Crystal Cove Post Acute

Inspectors wroteBased on observation, interview and record review the facility failed to serve food at appropriate temperatures for 3 of 4 halls reviewed. This failure placed residents at increased risk for foodborne illnesses and decreased quality of life.

Inspectors wroteBased on observation and interview, the facility failed to ensure a comfortable homelike environment by not providing adequate temperatures in resident rooms in 1 of 4 hallways reviewed for comfortable temperature. This failure placed residents at risk for diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure new interventions were appropriately developed or timely initiated in an effort to prevent future falls and failed to supervise residents to prevent falls for 3 of 4 sampled residents (Residents 1, 2 and 3) reviewed for accidents. These failures placed residents at risk of injuries, and a diminished quality of life.

Inspectors wroteBased on review of the facility policy, observation, interview and record review the facility failed to document timely dishwasher temperatures, failed to complete dishwasher chemical sanitation testing and failed to serve food at appropriate temperatures for 2 of 4 halls reviewed. This failure placed residents at increased risk for foodborne illnesses and decreased quality of life.

Inspectors wroteBased on interview and record review the facility failed to submit complete and accurate direct care staffing information to the Centers for Medicare and Medicaid Services (CMS- a federal agency managing healthcare programs and health insurance standards) for Quarter 3 (Q3, July 2025, August 2025, September 2025) reviewed for Payroll Based Journal (PBJ-mandatory reporting of staffing information based on payroll data) submission. This failure affected the accuracy of Nursing Home (NH) staffing level data collected by CMS and had the potential to impact provisions of resident care and services.

Inspectors wroteBased on interview and record review, the facility failed to timely recognize and respond to an acute clinical change in condition, contact on-call clinical leaership if the resident's condition does not clearly support in-house monitoring, and contact emergency medical services timely when the resident's condition appeared unstable or life threatening for 1 of 3 residents (Resident 1) reviewed for an acute change of condition. Resident 1 experienced harm when the facility delayed obtaining emergency medical services and access to a higher level of care despite signs and symptoms consistent with a significant change in neurological status. The resident was subsequently transferred to the hospital where they were diagnosed with a non-operable intracranial hemorrhage (brain bleed).

Inspectors wroteBased on review of the facility policy, interview and record review the facility failed to provide written notice of bed holds (holding or reserving a resident's bed while the resident was absent from the facility) given at the time of hospital transfer for 2 of 7 residents (Resident 11 and 13) reviewed for discharge process. This failure placed residents at risk of not being informed of their rights.

Inspectors wroteBased on record review and interview the facility failed to provide restorative nursing services for 1 of 3 residents (Resident 3) reviewed for therapy services. This failure placed residents at risk for decline in mobility, functional ability and a decreased quality of life.

Inspectors wroteBased on observation and interview, the facility failed to ensure the shower rooms were clean and in good condition, for 4 of 4 shower rooms (Hall A & Hall C [two shower rooms each]) reviewed. This failure placed residents at risk of feeling their showers were not homelike or clean, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure psychotropic medications (any drug that alters the brain affecting mood, behavior, perception and thought processes) were regularly monitored and documented on for 3 of 5 residents (Residents 22, 6, and 9) reviewed for unnecessary medication. This failure placed residents at risk of unnecessary medication usage and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 7 of 21 sampled residents (Resident 22, 8, 12, 11, 15, 6 & 94) reviewed care plans. This failure placed residents at risk of not receiving needed services, unmet care needs and a diminished quality of care.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents remained free of unnecessary drugs for 3 of 5 residents (7, 22, and 6) reviewed for unnecessary drugs. This failure placed residents at risk for increased sedation, inadequate pain relief, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medication was stored in manners that met professional standards of practice, for 1 of 1 medication storage rooms (A&B Medication Room) and 2 of 2 medication carts (Halls C &B) reviewed. This failure placed residents at risk of receiving expired medications, cross-contamination, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents approved of a 15-hour mealtime gap and were served a nourishing snack at bedtime, when the time between the dinner and breakfast meals was increased to 15 hours. This failure placed residents at risk of feelings of hunger and inadequate nutrition.

Inspectors wroteBased on interview and record review, the facility failed to have a system that ensured residents were screened, educated and offered the COVID-19 (a contagious disease caused by the coronavirus SARS-CoV-2) vaccine for 2 of 5 residents (Residents 15 & 7) when reviewed for immunizations. This failure precluded residents from the opportunity to make an informed decision regarding receiving Covid-19 vaccines.

Inspectors wroteBased on interview and record review the facility failed to ensure dignity was provided to 2 of 2 Residents (6 & 79) reviewed for resident rights during a meeting with Resident Counsel. This failure placed the residents at risk for diminished self-worth and a decreased quality of life. Findings Included. Resident 6Resident 6 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS-an assessment tool), dated 12/16/2025, documented Resident 6 was cognitively intact. On 01/07/2026 at 11:00 AM Resident 6 said they felt harassed when Staff R, Business Office Manager, asked them why aren't you paying your bill? Resident 6 said if your bill is not paid [Staff R] will hassle you. Resident 79Resident 79 was admitted to the facility on [DATE]. The Quarterly MDS, dated [DATE], documented Resident 79 was cognitively intact. [...]

Inspectors wroteBased on interview and record review, the facility failed to communicate resolutions about the concerns brought forward by the resident council (RC) for 6 of 6 months (July, August, September, October, November and December 2025) of RC minutes reviewed. These failures resulted in RC members feeling frustrated, unheard and powerless to affect their care.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents received their personal funds (money kept for the resident by the facility) within 30 days of discharge for 1 of 1 residents (Resident 107) reviewed for personal funds with discharge. This failure placed residents at risk of delay in access to their money and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to thoroughly investigate a fall with injury for 1 of 2 residents (Resident 52) reviewed for falls. The facility's failure to identify and assess the location where a fall occurred, to identify and consider what environmental factors such as uneven surfaces, and insufficient lighting, were present at the time of the fall and to interview all residents and staff with knowledge about the incident, prevented facility staff from identifying the external factors that were present and led to the residents fall. These failures detracted from the ability to identify what interventions needed to be implemented to prevent reoccurrence and placed residents at risk for continued falls and injuries.

Inspectors wroteBased on interview and record review, the facility failed to ensure Minimum Data Set (MDS) assessments were accurate for 2 of 21 sampled residents (Resident 33 & 6) reviewed. This failure placed residents at risk of a lack of care or services related to the assessments, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure services provided met professional standards of practice for 6 of 21 sample residents (Resident 22, 87, 21, 8, 12 & 72) reviewed. The failure to obtain, follow and/or clarify physician's orders when indicated, and to only sign for tasks they completed, placed residents at risk for medication errors, respiratory infections, unmet care needs and other adverse health outcomes.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure interventions to prevent development or promote pressure ulcer healing were implemented as ordered for 1 of 3 residents (Resident 72) reviewed for pressure ulcers. This failure placed residents at risk of worsening wounds, delay in care, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to secure cigarettes and failed to complete a smoking assessment for 1 of 3 residents (8) reviewed for accident hazards. The facility also failed to maintain an environment with adequate lighting (the lights were turned off) related to resident safety for 31 for 31 residents utilizing the smoking area. These failures placed residents at risk for accidents, injury and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow a prescribed therapeutic diet or offer alternatives to residents on a therapeutic diet and monitor and document fluid restrictions (a diet which limits the amount of daily fluid intake) for 2 of 3 sampled residents (Resident 12 & 94), reviewed for nutrition/hydration. This failure placed the residents at risk of inadequate diet, fluid overload, medical complications, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Peripherally Inserted Central Cather (PICC) line Intravenous (IV) treatments were provided consistent with professional standards of practice for 1 of 1 resident (Resident 76) reviewed. These failures placed the resident who required IV services at risk for loss of vascular access and complications related to IV therapy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure oxygen therapy was provided in accordance with physician's orders and accepted professional standards of practice for 1 of 1 resident (Resident 22) reviewed for respiratory care. Facility staffs' failure to administer oxygen at the physician ordered rate and to change oxygen tubing as the frequency ordered, placed residents at risk for respiratory infections and unmet respiratory needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure ongoing communication and collaboration with Hemodialysis (dialysis, a machine that is used to remove waste and extra fluid from blood and return the filtered blood into the body), receive/obtain dialysis communication documentation including resident's plan of care and post dialysis communication, and/or follow up on dialysis recommendations for 2 of 3 sampled residents (Resident 15 &12) reviewed for dialysis. This failure placed residents at risk for medical complications, missed dialysis treatments and a decreased quality of life.

Inspectors wroteBased on interview and record review the facility failed to complete annual staff performance reviews yearly as required and provide education based on the outcome of these reviews for 1 of 1 sampled veteran staff (Staff BB) reviewed for performance reviews. This failure placed residents at risk of receiving care from inadequately trained and/or under-qualified care staff, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure prompt dental services were provided for 2 of 2 sampled residents (Residents 33 &11) reviewed for dental services. This failure placed residents at risk for difficulty chewing, pain/discomfort due to unmet dental needs, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents received foods that accommodated the residents' preferences, diet types and tolerances for 3 of 8 sampled residents (Resident 12, 66 & 15) reviewed for preferences. This failure placed residents at risk for meal dissatisfaction, nutrition at risk, and a diminished quality of life.

Inspectors wroteBased on observation and interview, the facility failed to ensure food was stored under sanitary conditions by not ensuring a resident refrigerator maintained cold food at or below 41 degrees Fahrenheit. This failure created the potential to expose residents to improperly stored food and increased risk of foodborne illness.

Inspectors wroteBased on interview and record review, the facility failed to ensure the facility's binding arbitration agreements (legal document that required the use of a third party to resolve disputes) was reviewed and explained in a form, manner, and/or language understood by the resident and/or their legal representative for 3 of 3 sampled residents (Resident 46, 60 & 79) reviewed for binding arbitration agreements. This failure placed residents at risk for lacking understanding of the legal document signed, forfeiture (loss or giving up of something) of the right to a jury or court, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to have a system in place that ensured effective communication, collaboration, and coordination of care occurred between the facility and the hospice provider for 1 of 1 resident (Resident 87) reviewed for hospice services. The facility failed to designate a staff member to be responsible for coordinating care with hospice staff, to obtain and maintain a current copy of the coordinated hospice plan of care, and to have a system/ documentation of what hospice staff had visited (e.g., registered nurse, chaplain, certified nursing assistant, massage therapist), when they visited, and what care was provided. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to operationalize an effective Infection Prevention and Control Program (IPCP) in accordance with facility policy, state, federal and or local infection control guidelines, regulations and practices when facility staff failed: to performed required hand hygiene and gloves changes with wound care; to ensure urinals were emptied/rinsed after use; to follow standard precautions (common sense practices to prevent the spread of infection in healthcare), enhanced barrier precautions (EBP, a set of infection control measures that use gowns and gloves to reduce the spread of multidrug-resistant organisms (MDROs) and transmission based precautions used when someone has confirmed or suspected infections) for 2 of 3 (Residents 66 & 72) and reviewed for infection control. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement an effective Antibiotic Stewardship Program (ASP), to promote appropriate use of antibiotics, reduce the risk of unnecessary antibiotic use and decrease the development of antibiotic resistance and adverse side effects for 3 of 5 residents (Residents 74, 25 & 32) reviewed for antibiotic stewardship. This failure placed residents at risk for potential adverse outcomes associated with the inappropriate and/or unnecessary use of antibiotics and a decreased quality of life.

Inspectors wroteBased on interview and record review the facility failed to ensure Nursing Assistants (NA) received a minimum of 12 hours of required in-service training per year which was to include dementia management, abuse prevention, and caring for individuals with cognitive impairment for 1 of 1 sampled veteran NA, (Staff BB), reviewed for staff training. This failure placed residents at risk of receiving care from inadequately trained and/or under-qualified care staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide staff supervision and implement fall prevention strategies for a resident assessed at high fall risk for 1 of 3 residents (Resident 1) reviewed for falls. Resident 1, who had at least three prior unwitnessed falls from their bed, experienced harm when they were positioned on the edge of their bed unsupervised, was subsequently found on the floor and required transfer to the hospital where they were diagnosed with multiple fractures at the right wrist. This failure placed resident at risk for falls, injury and decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a comfortable homelike environment by not providing adequate heat in resident rooms in 3 of 4 hallways reviewed for comfortable temperature. This failure placed residents at risk for diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure wound and indwelling catheter (flexible tube inserted into the bladder to drain urine) cares were provided to 1 of 3 residents (Resident 3) reviewed for quality of care. This failure placed residents at risk for developing infection and diminished quality of lifeFindings included .Review of the facility policy, titled Wound Treatment Management, undated, showed, wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing [NAME]. In absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders. Treatments will be documented on the Treatment Administration Record or in the electronic health record. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure sufficient dietary staff were trained and competent in recognizing and documenting appropriate food temperatures, appropriate chemical sanitation of the dishwasher, sanitizer bucket and three compartment sink, and providing meals at the established mealtimes for 1 of 1 kitchen. This failure placed residents at risk of food born illness and decreased quality of life.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure food temperatures were taken and documented, failed to ensure foods were cooked and served at the appropriate temperatures, failed to ensure food was stored and prepared in a sanitary manner, failed to ensure chemical solutions and water temperatures were maintained and documented and failed to ensure staff utilized proper handwashing during meal preparation and serving in 1 of 1 kitchen. This failure placed residents at risk for food borne illness.

Inspectors wroteBased on observation, interview and record review the facility Administration failed to ensure there was active and engaged oversight and a monitoring system in place to correct findings from an internal audit related to treatment and service to prevent/heal pressure ulcers, food procurement, sufficient dietary support personnel and a sanitary kitchen. This failure placed residents at risk for development or worsening pressure ulcers, food borne illness and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure adequate care and services were provided to promote wound healing and prevent pressure ulcers from developing or worsening by assessing wounds timely, and following physicians' s orders timely for 2 of 3 sampled residents (Resident 1 and 4) reviewed for pressure ulcers. This failure placed residents at risk for worsening pressure ulcers, infections and medical complications.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide prescribed nutritional supplements with meals for 2 of 2 residents (Resident 1 and 5) reviewed for nutrition. This failure placed residents at risk for decreased quality of life and weight loss.

Inspectors wroteBased on review of observation, interview and record review the facility failed to follow infection control practices for transmission-based precautions for 1 of 1 resident (Resident 6) reviewed for infection control. This failure placed residents at risk for spread of infection, health complications, and a diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to obtain weights and failed to provide a recommended nutritional supplement for 1 of 3 (Resident 1) residents reviewed for nutrition. The facility's failure placed residents at risk for weight loss and decreased quality of life.

Inspectors wroteBased on interview and record review the facility failed to ensure accurate acquiring and receiving of all drugs and biologicals to meet the needs of 2 of 4 residents (6 and 9) reviewed. Failure to ensure ordered medications were received from pharmacy placed residents at risk for experiencing increased pain and a decreased quality of life.

Inspectors wroteBased on interview and record review the facility failed to ensure staff performed Cardio-Pulmonary Resuscitation (CPR/an emergency procedure consisting of chest compressions combined with giving breaths of air) and failed to assure required staff had unexpired CPR certifications for 1 of 1 resident (Resident 1) who was found unresponsive and had a physician's order for CPR. The failure of facility staff to initiate CPR placed all residents who chose to have CPR initiated at risk for serious injury, harm, impairment or death and represented an Immediate Jeopardy (IJ) situation. On [DATE] at 2:45 PM, the facility was notified of an IJ at CRF 483.24 (a)(3), F678 CPR, the IJ was determined to have begun on [DATE] when the facility failed to perform CPR. The facility's failure placed residents at risk for serious injury, harm, impairment or death. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure adequate care and services were provided to promote wound healing and prevent pressure ulcers from developing or worsening by implementing and following care interventions timely for 4 of 7 sampled residents (Residents 1, 2, 5 and 6) reviewed for pressure ulcers. Resident 1 experienced harm when the resident's skin was not assessed, and they developed an unstageable pressure ulcer to the left heel with no treatment initiated for 12 days. These failures placed residents at risk for worsening pressure ulcers, infection, medical complications and diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to assess gastrostomy tube (surgically placed tube through the abdominal wall into the stomach to provide nutrition) placement prior to initiating an enteral feeding (feeding through tube) and failed to follow the prescribed orders for hydration for 1 of 2 residents (Resident 7) reviewed for tube feeding management. This failure placed residents at risk for alteration in nutrition and decreased quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure their systems were in place to address and monitor weight loss experienced by 2 of 4 residents (Resident 71 and 65) reviewed for nutrition and failed to monitor and implement accurate fluid restrictions for 3 of 4 sampled residents (Residents 1, 6, and 12) reviewed for fluid restrictions. Resident 71 experienced harm when the facility failed to obtain weekly weights per their care plan, update the physician with the registered dietician's recommendations to add an appetite stimulant and calorie supplement and failed to offer supplemental food when the resident consumed less that fifty percent of their meal that resulted in a significant weight loss of 14.41 percent in 55 days. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure sufficient qualified nursing staff were available to provide care and services as evidenced by information provided in Resident/Surveyor interviews for 4 residents (Residents 1, 7, 71 & 12) interviewed, and 5 staff (Staff T, X, OO, N & PP) interviewed. The facility had insufficient staff to ensure residents received assistance with activities of daily living, restorative services and staff documentation. Additionally, the aides from the Restorative Nursing Program (RNP) department were removed from restorative nursing duties to cover direct care staff absences resulting in the RNPs not being done for 3 of 4 residents (Residents 42, 1 & 32) reviewed for RNP. These failures placed residents at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure licensed nurses and nursing aides had the appropriate competencies/skill sets to provide nursing services that included appropriate transmission-based precaution (TBP) identification, staff correctly identifying which residents were on enhanced barrier precautions (EBP) and failed to implement correct usage of personal protective equipment (PPE) for residents on EBPs. The facility also failed to implement policies for orientation of agency/contracted staff, provide updated trainings for EBPs, ensure licensed staff were trained and competent in the management and monitoring of central venous catheters (centrally inserted access to veins), and to provide oversight of the Restorative Nursing Program (RNP). [...]

Inspectors wroteBased on observation, interview and record review, the governing body acted with disregard to the well-being of the residents of the facility by not ensuring adequate oversight and monitoring of appointed Administration and/or Directors of Nursing to ensure clinical systems were in place and followed and staffing levels were appropriate for the care required by the residents admitted to their facility. The governing body failed to ensure the facility was staffed sufficiently to meet the needs of the residents, so they received showers and other activities of daily living (ADLs) such as grooming and nailcare timely, that restorative programs were completed, and meals were delivered timely and accurately and that residents could access their personal funds. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Quality Assessment and Performance Improvement (QAPI) program self-identified deficiencies and failed to develop/implement effective plans of action to sustain plan of corrections for previous deficiencies. Failure to have an effectively functioning QAPI program that consistently self-identified deficient practices led to repeated deficiencies, a pattern of deficiencies, widespread deficiencies, and a pattern of actual harm that placed residents at repeated risk for unmet needs that could negatively impact their safety, quality of life and quality of care.

Inspectors wroteBased on observation, interview and record review, the facility failed to operationalize an effective Infection Prevention and Control Program (IPCP) in accordance with facility policy, state, federal and or local infection control guidelines, regulations and practices when the facility failed to follow standard precautions (common sense practices to prevent the spread of infection in healthcare), enhanced barrier precautions (a set of infection control measures that use gowns and gloves to reduce the spread of multidrug-resistant organisms (MDROs) and transmission based precautions (used when someone has confirmed or suspected infections) related to lack of prompt isolation and use of precautions when several residents and staff had vomiting and diarrhea and a suspected gastrointestinal outbreak. [...]

Inspectors wroteBased on interview and record review, the facility failed to address, respond to and/or resolve concerns and/or suggestions brought forward by the resident council (RC) for 3 of 3 months (October, November and December 2024) of RC minutes reviewed. These failures resulted in the same unresolved/unaddressed concerns being brought forward for consecutive months without resolution, and resulted in RC members feeling frustrated, unheard and powerless to affect the care they receive and/or their environment.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents with personal funds/resident trust accounts had ready access to their accounts during evenings and weekends for 12 of 12 residents reviewed for person funds accounts. This failure placed residents at risk of not having access to their accounts during non-banking hours, a decreased sense of autonomy and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure quarterly personal fund statements were provided to residents with personal fund accounts for 3 of 3 sampled residents (Residents 4, 32, and 5) reviewed for personal fund accounts. This failure placed residents at risk of not having an accurate accounting of their personal funds held in trust by the facility.

Inspectors wroteBased on observation and interview the facility failed to maintain a safe, clean and comfortable homelike environment for 4 of 4 Wings (A Wing, B Wing, C Wing and D Wing) observed. The failure to ensure doorways were free from gouges, blue decorative coverings over resident doors were secured to doors, light fixtures and resident medical equipment and shower rooms were clean and in good condition, left residents at risk for a diminished quality of life and a less than homelike environment.

Inspectors wroteBased on interview and record review the facility failed to have a system in place that ensured grievances were initiated, logged, timely addressed, and resolved in response to residents' verbal conveyance of concerns during Resident Council for 3 of 3 months (October, November and December 2024) of resident council minutes reviewed. The failure to identify the initiate, log, investigate and timely resolve reported complaints/concerns, and inform residents of the findings and actions taken to correct the issues, placed residents at risk of feelings of frustration, unimportance, diminished self-worth, and quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to obtain assessments, orders, consent, and/or develop a care plan for the use of potential restraints for 4 of 5 residents (Resident 4, 1, 65, and 6) reviewed for physical restraints. This failure placed residents at risk for potential injury, potential restraint, unmet care needs, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide a written transfer/discharge notice to the resident and/or their representative for 5 of 6 sampled resident (Residents 4, 11, 42, 57 & 58), failed to provide the Ombudsman notification for 6 of 6 sampled residents (Residents 3, 4, 11, 42, 57 & 58), and failed to update a resident representative for 1 of 6 sampled residents (Resident 11) reviewed for hospitalization. This failure placed the resident and/or their representative at risk for not having an opportunity to make informed decisions about transfers/discharges.

Inspectors wroteBased on interview and record review, the facility failed to provide written bed hold notices at the time of transfer to the hospital for 4 of 6 sampled residents (Resident 4, 11, 42 & 57) reviewed for hospitalization. This failure placed the residents at risk for lack of knowledge regarding their right to hold their bed while in the hospital.

Inspectors wroteBased on record review and interview, the facility failed to ensure the Minimum Data Set Assessments (MDS) were complete and accurate for 9 of 23 sampled residents (Residents 27, 11, 12, 42, 1, 65, 16, 32 & 57). This failure placed the residents at risk of unmet and unidentified care needs, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to review and revise a comprehensive plan of care to include resident specific interventions for 7 of 23 sampled residents (Residents 65, 4, 6, 11, 27, 12 and 61) reviewed for care plans. The failure to establish care plans that were individualized, accurately reflected assessed care needs and provided direction to staff, placed residents at risk to receive inappropriate and inadequate care to meet their individualized needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure care plans were consistently reviewed and revised to meet residents' current needs for 7 of 23 sampled residents (Residents 65, 27, 58, 51, 7, 18 & 32) reviewed for care plans. This failure to revise care plans placed residents at risk for unmet care needs.

Inspectors wrote4) Resident 55 had an order for lisinipril (blood pressure medication) daily, with direction to hold the medication for a systolic blood pressure (SBP) less than 100 or a pulse (P) less than 60. Review of the January 2025 MARs showed on the following dates facility nurses failed to hold the medication as ordered: - 01/13/2025- SBP 98; P 58 - 01/18/2025- P 58 A 01/09/2025 order for hydrochlorothiazide (hctz, a diuretic) daily, with direction to hold the medication for a SBP less than 100 or P less than 60. Review of the January 2025 MARs showed on the following dates facility nurses failed to hold the medication as ordered: - 01/09/2025- SBP 98; P 43 - 01/13/2025- SBP 97; [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide assistance with Activities of Daily Living (ADLs) for 3 of 8 residents (Residents 124, 32 and 27) reviewed for ADLs. The failure to assist dependent residents with oral care, shaving and meals, placed residents at risk for decreased nutritional intake, weight loss, poor hygiene, feelings of embarrassment, diminished self-worth and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure bowel management interventions were implemented for 3 of 8 residents (Residents 32, 65 & 3) reviewed for quality of care. This failure placed residents at risk for discomfort, further complications, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide restorative services at the frequency residents were assessed to require for 5 of 6 sample residents (1, 42, 61, 69, and 32) reviewed with restorative nursing programs (RNPs). These failures placed residents at risk for decrease in Range of Motion (ROM/movement of a joint through the range of motion with no effort from the patient), increased dependance on staff for care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure Peripherally Inserted Central Catheters (PICC line, is a long, thin tube that's inserted through a vein in your arm and passed through to the larger veins near the heart.), were assessed, maintained and monitored in accordance with professional standards of practice for 2 of 2 residents (Residents 55 & 12) reviewed for intravenous (IV) therapy. The failure to ensure IV orders included: the type and location of IV access, the method of delivery, the infusion rate and duration, monitoring of the insertion site, flush orders, changes of needleless injection caps, and initial and weekly external catheter measurements, placed residents at risk for loss of vascular access, infection, and other potential complications and negative outcomes.

Inspectors wroteBased on interview and record review, the facility failed to ensure freedom from unnecessary medications for 4 of 6 sampled residents (Resident 1, 32, 27, and 42) when reviewed for unnecessary medications. The failure to assess, monitor, and evaluate the need for medications ongoing use, and administration of medications without clinical indication resulted in residents receiving unnecessary medications and placed them at risk of experiencing avoidable adverse side affects to medications, and other potential negative health outcomes.

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents receiving psychotropic (used for treating mental health conditions) medications had specific target behaviors identified for there use, behavior and adverse side effect monitoring were in place, non-pharmacological (non-medication) interventions were identified and documented, informed consent was obtained prior to administering the medication, and resident specific care plans and interventions were developed and implemented for 4 of 5 sampled residents (Residents 12, 27, 3, & 40) reviewed for unnecessary medications. These failures detracted from staffs' ability to monitor the effectiveness and need for continued use of psychotropic medications and placed residents at risk of medication complications, unidentified adverse effects, unmet care needs, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the medication storage room and medication carts were free from expired medication for 1 of 1 medication rooms (A and B Medication Nursing Station Room) and 2 of 2 medication storage carts (C Wing Cart & B Wing Cart) reviewed for medication storage and labeling. The facility failed to ensure that medications of different routes were safely stored in medication carts, that medication was appropriately labeled, that medication was not stored with possible items of contamination, and that controlled substances were appropriately stored, recorded, and wasted in a timely manner. The facility also failed to ensure that medication was stored inside the medication carts or with nursing present, for 1 of 3 medication carts (A Wing Cart) reviewed. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents who were prescribed therapeutic diets (as ordered by a physician or a dietician) received the correct foods/drinks that would fulfill the unique properties of each diet. This failure placed residents at risk for nutritional compromise and related negative health outcomes. On 01/28/2025 at 12:08 PM, staff began to plate the noon meal. The main meal consisted of roasted pork, cooked spinach, stuffing with apples, rolls, and pumpkin pie. Alternatives to the main meal were cold sandwiches, grilled cheese sandwiches, salads, and chicken noodle or tomato soup. Each plate was dished up the same way with the same food, unless the ticket said there was an allergy or a dislike. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the facility's binding arbitration agreements (legal document that required the use of a third party to resolve disputes) included necessary wording of resident rights, and failed to explain to residents what a binding arbitration agreement was in a manner to allow them to understand, for 2 of 3 sampled residents (Residents 53 and 18) reviewed for binding arbitration agreements. This failure placed residents at risk for legal complications and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to maintain a Quality Assessment and Assurance (QAA) committee that included the Infection Preventionist (IP) and the Medical Director or his/her designee, to conduct required Quality Assurance and Performance Improvement (QAPI) and QAA activities. This failure detracted from the effectiveness of the QAA committee and placed residents at risk for quality deficiencies, adverse events, and diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide privacy for 1 of 3 sampled residents (Resident 1) reviewed for dignity. This failure placed residents at risk for feelings of embarrassment, diminished self-worth, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to offer and/or honor bathing choices for 3 of 8 residents (Residents 124, 42 and 51) reviewed for choices. The failure to promote and facilitate resident choice related to type and frequency of bathing, placed residents at risk for poor hygiene, feelings of powerlessness, and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure the transfer of funds, from a resident trust account, was completed within 30 days following their discharge for 1 of 4 residents (Resident 177) reviewed for resident trust. This failure placed the resident and/or their representatives at risk for loss of funds and the interest accumulated.

Inspectors wroteBased on observation and interview, the facility failed to ensure residents' medical information was maintained in a manner to ensure privacy and confidentiality when staff failed to properly secure medical records for 1 of 1 sampled resident (Resident 60) reviewed for privacy and confidentiality. These failures placed residents at risk for loss of confidential medical information and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure the documentation during transfer or discharge of the residents was complete with appropriate information provided to the receiving health care institution or provider, for 1 of 2 residents reviewed (Resident 11) for closed records. This failure placed residents at risk of unidentified and unmet medical needs, and a diminished qualify of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Level I Preadmission Screening and Resident Reviews (PASRR) were complete and accurate for 2 of 7 sampled residents (Residents 11 & 12) reviewed for PASRR. This failure placed the residents at risk of unmet and unidentified care needs, and a diminished quality of life.

Inspectors wrote2) Resident 61 admitted to the facility on [DATE]. Review of the 11/24/2024 Quarterly MDS showed the resident was cognitively intact, and identified that being around animals such as pets, keeping up on the news, and getting fresh air when the weather was nice were somewhat important to them, while listening to music they liked was Very important. On 01/22/2025 at 9:40 AM, 01/23/2025 at 10:19 AM, 01/27/2025 at 02/03/2025 at 9:57 AM and 10:26 AM, and 02/05/2025 at 10:57 AM, Resident 61 was observed lying in bed without their television on or music playing. An activity care plan, revised 11/12/2024, documented the following goals: will have opportunities to watch TV or listen to music and will socialize in a one-to-one setting with a volunteer/visitor/activity staff two to three times a week. The care plan did not address getting fresh air or being around animals. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Podiatry (the treatment of feet and their ailments) care and services were provided for 1 of 1 resident (Resident 27) reviewed for foot care. This failure placed the resident at risk for further skin impairment, discomfort, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to consistently implement fall prevention interventions for 1 of 3 residents (Resident 27) reviewed for falls. This failure placed residents at risk of falling, injury, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents with indwelling catheters (a flexible tube inserted into the bladder through the urethra to drain urine) without a documented justification for use, were assessed for catheter removal as soon as possible, that catheter tubing properly positioned and secured to prevent trauma, and urology referrals were made when ordered for 1 of 3 residents (Resident 42) reviewed for urinary catheters. These failures placed residents at risk for unnecessary catheterization, urinary tract infections, decreased bladder tone, urethral erosion and a decreased quality of life.

Inspectors wrote2) Resident 42 admitted to the facility on [DATE]. Review of the 01/12/2025 Quarterly MDS showed the resident was cognitively intact, had a diagnosis of lung disease and required supplemental oxygen during the assessment period. Review of Resident 42's orders showed a 01/05/2025 order for O2 at 2 Liters/minute (how much oxygen flowed in per minute) via NC to maintain O2 saturation (SpO2) above 90%. On 01/22/2025 at 10:05 AM, Resident 42 was lying in bed receiving 02 at 1.5L/min via NC. The O2 tubing and humidifier bottle were undated, and the humidifier bottle was empty. On 01/23/2025 at 10:36 AM, Resident 42 was in bed receiving O2 via NC at 4L/min. The humidifier bottle and O2 tubing had been replaced and were dated 01/22/2025. 01/23/2025 at 11:40 AM, Staff L, Infection Preventionist, observed Resident 42 and confirmed they were receiving O2 via NC at 4L/min. [...]

Inspectors wroteBased on interview and record review, the facility failed to identify, plan, and implement interventions for the individual needs of 1 of 2 residents (Resident 57) reviewed for dialysis. This failure placed residents at risk for unmet care needs, rehospitalizations, and further medical complications.

Inspectors wroteBased on interview and record review the facility failed to follow up on pharmacy recommendations for 1 of 5 sampled residents (Resident 65) reviewed for unnecessary medications. This failure placed residents at risk for medical complications and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure it was free from a medication error rate of 5% or greater, with an error rate of 16% with errors observed for 2 of 7 sampled residents (Residents 69 and 1) reviewed for medication administration observation. This failure placed residents at risk for medical device complications, delay in medication, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that 2 of 10 sampled residents (Resident 12 & 51) received foods that accommodated the residents' preferences and allergies. This failure placed residents at risk for meal dissatisfaction, allergic reaction, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to implement an effective Antibiotic Stewardship Program (ASP) for three of three months (October 2024, November 2024 and December 2023) reviewed. This failure placed residents at risk for adverse outcomes associated with inappropriate and/or unnecessary use of antibiotics, including for Multi Drug Resistant Organisms (MDRO: germs that are resistant to many antibiotics), and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to maintain documentation of staff COVID 19 (an infectious respiratory disease caused by a virus) vaccination status. This failure placed residents at risk of contracting COVID 19, medical complications and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure staff followed the facility policy for safe use of dryers for 1 of 2 dryers (dryer 2) and the facility failed to provide the necessary monitoring and supervision for 3 of 4 residents (Resident 1, 3 and 4) with wandering behaviors reviewed for accidents, hazards, and supervision. These failures contributed to a fire in dryer 2 and Resident 1 eloping from the facility and placed resident at risk for injury and a diminished quality of care.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure safe food preparation by documenting food temperatures for 1 of 1 kitchen. This failure placed residents at risk for food-borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the accurate acquiring and receiving off all drugs and biologicals to meet the needs of 3 of 4 residents (Resident 3, 5 and 6) reviewed for medications and pharmacy services. Failure to ensure ordered medications were received from the pharmacy placed residents at risk for pain and decreased quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to provide timely assessment and treatment by a qualified professional in response to a significant and acute change in condition for 1 of 3 residents (Resident 5) reviewed for death in the facility. Resident 5, who had a recent history of aspiration (inhalation of foreign material into the lungs), experienced harm when they vomited, and experienced a sudden change in breathing pattern with bluing around the lips and eventually expired. These failures placed residents at risk of not receiving basic life support and a delay of care and treatment, serious harm, impairment or death and constituded an Immediate Jeopardy (IJ). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from avoidable accidents during a resident transfer for 1 of 3 residents (Resident 1) reviewed for accidents. Resident 1 experienced harm when facility staff did not follow recommended procedures for transportation and the resident sustained a fracture and laceration requiring hospitalization and surgery. This failure placed residents at risk for injury and a diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to notify the resident's Power of Attorney (POA) of a change in condition for 1 of 4 residents (Resident 10) reviewed for notification of changes. This failure placed residents at risk for not having the opportunity to have family notified of changes in condition and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to provide condom catheter care for 1 of 1 resident (Resident 6) reviewed for condom catheter care.

Inspectors wroteBased on interview and record review the facility failed to ensure transfer discharge documentation was completed including physician's order and necessity for transfer for facility-initiated transfer/discharge for 1 of 3 sampled residents (Resident 1) reviewed for transfer/discharge. This failure placed residents at risk for un-met care needs and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure policies to promote smoking safety were established in accordance with state and local laws for 3 of 3 (Residents 1, 7 & 8) sampled residents reviewed for smoking. These failures placed residents, staff, and visitors at risk for ignition of combustible material.

Inspectors wroteBased on interview and record review the facility failed to ensure an allegation of financial exploitation was reported timely for 1 of 4 residents (Resident 2) reviewed for abuse. This failure placed residents at risk for abuse, neglect and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement interventions to address dementia care needs for 1 of 3 residents (Resident 4) reviewed for dementia care. This failure placed residents at risk for diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to promote and facilitate resident choices related to frequency of bathing for 3 of 7 residents (Residents 5, 64 & 37) reviewed for choices related to bathing. This failure placed residents at risk for feelings of un-cleanliness, powerlessness and diminished a quality of life.

Inspectors wroteBased on observation and interview, the facility failed to provide a clean, comfortable and homelike environment in 1 of 1 dining rooms (Main Dining) review for homelike environment, 2 of 10 resident rooms (room [ROOM NUMBER] & 15) observed for cleanliness and 1 of 9 resident rooms observed for odors. This failure placed residents at risk of feeling unclean, undignified, and diminished self-worth and/or quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 5 of 24 residents (Residents 56, 90, 292, 12 & 64) reviewed for Minimum Data Set (MDS), an assessment tool, were completed accurately to reflect the resident's condition. This failure placed residents at risk for unidentified and/or unmet needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) Level 2 comprehensive evaluations (the process to determine what types of mental health services are required after a Level 1 PASRR determined services were necessary) were obtained and/or implemented and incorporated into the Care Plan (CP) for 5 of 6 residents (Residents 12, 11, 56, 5 & 47) reviewed for PASRRs. This failure placed residents at risk for not receiving necessary mental health care and services.

Inspectors wroteBased on interview and record review, the facility failed to provide residents and/or their representatives with a summary of the baseline care plan for 3 of 3 residents (90, 66 & 292) reviewed for newly admitted residents. Failure to provide baseline care plans placed residents at risk to be uninformed of their healthcare goals, treatments, and services.

Inspectors wroteBased on interview and record review the facility failed to review and revise care plans for 6 of 24 residents (Residents 56, 12, 66, 21, 5 & 37) reviewed for care plans. The failure to review and revise care plans, by the interdisciplinary team, after each assessment, placed the residents at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure services provided met professional standards of practice for 8 of 24 residents (Residents 84, 11, 56, 90, 79, 21, 5 & 8) reviewed. The failure of nursing staff to obtain, follow or clarify physicians' orders when indicated, and to document for only those tasks completed, placed residents at risk for medication errors, delayed treatment, and other adverse outcomes.

Inspectors wroteBased on interview and record review, the facility failed to provide the necessary care and services to maintain residents' highest practicable level of well-being for 4 of 7 residents (Residents 21, 5, 37 & 47) reviewed for bowel management and 1 of 1 resident (Resident 5) reviewed for a fluid restriction. The failure to initiate bowel care in accordance with physician's orders and to accurately document, total, and assess fluid intake placed residents at risk for fluid volume overload, pain/discomfort, and other health complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the accurate acquiring and receiving off all drugs and biologicals to meet the needs of 3 of 4 residents (Resident 292, 90 & 79) reviewed. Failure to ensure ordered medications were received from the pharmacy placed residents at risk for pain and nutritional deficit.

Inspectors wroteBased on interview and record review, the facility failed to ensure 4 of 5 residents (Resident 11, 56, 21 & 34) reviewed for unnecessary medications were free from unnecessary psychotropic (affect mind, emotions and/or behaviors) medications related to the failure to: adequately monitor, ensure adequate indications for use, or identify non-pharmacological (non-drug) interventions for behaviors. These failures placed residents at risk to receive unnecessary medications and/or adverse side effects.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5 percent when 2 of 4 nurses (Staff E and G) failed to properly administer 4 of 30 medications for 3 of 9 sampled residents (Resident 69, 292 & 53) observed during medication pass resulting in a medication error rate of 13.3 percent. These failures placed residents at risk to not receive the therapeutic effects of medications prescribed by the physician.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure insulin was dated when opened, drugs and biologicals were removed when expired, medications were stored at proper temperatures, and medication carts and rooms were secured, in accordance with currently accepted professional standards in 2 of 4 medication carts and 1 of 2 medication rooms reviewed. The facility failed to ensure medications were secured in locked storage for 2 of 2 sampled residents (Residents 90 and 56) observed with medications in their rooms. This placed residents at risk to receive expired medications and biologicals.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure prompt dental services were provided for 3 of 5 residents (Residents 66, 5 & 21) reviewed for dental services. This failure placed residents at risk for difficulty chewing, pain discomfort due to unmet dental needs, and a diminished quality of life.

Inspectors wroteBased on interview, observation and record review, the facility failed to provide appetizing and palatable food to residents. This failure placed residents at risk for weight loss, inadequate nutrition and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff provided meal service according to the facility's posted meal service schedule for 2 of 2 (Lunch meals on 03/04/2024 and 03/06/2024) reviewed for meal service. These failures placed residents at risk for not receiving their meals as scheduled, medical complications and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the kitchen followed proper safe food preparation/storage for 1 of 1 kitchen reviewed for food safety. The facility failed to discard rusted and dented dry food storage cans, identify expiration dates on dry food storage cans, maintain temperature logs for 3 of 3 refrigerators/freezers, and maintain walk in freezer in appropriate working conditions. These failures contributed to an unsanitary kitchen environment and placed residents at risk for food-borne illness.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure infections control standards were followed related to use of required Personal Protective Equipment (PPE) with residents on Transmission Based Precautions (TBP), use of barriers and sanitization of glucometers, prevention of cross-contamination during administration of eye drops and handling of laundry to prevent spread of infection. These failures paced residents at risk of spreading and/or contracting infectious diseases.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care in a manner that promoted resident dignity for 3 of 18 residents (Residents 11, 57 & 9) observed in the dining room. The facility also failed to respect and value residents' private space by knocking and/or announcing themselves prior to entering a resident's room for 4 of 9 rooms (Rooms 32, 33, 29 & 31) reviewed for dignity. These failures placed residents at risk for being treated with a lack of dignity and respect and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to address the required documentation for advanced directives (AD) for 1 of 2 residents (67) reviewed for AD. This failure placed residents at risk of losing their right to have their preferences/decisions regarding end-of-life care followed.

Inspectors wroteBased on interview and record review, the facility failed to ensure that Skilled Nursing Facility (SNF) Advanced Beneficiary Notices (ABN: a notification that provides an estimated cost of continuing services which may no longer be covered by Medicare. Beneficiaries may choose to continue the services but may be financially liable) was completed as required for 1 of 3 residents (Resident 59) reviewed for Beneficiary Notification. This failure placed residents at risk of not being allowed to make informed choices about further treatment or services as required by the Medicare Program and of not being informed of their appeal rights prior to the end of Medicare covered services.

Inspectors wroteBased on observation, interview and record review, the facility failed to initiate, log, promptly respond to and resolve grievances for 2 of 6 residents (Residents 21 & 46) reviewed for missing property. The failure to initiate, log, and promptly address resident grievances prevented staff from identifying care trends and ensuring resident concerns were timely and effectively addressed. This placed residents at risk of feelings of frustration, unimportance, decreased self-worth and quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide the resident and/or the resident's representative a written notice of the facility's bed-hold policy, at the time of transfer or within 24 hours, for 2 of 6 residents (Residents 66 & 56) reviewed for hospitalization. This failure placed the residents and their representatives at risk of not being informed of their right to, and the cost of, holding the resident's bed while hospitalized .

Inspectors wroteBased on interview and record review, the facility failed to ensure Pre-admission Screening and Resident Review (PASRR) assessments accurately reflected residents' mental health conditions for 2 of 6 residents (Residents 11 & 21) reviewed for PASRR. This failure placed residents at risk for inappropriate placement and/or not receiving timely and necessary services to meet their mental health needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide assistance with Activities of Daily Living (ADLs) for 2 of 6 residents (Residents 66 & 50) reviewed for ADL care for dependent residents. This failure to provide dependent residents with nail care and overall grooming placed them at risk for poor hygiene, embarrassment, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow pressure ulcer orders and prevention measures for 1 of 4 residents (Resident 50) reviewed for pressure injuries. This failure placed residents at risk for new and worsening pressure injuries, pain, and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide necessary foot care and treatment in accordance with professional standards, including provision of nail care for 2 of 6 residents (Resident 12 & 666) reviewed for nail care. This failure to provide timely foot/nail care, placed residents at risk for decreased quality of life and negative health outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure resident supervision, thorough accident investigations to determine the circumstances of resident accidents and implementation of measures to prevent reoccurrence for 1 of 8 residents (Resident 56) reviewed for accidents. These failures placed residents at risk for avoidable accidents and injury.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 1 of 4 residents (Resident 5) reviewed for respiratory care, were provided such care, in accordance with professional standards of practice. Failure of the facility to maintain and monitor oxygen equipment, obtain the prescribed pressure settings and care and maintenance orders for continuous positive airway pressure (CPAP/an external device that provides a fixed pressure to keep breathing airways open while you sleep) therapy, placed residents at risk for ineffective assisted ventilation and unmet respiratory needs.

Inspectors wroteBased on interview and record review, the facility failed to provide Registered Nurse (RN) coverage for at least 8 hours for 1 of 30 days reviewed for staffing. This failure placed residents at risk for unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to fully inform in advance 1 of 1 sampled residents (Resident 2) reviewed for the use of a ankle wander guard alarm (sounds alarm when an at-risk wanderer approaches a monitored door ). This failure placed residents at risk for not knowing treatment risks, benefits, options, and alternatives.

Inspectors wroteBased on interview and record review, the facility failed to ensure a safe discharge for 1 of 3 sampled residents (Resident 1) reviewed for discharges. This failure led to Resident 1 utilizing emergency services on the day of discharge, re-hospitalization and placed residents at risk for psychosocial distress and medical complications.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a person-centered care plan to address the use of a wander guard (sounds alarm when an at-risk wanderer approaches a monitored door) and potential elopement for 1 of 9 sampled residents (Resident 2) reviewed for care planning. This failure placed residents at risk of receiving inappropriate and inadequate care to meet their individualized safety needs.