprons were provided or offered to four of four sampled residents (Resident 7, 29 36, 55). This deficient practice had the potential for placing the residents at risk for sustaining injuries related to cigarette burns. 2. Ensure bilateral floor mats (high-impact foam and are designed to help prevent injury from potential falls) were provided for Resident 77 as ordered by the physician. This deficient practice had the potential to result in fall related injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one Nursing Aide (Nursing Aide 1 [NA 1]) was competent to provide indwelling catheter care (reduces the risk of complications such as infections) for one of one sampled resident (Resident 77), who had physician order for indwelling urinary catheter (a tube that is inserted into the bladder, allowing urine to drain freely). This deficient practice had the potential for residents to develop catheter associated urinary tract infection (CAUTI, an infection of the urinary tract caused by a tube [urinary catheter] that has been placed to drain urine from the bladder). Cross reference to F690 and F728.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow proper sanitation and food handling practices by: 1. Failing to store food in accordance with professional standards for food service safety by failing to discard: A. [NAME] cooking wine, which expired on 7/28/2022 and was observed in the dry storage room on 10/31/2023. B. [NAME] pie shell wrapped in plastic wrap, dated 9/9/2023, with no expiration date, which was observed in the dry storage room. C. Traditional Stuffing mix, with no expiration date, which was observed in the dry storage room on 10/31/2023. D. Thawing ground beef, dated 10/28/2023, which was observed in the refrigerator on 10/31/23. E. Ground beef, dated 10/28/2023, and ground chicken, dated 10/31/2023, thawing in the same pan, which were observed in the refrigerator on 10/31/2023. F. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Certified Nursing Assistant 5 (CNA 5) was not standing over a resident while feeding the resident for one (Resident 70) out of one sampled resident investigated for dignity. This deficient practice had the potential to affect the residents' sense of self-worth and self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light is within the resident's reach for two of two sampled residents (Resident 36 and Resident 50). This deficient practice had the potential for delaying care and services requested by the residents and placing the residents at risk for falls and injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a written notice of bed hold (holding or reserving a resident's bed while the resident is absent from the facility for therapeutic leave or hospitalization) policy and return for one out of five residents (Resident 70) investigated addressing the care area of hospitalization. Resident 70 was transferred from the facility to a general acute care hospital (GACH) on 10/30/2023. This deficient practice had the potential to deny Resident 70's timely return to the facility due to no available bed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care consistent with professional standards of practice to prevent pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) for one of one sampled resident (Resident 77) by failing to ensure Resident 77's bilateral heel protectors were placed on the resident's heels as ordered. This deficient practice had the potential for development and worsening of pressure ulcer/injuries to the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide catheter care (reduces the risk of complications such as infections) in a manner to prevent odors, and infection for one of one sampled resident (Resident 77) investigated under the urinary catheter (a tube that is inserted into the bladder, allowing urine to drain freely) or urinary tract infection (UTI, an infection that affects part of the urinary tract-kidneys, ureters, urinary bladder and the urethra) care area. This deficient practice had the potential for residents to develop catheter associated urinary tract infection (CAUTI, an infection of the urinary tract caused by a tube [urinary catheter] that has been placed to drain urine from the bladder). Cross reference to F726 and F728.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide respiratory care consistent with professional standards of practice to one of twenty-four sampled residents (Resident 41) by failing to ensure: 1. The nasal prongs of the nasal cannula (a lightweight tube which on one end splits into two prongs which are placed in the nostrils to provide supplemental oxygen to the body) were inserted on both nostrils of Resident 41. The deficient practice had the potential for Resident 41 not to get enough oxygen in the system causing shortness of breath leading to hypoxia (low levels of oxygen in the body). 2. The nasal cannula tubing was labeled with the date it was last changed. The deficient practice had the potential for Resident 41's nasal cannula tubing to grow bacteria that could cause respiratory infections.

Inspectors wroteBased on interview and record review, the facility failed to ensure Nurse Aide 1, who was employed as a Certified Nursing Assistant, had successfully completed the state's Certified Nursing Assistant (CNA) competency evaluation examination (a standardized assessment that measures the knowledge and skills of individuals seeking certification as a CNA). The facility failed to provide NA 1's CNA certificate number. This deficient practice had the potential to result in the residents receiving substandard care, leading to potential health risks and complications. Cross reference to F690 and F728.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled residents (Residents 81) reviewed for unnecessary medications was free from unnecessary psychotropic medications (medications capable of affecting the mind, emotions, and behavior) by failing to provide documented diagnosis for administering Olanzapine (antipsychotic medication, drug used to manage abnormal condition of the mind described as involved a loss of contact with reality) to Resident 81. This deficient practice had the potential to result in ineffective treatment and placed the resident at risk for receiving unnecessary psychotropic medication and adverse effects (unwanted effects that a medication may have) including sedation, fatigue, death typically occurred due to heart failure (a progressive heart disease that affects pumping action of the heart muscles), or sudden death.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain safe and proper temperatures for all medications for one of two medication room refrigerators (Med Ref 1) by: 1. Failing to ensure the medication refrigerator freezer did not have ice buildup. 2. Failing to ensure the refrigerator temperature was maintained between 36 Fahrenheit (F, a unit of measure) to 46 F. This deficient practice had the potential to result in degradation or alteration of the medications, rendering them ineffective or even potentially harmful. Cross reference to F908.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide food that accommodates resident preferences for one out of twenty-four sampled residents (Resident 36) by failing to ensure Resident 36's preferences were updated per facility's policy and procedure. The deficient practice had the potential for resident to have poor appetite that could potentially result in weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain one of two medication room refrigerators (Med Ref 1) in safe operating condition by: 1. Failing to ensure the medication refrigerator freezer did not have ice buildup. 2. Failing to ensure the refrigerator temperature was maintained between 36 Fahrenheit (F, a unit of measure) to 46 F. This deficient practice had the potential to result in degradation or alteration of the medications, rendering them ineffective or even potentially harmful. Cross reference to F761.