Country Oaks Care Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure to prevent accident for three of three sampled residents' (Resident 28, Resident 1, and Resident 9) by failing to maintain Resident 28, Resident 1 and Resident 9's beds at a low position at all times. Resident 28, Resident 1, and Resident 9 were assessed at risk for falls on admission. This failure could have potentially caused Resident 28 to fall on 5/1/2026 resulting in Resident 28's laceration (a cut, tear or rip somewhere on or in your body) above Resident 28's left eyebrow and could potentially result in Resident 28, Resident 1 and Resident 9 who had history of multiple falls to sustain another fall.a. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain safe and proper storage of food practices in accordance with the facility's policy and procedures (P&P) by failing to:1. Ensure one of one kitchen staff's (Cook [CK]) personal food item was not stored inside one of three freezers (Freezer 1) located in the facility's kitchen.2. Discard two-week old personal food items, brought to the facility from outside for one of one sampled resident (Resident 17), stored at Resident 17's bedside. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection (the invasion and growth of germs in the body) prevention and control practices by failing to label and properly store personal care items found in two of five sampled [NAME] & [NAME] restrooms ([a shared restroom situated between two bedrooms with direct access from both rooms], Restroom [ROOM NUMBER] and Restroom [ROOM NUMBER]). Restroom [ROOM NUMBER] was situated between Resident 50 and Resident 20's double-occupancy (two people sharing a single room) room and Resident 65 and Resident 6's double-occupancy room. Restroom [ROOM NUMBER] was situated between Resident 48 and Resident 45's double-occupancy room and Resident 40 and Resident 67's double-occupancy room. [...]

Inspectors wroteBased on observation and interview the facility failed to ensure three of 24 sampled residents (Resident 8, 23, and 84) had their call light within reach. This failure had the potential to affect the residents' ability to request assistance when needed. During a review of Resident 8's Face Sheet, the Face Sheet indicated the resident was admitted on [DATE], with the diagnosis that include sequelae of cerebral infarction (when a blood clot blocks blood flow to the brain), abnormalities of gait (natural pattern or style of walking), lack of coordination, retention of urine, contracture (permanent tightening or shortening of muscles, tendons, skin, or joint capsules ) of right elbow and right hand. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop or implement individualized person-centered care plans (CP) for two of two sampled residents (Resident 4 and Resident 26) when:a. For Resident 4, the facility failed to implement a CP addressing bipolar disorder (mental health condition that causes extreme mood swings).b. For Resident 26, the facility failed to create a CP addressing impaired hearing and the use of hearing aids. These deficient failures had the potential to result in unmet individualized needs for Resident 4 and Resident 26 and the potential to affect the resident's physical and psychosocial well-being.a. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure their process for over the counter (OTC) product self-administration (the process where patients manage and take their own medications) was followed, for one of one sampled resident (Resident 45) when on 5/5/2026 Resident 45 had a non-legend (drug that can be purchased OTC without a prescription) product at Resident 45's bedside without a self-administration assessment or a physician's order. This deficient practice had the potential to result in misuse and side effects (SE - an unwanted, unintended, or secondary effect that occurs in addition to the desired therapeutic effect of a drug) of the OTC product to Resident 45 and the potential for OTC product sharing with other residents (in general) by Resident 45.

Inspectors wroteBased on observations, interview and record review, the facility failed to ensure that two of eight sampled residents (Resident 1 and 72) with active skin breakdown were repositioned frequently in accordance with their individualized care plans. This failure had the potential to cause the residents' existing pressure injuries to worsen. During review of Resident 1's Face Sheet, the Face Sheet indicated the resident was admitted on [DATE], with the diagnoses that included metabolic encephalopathy (sudden change in brain function like confusion, severe drowsiness, or memory loss), abnormal posture, muscle weakness and bilateral osteoarthritis (cartilage cushioning the ends of bones wears down) of hip. During review of Resident 1's care plan, dated 1/14/2026, the care plan indicated Resident 1 is to be reposition every 2 hours and as needed. [...]

Inspectors wroteBased on observations, interview and record review, the facility failed to ensure that the Bed Rail Assessment (a safety check to determine if side rails are needed, if they are safe, and if they pose more risks than benefits) was completed for one of eight sampled residents (Resident 1) with bedrails in use. This failure had the potential to result in entrapment and/or injuries to the resident. During review of Resident 1's Face Sheet, the Face Sheet indicated the resident was admitted on [DATE], with the diagnoses that included metabolic encephalopathy (sudden change in brain function like confusion, severe drowsiness, or memory loss), abnormal posture, muscle weakness and bilateral osteoarthritis (cartilage cushioning the ends of bones wears down) of hip. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure complete and accurate medical records for one of three sampled residents (Resident 2) when:Resident 2's admission Record (AR) did not indicate the responsible party (RP-an individual chosen by the resident to act on behalf of the resident to support the resident in decision-making) or the RP's contact information. Resident 2's Consent for Treatment did not indicate the RP's last name or the date the consent was signed. These failures had the potential to result in the RP not being informed of the need for treatment or of a medical emergency involving Resident 2, leading to unmet medical needs or interrupted continuity of care to Resident 2.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents' (Resident 1's) medical record was complete and accurately documented when:1. Resident 1's Change in Condition Evaluation form (CICE- a standardized documentation form, used in healthcare to detect, document, and communicate changes in a resident's baseline condition), dated 3/5/2026 and timed at 9:35 PM, was completed and contained the most recent vital signs (measurements of the body's basic functions, such as heart rate, breathing rate, blood pressure, and temperature) of Resident 1.2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure six of six licensed nurses (Treatment Nurses [TN], 1, 2, 3, 4, 5 and 6) had assessments to demonstrate competency for the handling and management of Pleurx catheters (a small, soft tube that doctors put into the chest to help drain extra fluid that builds up around the lungs). This failure had the potential to result in compromised safety for the residents with Pleurx catheters and the potential to result in TNs 1, 2, 3, 4, 5, and 6 not to deliver high quality of care when handling Pleurx catheters due to lack of competency validation. Cross Reference: [...]

Inspectors wroteBased on interview and record review, the facility failed to develop a care plan (CP) upon admission for one of three sampled residents (Resident 1) who had a Pleurx catheter (a small, soft tube that doctors put into the chest to help drain extra fluid that builds up around the lungs). that addressed the presence of the device. This failure had the potential to result in unmet individualized needs for Resident 1 and the potential to affect Resident 1's physical well-being. Cross Reference: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) received treatment and services in accordance with professional standards of practice. The facility failed to obtain a physician's order prior to draining Resident 1's Pleurx catheter (a small, soft tube that doctors put into the chest to help drain extra fluid that builds up around the lungs) on 7/5/2025. This failure placed Resident 1 at risk for complications like hypotension (low blood pressure, complication from Pleurx drainage due to rapid fluid shifts), infection, respiratory complications, and fluid imbalance. Additionally, the failure had the potential to result in a physical decline to Resident 1. Cross Reference: [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain accurate medical records for one of four sampled residents (Resident 3), according to the facility's policy and procedure (P&P) titled, Documentation in Medical Record, by failing to: Ensure licensed nurses (LNs) documented the redness on and leaking from Resident 3's gastrostomy tube (G-tube- tube inserted through the belly that brings nutrition directly to the stomach) stoma (surgically created opening in the abdomen) in Resident 3's Progress Notes (PN) under Advanced Skilled Evaluation (PN ASE) between 2/17/2025 and 2/20/2025. This failure had the potential for Resident 3 to not receive the care and services needed to appropriately treat the redness and leaking from Resident 3's G-tube stoma, and for Resident 3 to develop further infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the facility ' s policy and procedure (P&P) titled, Safe Resident Handling/Transfers, by failing to ensure one of three sampled residents (Resident 1) had two staff members with Resident 1 when staff used a mechanical lift (a device used to assist in lifting and transferring individuals who have difficulty moving independently). This deficient practice had the potential to place Resident 1 ' s safety at risk.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policies and procedures (P&P) titled, Hand Hygiene (procedures that included the use of alcohol-based hand rubs (containing 60%-95% alcohol) and hand washing with soap and water), and Enhanced Barrier Precautions (EBP- set of infection control measures that use personal protective equipment [PPE- equipment worn to minimize exposure to hazards] to reduce the spread of multidrug-resistant organisms [MDRO- organism that is resistant to most antibiotics] by wearing a gown and gloves), for one of four sampled residents (Resident 3) by failing to: 1. Ensure Sitter 1 and Sitter 2 wore gloves while providing care to Resident 3. 2. Ensure Sitter 1 and Sitter 2 performed hand hygiene before donning gloves and providing care to Resident 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a clean, safe, sanitary, and homelike environment for the following: a. 1 of 1 kitchen affecting 31 of 64 residents, who received food from the kitchen. b. 2 resident rooms affecting 4 residents (Resident 54, Resident 14, Resident 43, and Resident 45) c. Bathroom [ROOM NUMBER] affecting 4 residents (Resident 16, Resident 34, Resident 166, and Resident 167). This practice had the potential for residents to be exposed to dirt, mold, rust and drywall dust, which can lead to a decline in the residents' health and result in irritation of the eyes, skin, nose, throat, and lungs. This deficient practice could result in prolonged exposure that could cause serious problems such as acute (sudden) respiratory illness, persistent coughing, and asthma (narrowed airways in the lungs that make it difficult to breath).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate gastrostomy tube (GT, a tube inserted into the stomach through a surgical incision used for feeding and administration of medications for a resident unable to swallow) treatment and services were provided for two of two sampled residents (Resident 40 and Resident 20), who were receiving enteral feedings (liquid nutrition, delivery of nutrients through a feeding tube directly into the stomach) when: A.On 3/5/2025, Resident 40's GT was observed disconnected from the GT feeding pump with enteral feeding spilling on the floor. B.On 3/3/2025, the facility failed to follow infection control precautions to minimize the risk of GT contamination, Resident 20's GT tip touched the floor. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Resident 52 and Resident 116) received care and services for the provision of peripheral IV (intravenous, the administration of substances, such as fluids, medications, or blood products, directly into the vein) site (a thin, flexible tube is inserted through the skin into a small vein in the periphery such as the hand, elbow, or foot and can remain in place for several days) in accordance to facility's policy and procedure (P&P), titled, Intravenous Therapy, when, A and B.On 3/3/2025, Resident 52 and Resident 116's IV sites were not labeled with a date and time, to indicate when the IV dressings were changed. These failures had the potential to result in IV complications and infections to Residents 52 and Resident 116 and the potential to affect the resident's well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate acquiring and dispensing of medications by failing to: A. Ensure accountability of the narcotic (medications that have compounds with paralyzing [causing a person or part of the body to become partly or wholly incapable of movement] or numbing properties) medications stored in one of two medication carts (Med Cart #2) between the off-going nurse and the on-coming nurse on 3/1/2025 for the morning (AM) and the evening (PM) shifts. B. Ensure, the correct dose of Polyvinyl Alcohol Ophthalmic Solution (eyedrops, medication used to relieve eye dryness an soreness, particularly where the dryness is caused by a reduced flow of tears) was administered as ordered by the physician for one of one sampled resident (Resident 50). [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to implement infection control practices to reduce and/or prevent the spread of infection when: A. One of two staff (Respiratory Therapist, RT) failed to properly wear an isolation (staying away/kept away from others) gown during tracheostomy care (procedure performed routinely to keep tracheostomy [surgical opening created through the neck into the windpipe to allow air to fill the lungs] and the surrounding area clean and reduce the induction of bacteria [living organism that can cause an infection] into the windpipe and lungs) for one of six sampled residents (Resident 6) who was under enhanced barrier precaution (EBP-infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDRO, bacteria that are resistant to three or more classes of antimicrobial drugs] that employs [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe and sanitary bathroom (Bathroom [ROOM NUMBER]) for 4 of 4 sampled residents (Resident 16, Resident 34, Resident 166 and Resident 167). This deficient practice had the potential for residents to be exposed to dirt, mold, rust and drywall dust, which can cause respiratory/breathing problems.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a call light was kept within reach for one of one sampled resident (Residents 55) in accordance with the facility's policy and procedure (P&P), titled, Call Lights: Accessibility and Timely Response. This failure had the potential for Resident 55 to receive delayed care and services necessary to meet the residents' needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure information regarding an Advance Directive (AD, a written preferences regarding treatment options, a process of communication between individuals and their healthcare agents to understand, reflect on, discuss, and plan for future healthcare decisions for a time when individuals are not able to make their own healthcare decisions) was provided to one of one sampled resident's (Resident 20) Responsible Party (RP) 1 in accordance with the facility's policy and procedure (P&P), titled, Residents' Rights Regarding Treatment and Advance Directives. This deficient practice had the potential to result in lack of knowledge regarding care and treatment decision making and in result in provision of medical treatment that was against RP 1's wishes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the assessment entries on the Minimum Data Set (MDS - a resident assessment tool) related to active diagnoses was accurately documented to reflect the resident's health status for one of two sampled residents (Resident 168). This deficient practice resulted in an inaccurate MDS assessment for Resident 168. Resident 168 received Aripiprazole (medication to treat psychosis [mental health condition characterized by a loss of touch with reality]) for 5 days for schizophrenia (a mental illness that is characterized by disturbances in thought, perception, emotions, and social interactions) with no documented diagnosis of schizophrenia.

Inspectors wroteBased on interviews and record review, the facility failed to develop a care plan (CP), for one of one sampled resident (Resident 52), that included management of intravenous (IV, the administration of substances, such as fluids, medications, or blood products, directly into the vein) therapy for Resident 52. This failure had the potential to result in unmet individualized needs for Resident 52 and the potential to affect the resident's physical well-being.

Inspectors wroteBased on interview and record review the facility failed provide supervision, consistent with the needs of one of one sampled resident (Resident 18), and implement interventions indicated in the facility's policy and procedure (P&P) titled, Fall Prevention Program. This deficient practice resulted in Resident 18 experiencing an unwitnessed fall on 2/27/2025 and had the potential to result in injury to Resident 18.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow appropriate infection control guidelines related to a urinary catheter bag lying on the floor for a resident with an indwelling urinary catheter for 1 of 2 sampled residents (Resident 167). This deficient practice had the potential to result in urinary tract infections for Resident 167.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled resident's (Resident 50) nasal cannula tubing (a medical device, a soft tubing, used to deliver supplemental oxygen, the tube's ends splits into two prongs) was place properly by placing both nasal prongs in the Resident 50's nostrils in accordance with the facility's policy and procedure (P&P), titled, Oxygen administration. This deficient practice placed Resident 50 at risk for shortness of breath and/or hypoxia (low levels of oxygen in the body tissues) and had the potential to result in a physical decline to Resident 50.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled staff (Certified Nurse Assistant 1 [CNA 1]) was competent with providing gastrostomy tube (GT, a tube inserted through the abdomen that delivers nutrition directly to the stomach) care for one of two sampled residents (Resident 20) in accordance with the facility's policy and procedure (P&P), titled Care and Treatment of Feeding Tube. This failure had the potential to place the residents with GTs, under the care of CNA 1, at risk for not having their needs met safely and in a manner that promoted each resident's physical well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure specific indication for the use of Ativan (medication used to treat anxiety [group of mental disorders characterized by feelings of anxiety [an unpleasant state of inner turmoil] and fear]) for one of five sampled residents (Resident 55) as indicated in the facility's policy and procedure (P&P), titled Use of Psychotropic [medications that affect the brain and nervous system, used to treat mental health conditions], Medications. This deficient practice had the potential to result in the use of unnecessary psychotropic drugs and result in an adverse drug event (injuries resulting from medication use including physical and mental harm, or loss of function) to Resident 55.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper food handling practices by one of three dietary staff observed during lunch tray line. This deficient practice had the potential for cross-contamination of food that could result in food borne illness (any illness resulting from eating contaminated/spoiled foods) for 31 of 64 residents who received food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 11 of 32 resident rooms (rooms 115, 116, 117, 118, 119, 120, 129, 130, 131, 132, 133) met the minimum requirement of 80 square feet (sq.ft. - unit of measure) per resident in bedrooms with more than one resident. This deficient practice had the potential to result in inadequate space for nursing care or resident care devices.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for one of three sampled residents (Resident 1) by failing to develop and implement interventions to address Resident 1's behavior of refusing to be changed after becoming soiled with urine. This failure had the potential for Resident 1 to contract a urinary tract infection (UTI, an infection in any part of the urinary system, including the kidneys, bladder, or urethra).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for one of three sampled residents (Resident 1) when a trash can liner was tied to the end of a pull cord which operated Resident 1's overhead light. This failure had the potential for Resident 1 to feel uncomfortable in her room.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect a resident's right to remain free from verbal (the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents) and physical abuse (willful infliction of injury, deliberate aggressive or violent behavior with the intention to cause harm) for one of three sampled residents (Resident 1), when Certified Nursing Assistant 1 (CNA 1) physically and verbally abused Resident 1 on 10/27/2024. This failure had the potential to result in bodily injury to Resident 1 and/or for Resident 1 to feel afraid and not safe while under the care of the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure abdominal X-ray (pictures of the inside of the abdomen) results were received timely for 2 of 3 sampled residents (Resident 1 and Resident 2). These failures resulted in Resident 1 and Resident 2 not receiving their gastrostomy tube (G-tube, a feeding tube inserted through the abdomen that brings nutrition directly to the stomach) feeding (liquid nutrition given through the G-tube) and medications for 3 days.

Inspectors wroteBased on interview and record review, the facility failed to ensure four of six sampled staff (Licensed Vocational Nurses [LVN] 1, 2, 3, and 4) received In-service training (a type of professional training or staff development that is given to staff while they are employed) before signing the facility's document titled, In-Service Form (signing the In-service Form indicated the staff received training). This failure had the potential for facility staff to not receive the required training while employed at the facility and had the potential to negatively affect residents' safety and the provision of care to the residents of the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of four sampled residents (Residents 8 and 9), who were incontinent of bladder, received appropriate treatment and services to prevent urinary tract infections (UTI, an infection in any part of the urinary system, including the kidneys, bladder, or urethra) according to the facility's policy and procedure (P&P) titled, Incontinence, dated 12/19/2022. The facility staff failed to check for incontinence and/or provide incontinent (lacking voluntary control over urination or defecation) care to Resident 8 and Resident 9 every two hours. This failure had the potential to result in Residents 8 and 9 to experience skin breakdown and/or placed Residents 8 and 9 at risk of experiencing a UTI. (Cross Reference F725)

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide sufficient staffing to ensure incontinence (cannot holding in urine or stool) care was provided for two of four sampled residents (Residents 8 and 9) in a timely manner. This failure had the potential to result in Residents 8 and 9 to experience skin breakdown and/or placed Residents 8 and 9 at risk of experiencing a urinary tract infection (UTI, an infection in any part of the urinary system, including the kidneys, bladder, or urethra). (Cross Reference F690)

Inspectors wroteBased on interview and record review, the facility failed to post actual worked nursing hours at the start of each shift for one of three days, according to the facility's policy and procedure (P&P) titled, Nurse Staffing Posting Information, dated August 2022. This failure had the potential to result in residents (in general) and/or visitors not knowing the facility's nurse staffing information.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure four of eight sampled residents (Residents 2, 4, 5, and 6) were free of risk from accidents using an assistive device based on the facility's Policy and Procedure (P&P) titled, Safe Resident Handling/Transfers, and the user manual for Battery Powered Patient Lift, by failing to: 1. Ensure Certified Nurse Assistants (CNAs) 5 and 7 used a Hoyer lift (mobile patient lift that helps caregivers safely transfer people from one surface to another) appropriately to transfer Resident 6 from the bed to geri-chair (large, padded chair designed to help the residents with limited mobility [ability to move]) on 8/12/2024. 2. Ensure CNA 4 used a Hoyer lift with the assistance of another staff member during the transfer of Residents 2, 4, and 5. [...]

Inspectors wroteBased on interview and record review the facility failed to conduct a reference check before hire, for one of three sampled staff (Certified Nursing Assistant [CNA] 1), in accordance with the facility's Policy and Procedure (P&P) titled, Abuse, Neglect and Exploitation, dated 5/31/2024 and CNA's, Pre-Employment Check List. This failure placed 70 residents residing at the facility at risk for abuse by CNA 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the facility's policies and procedures (P&P) titled, Infection Prevention and Control Program, Hand Hygiene, and Handling Soiled Linen, by failing to: 1. Ensure Housekeeping 1 (HK 1) wore gloves as a personal protective equipment (PPE- equipment worn to minimize exposure to hazards that cause serious workplace injuries or illnesses) and performed hand hygiene before and after the tasks. 2. Ensure HK 1 covered the barrel labeled soiled linen with a lid during transport in the facility's hallway. These deficient practices had the potential to result in cross-contamination (the transfer of harmful bacteria from one person, object, or place to another) and the spread of infection throughout the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a homelike environment by failing to ensure two of two shower rooms in the facility were kept clean. This failure had the potential to result in an unsanitary environment for the residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident's dignity was maintained for one of four sampled residents (Resident 4). This failure violated Resident 4's right to be treated with dignity and respect which could affect Resident 4's physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light for one of four sampled residents (Resident 4) was within reach. This deficient practice had the potential to result in the delay of care for Resident 4 when Resident 4 was unable to reach Resident 4's call light to call staff for assistance.

Inspectors wroteBased on interview and record review, the facility failed to prevent physical abuse (willful infliction of injury, deliberate aggressive or violent behavior with the intention to cause harm) for one of three sampled residents (Resident 1). On 6/5/2024, Resident 2 hit Resident 1 on the right upper arm. This failure had the potential to cause a decline in Resident 1's physical and/or psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of resident-to-resident physical abuse (intentional bodily injury that includes slapping, pinching, choking, kicking, shoving, grabbing, and punching) to officials including, the State Survey Agency (SSA), law enforcement, and adult protective services, immediately but not later than two hours for one of four sampled residents (Resident 2) from the time the incident occurred, by failing to: Ensure the Administrator (ADM), who is the abuse coordinator, reported an allegation of abuse on 4/22/2024 when Resident 4 approached Resident 2 and grabbed Resident 2's right upper arm. The ADM reported the allegation of resident-to-resident abuse to the Department of Public Health on 5/7/2024 (15 days after Resident 2's allegation of abuse was made to the ADM). [...]

Inspectors wroteBased on interview and record review, the facility failed to provide treatment and services to restore continence (ability to control movements of the bowels [intestines] and bladder [organ that stores urine]) to the extent possible for one of two sampled residents (Resident 1) by failing to: Ensure Resident 1, who was occasionally incontinent (less than seven episodes of incontinence [inability to control the bladder] in a seven-day period) of urine and had mobility issues, was provided alternative methods to go to the bathroom and assisted with the resident's toileting (urination) needs as indicated in Resident 1's care plan. These failures had the potential for Resident 1 to become more incontinent of urine and lead to a decline of Resident 1's health.

Inspectors wroteBased on interview and record review, the facility failed to provide one of two sampled residents (Resident 1) with dignity and respect in accordance with the facility's policy and procedure (P&P) titled, Resident Rights, by failing to: Ensure Certified Nursing Assistant (CNA) 1 and CNA 2 provided Resident 1 with alternative methods to go to the bathroom and assisted Resident 1 with the resident's toileting needs. CNA 1 and CNA 2 told Resident 1 to void (urinate) in Resident 1's incontinence brief (brief used to capture urine) for CNA 1 and/or CNA 2 to change after voiding. This failure caused Resident 1 to have feelings of depression and burden and made Resident 1 feel like an animal. This failure had the potential to cause further psychosocial (mental, emotional, social, and spiritual effects) harm to Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to complete the fall risk assessment (a screening tool used to predict a person ' s risk of falling) for two of three sampled residents (Resident 2 and 3). This deficient practice had the potential to result in an inaccurate assessment of Resident 2's and Resident 3's risk for falls.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement the care plan intervention to prevent potential falls (an unplanned descent [moving downward] to the floor with or without injury) for one of three sampled residents (Resident 2) by failing to ensure Resident 2's floor mat (a device used to reduce the severity of injury in falls) was placed on the left side of the floor next to Resident 2's bed. This deficient practice had the potential to affect Resident 2's safety and increase the risk for injury.

Inspectors wroteBased on interview and record review, the facility failed to implement their Fall Prevention Program Policy and Procedure (P&P) for one of three sampled residents (Resident 2) by failing to ensure Resident 2's care plan interventions were reviewed for effectiveness and revised after every fall. Resident 2 had five (5) falls in 38 days This failure had the potential for Resident 2 to sustain preventable falls and injuries from falls.

Inspectors wroteb. During a review of Resident 22's AR, the AR indicated Resident 22 was admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including hypertensive heart disease with heart failure (condition in which the heart cannot pump enough blood to all parts of the body), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), and pressure ulcer (bed sore, injury to skin and underlying tissue resulting from prolonged pressure on the skin) of sacral region (the portion of your spine between your lower back and tailbone). During a review of Resident 22's MDS, dated 12/27/23, the MDS indicated Resident 22 was severely impaired (never/rarely made decisions) in cognitive skills (ability to make daily decisions). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of three sampled residents (Residents 22, 29, and 37) were provided proper interventions and/or monitoring of edema (swelling caused by too much fluid trapped in the body's tissues): a. For Resident 22, the facility failed to monitor and document the amount of pitting (a swollen part of your body has a dimple [or pit] after you press it for a few seconds) edema on Resident 22's arms and legs. b-c. For Residents 29 and 37, the facility failed to elevate the resident's upper extremities to decrease edema. These failures had the potential to result in worsening of edema to Residents 22, 29, and 37 and result in pain to the swollen areas and the potential to result in physical declines for the residents. (Cross Reference F656)

Inspectors wroteb. During a review of Resident 22's admission Record (AR), the AR indicated Resident 22 was admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses including hypertensive heart disease with heart failure (condition in which the heart cannot pump enough blood to all parts of the body), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), and pressure ulcer/pressure injury (PI, bed sore, injury to skin and underlying tissue resulting from prolonged pressure on the skin) of sacral region (the portion of your spine between your lower back and tailbone). During a review of Resident 22's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 12/27/23, the MDS indicated Resident 22 was severely impaired (never/rarely made decisions) in cognitive skills (ability to make daily decisions). [...]

Inspectors wroteBased on interview and record review, the facility failed to perform weekly weights for one of six sampled residents (Resident 32) who had a history of weight loss. This deficient practice had the potential to result in delayed interventions concerning Resident 32's nutrition and the potential to result in a physical decline to Resident 32.

Inspectors wroteBased on interview and record review, the facility failed to have a complete Facility Assessment that included the nursing direct care hours for Licensed Nurses (LN, a Registered Nurse or Licensed Vocational Nurse who cared for people who were sick, injured, convalescent, or disabled) and certified nursing assistants (CNA, an entry-level role that provided vital support to both patients and nurses) throughout each shift (working day) in their plan. This deficient practice had the potential for the facility to not provide the sufficient number of qualified staff to meet the residents needs and could decrease the quality of care provided to the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were followed to prevent the transmission of disease and infection for five of eleven sampled residents (Residents 13, 15, 125, 22, and 124) when: a. For Residents 13, 15, and 125, who had foley catheters (urinary catheter, a medical device that drains urine from your bladder), the facility failed to provide enhanced barrier precautions (EBP, the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of multidrug-resistant organisms [MDRO] to staff hands and clothing). Residents 13, 15, and 125 had increased risks of acquiring MDROs per the facility's policy and procedure (P&P), titled, Enhanced Barrier Precautions. b. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Residents 38), was treated with dignity by failing to keep Resident 38's urinary catheter (a flexible tube used to empty the bladder [an organ like a bag inside the body of a person or animal that holds the urine] and collect urine in a drainage bag) bag unexposed in accordance with the facility's policies and procedures (P&P). This deficient practice had the potential for Resident 38 to feel humiliated, embarrassed, ashamed, and for Resident 38 to feel his value as a human being was not respected and could have resulted in Resident 38 not living comfortably during this period of care.

Inspectors wroteBased on interview, and record review, the facility failed to provide appropriate treatment to restore continence, to the extent possible, by failing to implement a prompted toileting program (caregiver prompts the resident to use the toilet) for one of one sampled resident (Resident 67). This failure resulted in Resident 67 urinating in the adult incontinence brief (diaper) and had the potential for Resident 67 to be at greater risk of developing a urinary tract infection (UTI, an infection in any part of the urinary system, including the kidneys, bladder, or urethra).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 17), received proper respiratory (relating to breathing) care such as oxygen (O2, a colorless, odorless, tasteless gas essential for living) therapy in accordance with the physician ' s order and resident care plan. This failure resulted in Resident 17 not receiving the right amount of O2 as ordered by the physician. This failure had the potential to compromise Resident 17's respiratory status that could lead to respiratory distress and/or death.

Inspectors wroteBased on interview and record review, the facility failed to communicate the pharmacy consultant's recommendation in the Medication Regimen Review (a thorough evaluation of a resident's medication regimen with the goal of promoting position outcomes and minimizing adverse consequences associated with medication) to the physician for one of two sampled residents (Resident 15). This deficient practice had the potential to exacerbate (worsen) Resident 15's existing conditions.

Inspectors wroteBased on interview and record review, the facility failed to monitor and record occurrences of target behavior symptoms for one of five sampled residents (Resident 173) who was receiving psychotropic medications (medications that affects brain activities associated with mental processes and behavior) in according to the facility's policy and procedure (P&P) titled, Use of Psychotropic Medication, dated 12/19/2022. This failure had the potential for Resident 173 to take psychotropic medications unnecessarily.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light (a device used by a resident to signal the need for assistance) system was within reach for one of one sampled resident (Resident 14) as indicated in the facility's policy and procedure (P&P) titled, Call Lights: Accessibility and Timely Response. This failure had the potential to result in Resident 14's needs were not met in a timely manner and/or Resident 14 to experience harm if Resident 14 was unable to alert staff during an emergency situation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 17) was provided a safe, sanitary, and comfortable environment. Resident 17's ceiling above the right side of Resident 17's bed was leaking rain water during a rainy day. This failure had the potential to result in Resident 17 getting wet and feeling uncomfortable and could be a fire hazard which had the potential to jeopardize the safety of the residents and staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 11 of 32 resident bedrooms (Rooms 115, 116, 117, 118, 119, 120, 129, 130, 131, 132, 133) met the minimum requirement of 80 square feet (sq. ft.) per resident in bedrooms with more than one resident. This deficient practice had the potential to result in residents not having adequate space for nursing care, and/or use of resident care devices and personal furniture, and visitors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 3) received foods according to the therapeutic diet (diet ordered by a physician as part of treatment for a disease) prescribed by Resident 3 ' s physician. This failure had the potential for Resident 3 ' s health to be negatively impacted.

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor how long the following food items were out of the refrigerator: resident snacks, nourishments, and supplements under refrigeration when a tray with sandwiches, bananas, fruit cups, crackers, a cup of sliced almonds, pureed fruits, puddings, and nutritional drinks. This failure had the potential to result in foodborne illness (caused by consuming contaminated foods or drinks) for 26 of 37 residents who received food from the kitchen.