Crystal Creek Post-Acute

Inspectors wroteBased on interview and record review, the facility failed to ensure that clinical assessments and corresponding interventions were accurately documented for one out of three sampled residents (Resident 1) when staff administered a pain medication without documentation supporting the clinical indication or rationale for the intervention. This failure resulted in inaccurate and unreliable clinical documentation for Resident 1, compromised the integrity of the medical record, and impaired the facility's ability to evaluate the resident's condition, response to treatment, and ongoing care needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure that physician-ordered pain management interventions were implemented for one out of three sampled residents (Resident 1) when staff failed to administer ordered pain medication in response to the Resident 1's reported pain. This failure could have resulted in Resident 1 experiencing unrelieved pain, placing the resident at risk for deterioration in condition and significant adverse outcomes.

Inspectors wroteBased on interview and record review, the facility failed to ensure that physician-ordered medications were administered as prescribed for one out of three sampled residents (Resident 1) when nursing staff omitted multiple scheduled medications. This failure resulted in Resident 1 not receiving essential prescribed medications, placing the resident at risk for worsening of underlying conditions, inadequate symptom control, and potential adverse outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safety measures were in place while providing care for one of three sampled residents (Resident 2), when:1. During a change of bedding, without securing Resident 2's right side of the bed, Certified Nursing Assistant (CNA) 2 turned Resident 2 to her right side, away from the CNA.This deficient practice resulted in Resident 2 falling out of bed and onto the floor on 1/23/26. Resident 2 sustained injuries including a fracture (broken bone) to her right elbow.2. The staff did not implement interventions timely to prevent further falls and to reduce the impact of potential falls after Resident 2's fall incident on 1/23/26. This failure exposed Resident 2 to potential falls and associated injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accommodate the needs of four out of 35 sampled residents (Resident 45, Resident 52, Resident 93 and Resident 149) when Resident 45, Resident 52, Resident 93 and Resident 149's call light (device used to contact staff for assistance) were not within their reach. This deficient practice placed Resident 45, Resident 52, Resident 93 and Resident 149 at increased risk for unmet care needs, delayed staff response, and potential for accidents or injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a care plan (a personalized document that outlines a person's health conditions, specific needs, goals, and the actions required to manage their well-being, ensuring consistent, coordinated, and effective support from caregivers or healthcare teams, helping everyone involved stay organized and focused on the individual's quality of life) was developed and revised for 2 of 35 sampled residents (Resident 9 and Resident 126), when: 1. A care plan was not developed for Resident 9 with a diagnosis of PTSD (Post-Traumatic Stress Disorder, is a mental health condition that can happen after someone experiences or witness a traumatic event such as violence, abuse war, serious accidents or disasters),2. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure three of 35 sampled residents had water or fluids available when,Resident 52 did not have water or fluids available at the bedsideResident 87 did not have water or fluids available at the bedsideResident 99 did not have water or fluids available at the bedsideThese failures had the potential to place Resident 52, Resident 87, and Resident 99 at risk for dehydration (when the body does not get enough fluids to function properly), falls, and/or chocking.

Inspectors wroteBased on observation, interview and record review the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety when:1. The can opener blade had shards of metal, layers of food residue, and metal chipped at the tip of the can opener,2. Several tray line pans (standard commercial-grade baking sheets or pans used in kitchens) were found stacked wet in the ready to use areas,3. One kitchen staff was observed washing dishes and going back and forth from the dirty dishes to the clean dishes without washing their hands or changing their apron, These failures had the potential to lead to cross contamination (when bacteria or germs spread from one place to another) and food borne illness (an illness that causes nausea, vomiting, and/or diarrhea) for the 149 residents who receive meals from the facility kitchen.

Inspectors wroteBased on interview and record review, the facility failed to offer, obtain informed consent and provide education to a resident or resident's representative (RP) about influenza (or the flu, is a contagious viral infection of the respiratory system that can range from mild to severe, causing symptoms like fever, cough, sore throat, muscle aches, and fatigue) vaccine for three out of five sampled residents when Resident 159, Resident 8 and Resident 110 was not offered the flu vaccine during the flu season. These failures had the potential for the residents and resident's responsible parties to not be fully informed about the risks and benefits, and potential side-effects of the flu vaccine prior to receiving or declining the vaccination.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure two of 35 sampled residents (Resident 2 and Resident 27) were treated with dignity, privacy and respect when: 1. Two staff members, Certified Nursing Assistant (CNA ) 10 and CNA 11 did not protect Resident 2's privacy by leaving the room door and privacy curtain open while providing care, which allowed care activities to be seen by others passing by the room, and2. Two staff members, licensed nurse (LN) 1 and certified nursing assistant (CNA) 1 called Resident 27 a feeder (a derogatory term used to describe someone who requires assistance with meals). This failure had the potential to negatively impact on Resident 2's and Resident 27's dignity and feelings of self-worth and could cause emotional discomfort to Resident 2 and Resident 27.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that a resident who lacked the capacity to make medical decisions (the ability to understand medical information and make informed choices about healthcare) had an appropriate legal representative (a person legally authorized to make decisions for someone who cannot decide for themselves) to participate in healthcare decisions, when the facility failed to initiate a timely referral for a representative for one of 35 sampled residents (Resident 9) who was identified as lacking decision-making capacity, had no family, no Power of Attorney (POA, a person you choose to make decisions for you if you are unable to do so), while being listed as her own Responsible Party (RP, indicating the resident is considered able to make her own decisions, sign paper work, and consent to treatments and care decisions). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 35 sampled residents' (Resident 3) PRN (as needed) order for Ativan (a medication used reduce anxiousness) did not exceed 14 days without a documented clinical rationale for extending the medication timeframe order. This failure placed Resident 3 at increased risk for adverse outcomes, including over-sedation, falls, and the potential use of a chemical restraint (a medication used to control a person's behavior or restrict their freedom of movement for reasons other than a standard treatment).

Inspectors wroteBased on interview and record review the facility failed to ensure one resident (Resident 71), in a sample of 35 residents, had person-centered care plans (a personalized document outlining an individual's health, support, and personal needs, detailing what care is required, how it will be given (tasks, timing, by whom), and the goals, preferences, and choices of the person receiving it, ensuring consistent, high-quality, person-centered support) when care plans for Resident 71's diagnoses of diabetes and anxiety were not developed and implemented. This failure had the potential for health care needs to go unrecognized, negatively affecting Resident 71's health, well-being, and psychosocial health and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide timely and proper pain relief for two of 35 sampled residents (Resident 72 and Resident 78), when:1. Resident 72 complained of sore gums and discomfort, and the ordered Magic Mouthwash [medicated liquid mouthwash mixture used to relieve pain from mouth and throat sores] and dental evaluation were not carried out and/or administered to Resident 72; and, 2. Resident 78 did not receive comfort measures or pain medication in a timely manner when Resident 78 reported moderate to severe (strong) pain. These failures resulted in Resident 72 and Resident 78 experiencing continued pain, which affected Resident 72's and Resident 78's comfort and emotional well-being (the resident's ability to feel calm, secure, and free from worry).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that informed consent (explaining the risks, benefits, and choices to the resident or their representative [someone authorized to act on behalf of a resident]) for the use of bed rails (adjustable metal or plastic bars along the sides of a hospital bed) was obtained from the appropriate resident representative for one of 35 sampled residents (Resident 107), when the informed consent was obtained from Resident 107, who lacked decision-making capacity. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate treatment and services to meet the dental health needs for one of thirty-five sampled residents (Resident 72), when Resident 72's mouth wash and dental consult ordered on 11/25/25 were not carried out timely. This deficient practice had the potential to negatively affect Resident 72's dental health needs and could contribute to unnecessary pain and suffering.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that staff utilized appropriate Personal Protective Equipment (PPE, special gear worn to protect themselves and others from germs) upon entering an isolation room for one of three sampled residents (Resident 37) when Licensed Nurse (LN) 3 was observed inside a contact isolation room (a room where a sick person is kept separate and staff use additional protective equipment, such as gloves and gowns, to prevent the spread of germs) checking Resident 37's pulse without wearing gloves or a gown. This failure increased the risk of spreading germs to staff, other residents and visitors in the facility.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of alleged abuse to the Department (the states licensing and certification agency whom conducts inspections of health care facilities) for one resident (Resident 1), in a sample of four residents when, Resident 1 reported to Family Member (FM) 1 that she had been hit on the head by an unknown person, FM 1 reported the allegation made by Resident 1 to facility staff on 7/30/25, and the allegation was not reported to the Department by the facility. This failure had the potential to result in continued abuse of Resident 1, with the potential to negatively affect Resident 1's physical and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of alleged abuse to the Department (the states licensing and certification agency whom conducts inspections of health care facilities) for one resident (Resident 1), in a sample of four residents when, Resident 1 reported to Family Member (FM) 1 that she had been hit on the head by a staff person while care was being provided to Resident 1, FM 1 reported the allegation made by Resident 1 to facility staff on 7/30/25, and the allegation was not reported to the Department by the facility. This failure had the potential to result in continued abuse of Resident 1, with the potential to negatively affect Resident 1's physical and psychosocial well-being.

Inspectors wroteBased on interview, and record review, the facility failed to ensure an Infection Preventionist (IP) was consistently employed by the facility from January 1, 2021 through December 31, 2022. This failure had the potential to increase the spread of illnesses within the facility and communicable illnesses not to be appropriately tracked and assigned the appropriate precautions; negatively impacting the health and safety of all residents residing in the facility. During an interview on 8/6/25, at 2:15 PM, with Payroll/Human Resources (Payroll/HR), Payroll/HR was unable to provide information on the IPs working in the facility between 1/1/21 and 12/31/22 as the facility no longer had the files. Payroll/HR explained the facility had shipped the employee files to the previous corporation (that owned/ managed the facility) the prior week. [...]

Inspectors wroteBased on interview, and record review, the facility failed to report a change of condition (COC - a change in the resident's normal, physical, mental, or behavioral state) to the responsible party (RP, a person has the authority to make decisions for another person) for one of three sampled residents (Resident 1), when Resident 1's change in behavior was not reported to Resident 1's RP. This failure resulted in Resident 1's family being uninformed that Resident 1 had gotten into an altercation with another resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe environment and adequate supervision for one of three sampled residents (Resident 1) with a history of falls when Resident 1 fell on 1/6/25, 1/11/25, 1/19/25, and 1/21/25 and no new interventions were added to Resident 1 Fall Care plan after the falls on 1/19/25 and 1/21/25. These failures had the potential for Resident 1 be injured as a result of falling.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage practices for a total of 127 residents receiving food from the kitchen when: 1. Food items available for use in the dry storage area, were found in an opened and unsealed container and/or past their use by or best by dates; 2. Vegetables available for use in the walk-in refrigerator were wilted, decomposing, and moldy, and containers of sour cream were past their best by dates; 3. Freezer #2 contained ice buildup on all four walls; and, 4. The dishwasher water temperature was not within range. These failures had the potential to expose the 127 residents receiving food from the kitchen to expired, contaminated foods, and placed these residents at risk of food borne illness (an illness/infection caused by consuming contaminated food).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 3 of 41 sampled residents (Resident 21, Resident 94, and Resident 50) needs were accommodated based on their physical limitations when, 1. Resident 21 was unable to easily use a push button call light (a handheld device with a button to call for staff assistance) and was not assessed for the need of an adaptive call light (a device that allows people with limited hand function to call for assistance); 2. Resident 94 was unable to easily use a push button call light, was not assessed for the need of an adaptive call light, and Resident 94's fall mat (a soft pad used to reduce risk of injury in case of a fall) was not in place near the bed; and, 3. Resident 50's wheelchair was lost, and the facility provided him with a wheelchair which was too large, uncomfortable, and did not fit through his door. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe smoking practices, for eight sampled residents out of nineteen residents who smoked (Resident 22, Resident 38, Resident 49, Resident 53, Resident 61, Resident 112, Resident 118, and Resident 120) when: 1. Resident 38 was observed to have cigarettes and a lighter unsecured in his room, and Resident 38 was assessed and determined not to be an independent smoker; 2. Resident 49 stated she kept her cigarettes and lighter in her room unsecured, and she was observed in her room to be receiving continuous oxygen via nasal canula (NC, tubing that delivers oxygen into your nose), and was assessed and determined to not be an independent smoker; and, 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare and serve foods in a consistent and appetizing manner when, 1. Resident 40 and Resident 120 were served food that was cold, and the test trays sampled on 11/7/24 were bland in flavor and not of an appetizing temperature; and 2. Recipes were not followed for 15 of 15 residents receiving pureed diets (food that have been ground to a soft, smooth consistency, like pudding) on 11/7/24. These failures had the potential to result in decreased meal intake for the 127 residents receiving meals in the facility, which could lead to weight loss and malnutrition.

Inspectors wroteBased on interview and record review, the facility failed to ensure coordination of care with hospice services (provides symptom management at the end of life) for three of fifteen residents (Resident 139, Resident 121, and Resident 25) receiving hospice services in the facility, when the facility failed to ensure Hospice Provider's Visit Notes were received and reviewed by the facility staff. These failures had the potential for Resident 139, Resident 121, and Resident 25, care needs to go unrecognized, negatively impacting their health and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain its Infection Prevention and Control Program for a census of 137, when: 1. Isolation precautions (measures taken to prevent spread of infection) were not implemented timely for Resident 68; and, 2. The facility did not ensure glucometers were cleaned and sanitized. These failures had the potential for cross contamination, negatively impacting the health and well-being of residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility did not ensure one of 41 sampled residents (Resident 118) was treated with dignity and respect, when Resident 118 heard certified nursing assistant (CNA) 2 speaking negatively about her to licensed nurse (LN) 2. This failure resulted in Resident 118 feeling upset and crying, negatively impacting Resident 118's feelings of self-worth (the internal sense of being good enough and worthy of love and belonging from others) and self-esteem (how you value and perceive yourself, and the degree to which you think your qualities are positive).

Inspectors wroteBased on interview and record review, the facility failed to consult the physician for 1 of 41 sampled residents (Resident 50) when Resident 50's physician recommended exercise in response to Resident 50's request for help with weight loss, and the facility did not notify Resident 50's physician of his inability to participate in an exercise program. This failure had the potential for a delay in interventions to assist Resident 50 with his goals for weight loss and to experience feelings of hopelessness.

Inspectors wroteBased on interview and record review, the facility failed to maintain 2 of 41 sampled residents (Resident 89 and Resident 95) personal privacy and confidentiality of medical records when Resident 89's medical record contained Resident 95's personal health information (PHI). This failure resulted in Resident 95's PHI being available to Resident 89, violating Resident 95's right for confidentiality of his PHI. Findings A review of Resident 95's admission Record, indicated Resident 95 was admitted to the facility with diagnoses which included anxiety disorder and depression. A review of Resident 89's admission Record, indicated Resident 89 was admitted to the facility with diagnoses which included depression. A review of Resident 89's Electronic Health Record [HER] revealed a clinical document titled, Consultation Report, dated May 1, 2024, through May 16, 2024. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that 2 of 41 sampled residents' (Resident 51 and Resident 102) Minimum Data Set (MDS -a federally mandated resident assessment and screening tool which identifies care needs) assessments reflected their current status when: 1. Resident 51's discharge MDS was not completed for discharge in July 2024 2. Resident 102's route of feeding was not correct on the MDS assessment. These failures had the potential for Resident 102's strengths and needs to go unassessed which could have resulted in inaccurate or missing individualized care plans, and led to Resident 51's health status upon discharge not being tracked in the MDS system.

Inspectors wroteBased on interview and record review, the facility did not ensure 1 of 41 sampled residents (Resident 43) had her Preadmission Screening and Resident Review (PASARR- a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes) form updated after a significant change in a mental illness diagnosis. This failure resulted in Resident 43 not receiving an updated screening assessment that could have provided services needed to improve Resident 43's mental health condition and quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure 2 of 41 sampled residents (Resident 54 and Resident 94) had individualized care plans (a document that indicates specific problems, goals, and interventions) developed and implemented when: 1. Resident 54's vision care plan was not developed to include admitting diagnoses of diabetic cataract (a clouding of the eye's lens that can lead to decreased vision and blindness) and glaucoma (a chronic eye disease that occurs when fluid builds up in the eye causing gradual loss of sight); and, 2. Resident 94's care plan to address falls was not developed. These failures could have resulted in Resident 54's care needs not being addressed, and Resident 94 could have sustained a preventable fall which could have resulted in an injury.

Inspectors wroteBased on interview and record review the facility failed to assist 1 of 41 sampled residents (Resident 54) with obtaining vision services in a timely manner when the outside vision provider deemed Resident 54 ineligible to receive vision services through them and the facility did not follow-up and/or attempt to find another vision provider. This failure resulted in Resident 54 feeling frustrated about his vision and had the potential to negatively impact Resident 54's psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were administered in accordance with professional standards of practice for two of forty-one sampled residents (Resident 111 and Resident 105) when: 1. Resident 111's medications, including controlled substances (a drug or chemical that is regulated by the government for its manufacture, possession, and use) were left at Resident 111's bedside; and 2. The facility did not ensure correct route of medication administration for Resident 105. These failures had the potential for Resident 111 not to receive his medication, and/or another resident to ingest medication not prescribed to them, and for Resident 105 to receive medications with an altered effect.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate was less than 5% (% or percentage is a fraction of a number out of 100) during medication administration. The facility had a total of five errors out of 28 opportunities, which resulted in a facility wide medication error rate of 17.8%. Medication observations were conducted over multiple days, at varied times, in random locations throughout the facility. The five medication errors were identified in one resident (Resident 105) out of six residents observed for medication administration observation when Resident 105's medications were administered via gastrostomy tube (G-Tube-a tube inserted directly into the stomach for nutrition and medication administration) when they were ordered to be administered by mouth (PO). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications were stored in a clean and sanitary environment, when medications were found not to be in its bubble pack (a way to store single doses of medication). The unidentifiable medication was loose at the bottom of the medication cart drawer. This failure had the potential for medications to be unaccounted for, and increased the risk of medication error.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food preferences were honored for Resident 28 and Resident 101 during lunch on 11/7/24, when Resident 28's meal tray was prepared with carrots and ground beef and Resident 101 did not receive a protein portion on her meal tray. These failures had the potential to result in unintended weight loss and other adverse health effects for Resident 28 and Resident 101.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 of 41 sampled residents (Resident 94) received rehabilitation services when Resident 94 was admitted to the facility and an order for Physical Therapy (PT; treatment that helps you improve how your body performs physical movements) and Occupational Therapy (OT; helps you improve your ability to perform daily tasks like getting dressed) was not initiated as indicated in Resident 94's hospital discharge summary. This failure had the potential to result in a decline in physical function for Resident 94.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the menu for 18 of 18 residents who received pureed diets (food that has been ground, pressed, and/or strained to a soft, smooth consistency, like pudding) during the lunch meal service on 9/23/24, when the vegetable served did not reflect what was listed on the menu. This failure had the potential for residents ' preferences not to be met and could result in decreased meal intake.

Inspectors wroteBased on observation and interview, the facility failed to ensure food served from the kitchen was appetizing when, 1. Pureed foods (food that has been ground, pressed, and/or strained to a soft, smooth consistency, like pudding) were not prepared according to recipe directions for the lunch meal on 9/23/24 for 18 of 18 residents who received a pureed diet, resulting in an unappetizing texture; and, 2. The lunch meal served on 9/17/24 was served late and was not at an appetizing temperature for two of four sampled residents. This failure had the potential to result in decreased meal intake. A decrease in meal intake could result in weight loss and malnutrition over time.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare and serve pureed food (food that has been ground, pressed, and/or strained to a soft, smooth consistency, like pudding) at the correct texture for 18 of 18 residents who received a pureed diet, when pureed foods were not prepared according to recipe directions for the lunch meal on 9/23/24. This failure increased the risk of swallowing difficulty for residents who required a modified food texture and could also result in decreased meal intake.

Inspectors wroteBased on observation and interview, the facility failed to store clean dishes in accordance with professional standards for food safety for a total of 144 residents who received food from the kitchen when: 1. Food trays were stacked and put away wet; 2. Plastic drinking glasses were stacked on a tray and still wet. This failure had the potential to put residents eating facility prepared meals at risk for foodborne illnesses.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sampled residents (Resident 2) was examined by a physician at least every 30 to 60 days. This failure had the potential to result in unidentified medical conditions being untreated for Resident 2.

Inspectors wroteBased on interview and record review, the facility failed to provide medically related social services for one of four sampled residents (Resident 3) when Resident 3 ' s follow up appointments with medical specialists were not scheduled as ordered. This failure had the potential to adversely affect Resident 3 ' s health and well- being.

Inspectors wroteBased on interview and record review the facility failed to respond to call lights in a timely manner for 7 out of 11 sampled residents (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, and Resident 9) when residents stated staff did not answer their call lights during the night shift. These failures caused the residents to have unmet needs, Resident 4 to experience an episode of incontinence (loss of bladder control), and Resident 6 and Resident 9 to remain in soiled briefs for over an hour.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe medication storage and labeling practices in three out of eight medication/treatment carts and one out of four medication storage rooms when: 1. The E-Kit (Emergency Kit - a small quantity of medications stored in a locked box that can be dispensed when pharmacy services are not available) was not completely locked and the contents were accessible without breaking the seal. 2. Unopened Insulin (medication used to lower blood sugar) bottles were stored at room temperature. 3. Lorazepam (a controlled medication that is addictive and used to treat anxiety) was not stored in a secured location inside the refrigerator. 4. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure oversight of the facility's nutrition services, when the Dietary Manager (DM) was not qualified, and the facility employed part time Registered Dietitian (RD) Consultants who did not meet the required fulltime 35 hours in a week to oversee the daily operations of the kitchen and food preparations. This failure had the potential to jeopardize the health and safety of a census of 146 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe food production for 139 residents of a census of 146 who received food service from the kitchen when: 1. Open food packages including produce as follows: A five gallon box of thickened water, five boxes of juice attached to a dispensing machine, a box of 40 bunches of celery, a 2.5 pound bag of ground beef, and one bag of fettuccini were not labeled with an open date and/or use by date. 2. Expired food products as follows: 19 health shake cartons, one bag of brussels sprouts, four bags of shredded cabbage, one bag of fettuccini, a 20 pound bin of pearled barley, a 10 pound box of couscous, and three boxes of 100 iced pops were not removed from kitchen and were available for use. 3. The walk-in refrigerator was not clean; and, 4. A cook was not wearing a hairnet while handling food. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the needs were accommodated for 2 of 30 sampled residents (Resident 106 and Resident 8) when Resident 106 and Resident 8's call light (a device used to request assistance from facility staff) were not within reach. This failure had the potential for Resident 106 and Resident 8 to not have their needs met and delay in care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 2 of 30 sampled residents (Resident 45 and Resident 67) were screened accurately for a mental disorder and/or intellectual disability, to determine the required level of care and services when: 1. Resident 67's Level 1 Preadmission Screening and Resident Review (PASRR-the initial tool used to evaluate all residents for mental illness and/or intellectual disability, to ensure the most appropriate setting and/or services are provided) was completed inaccurately, and the facility did not follow up to revise the evaluation; and, 2. Resident 45 was not re-evaluated for a Level 2 assessment (an evaluation to determine the need for specialized services) as required. These failures placed Resident 45 and Resident 67 at risk to not receive the care and services they were eligible for.

Inspectors wrote2b. During a concurrent observation and interview on 10/10/23, at 2:01 p.m., with LN 2 in Resident 9's room, LN 2 confirmed Resident 9's oxygen flow rate was at 3 LPM. LN 2 stated the oxygen flow rate for Resident 9 should be 2 LPM as ordered by physician. A review of Resident 9's Order Summary indicated, .Last Order Date 12/14/22 .Revision Date 10/10/23 .Order Description: Oxygen at 2/LPM continuous via Nasal Canula [ NC-a small flexible tube that contains two open prongs intended to sit just inside the nostrils] every shift for Shortness of Breath . A review of Resident 9's care plan titled, The resident has oxygen therapy initiated on 3/2/23, indicated interventions which included, .OXYGEN SETTINGS: O2[ oxygen] via NC at 2 l/min continuous . During an interview on 10/10/23, at 2:04 p.m., in Resident 9's room, Resident 9 stated his oxygen flow rate had been 3 LPM for months. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe handling of hazardous drugs (drugs that may pose health hazard upon exposure during handling and capable of causing serious effects including toxicity, fertility problems, and birth defects) during medication administration when: The nursing staff did not wear proper Personal Protective Equipment (PPE - gloves, mask, gown) when administering and handling hazardous drugs for two out of 30 sampled residents (Resident 77 and Resident 88). This failure had the potential for unsafe drug exposure that could have affected the health and safety of the licensed nurses who handled the hazardous drugs.

Inspectors wroteBased on interview and record review the facility failed to ensure the adverse effects (side effects) of psychotropic drugs (drugs that affect mood and mind) were monitored and resources were readily available to guide the nursing staff for safe monitoring in 1 out of 30 sampled residents (Resident 116). This failure could pose health risks in monitoring the adverse effects of medications in a timely manner.

Inspectors wroteBased on interview and record review, the facility failed to maintain complete medical records for 1 of 30 sampled residents (Resident 56) when the hospice (specialized in end-of-life care for all residents with an advanced, life-limiting illness) agency's nurse progress notes (provide an essential record of patient care that can help improve patient outcomes) were not contained in the clinical record. This failure had the potential to not provide sufficient information that reflected the condition, care, and services provided for Resident 56.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection prevention and control practices for 1 of 12 residents (Resident 111) with an indwelling urinary catheter (a tube inserted into the bladder to drain or collect urine) when Resident 111's indwelling urinary catheter drainage tubing was on the floor. This failure had the potential for Resident 111 to have complications related to indwelling urinary catheter use and/or risk for infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a sanitary environment when 2 of 30 sampled residents' room were observed with drywall damaged. The failure had the potential to cause infection from contamination. During an observation and concurrent interview, on 10/10/23, at 9:00 a.m., the wall behind Resident 124's bed was damaged. The paint had been removed and the drywall was exposed. Resident 124 stated it had been like that for a while. During an observation on 10/10/23, at 9:05 a.m., the wall behind Resident 102's bed was damaged. The paint had been removed and the drywall was exposed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the results of the most recent survey were readily accessible to residents, family members, and legal representatives of residents, for a census of 146, when the facility's most recent survey results were not posted. This failure prevented the residents, family members, and legal representatives of residents to examine the facility's survey results without asking to see them.