Delta Oaks Post Acute

Inspectors wroteBased on interview and record review the facility failed to implement effective interventions and supervision to ensure the safety of one resident (Resident 2), in a sample of six when Resident 1 (Resident 2's roommate), who had an extensive history of verbal aggression towards Resident 2, hit Resident 2 on his legs on 5/7/26. This failure resulted in Resident 2 having 3 out of 10 pain (A pain level of 3 on a standard 0 to 10 scale indicates mild, noticeable pain) and placed Resident 2 at risk of psychosocial harm including fear, anxiety, depression, withdrawal, and feelings of hopelessness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a comprehensive care plan (written plan that guides staff on daily care, safety, and interventions based on the resident's needs) for 1 of 6 sampled residents (Resident 1) when, Resident 1's trauma assessment and progress notes section of Resident 1's electronic health record indicated Resident 1 had PTSD (Post-Traumatic Stress Disorder. It is a mental health condition triggered by experiencing or witnessing a terrifying, life-threatening, or deeply shocking event. While it is completely normal to feel afraid or stressed immediately after trauma, people with PTSD experience long-lasting symptoms that interfere with their daily lives). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure interventions were implemented to maintain and prevent decline in psychological functional ability (represents an individual's capacity to perform essential daily tasks, work, and interact with their environment) for 1 of 6 sampled residents (Resident 2) when Resident 2 did not have a psychological or behavioral health consult as outlined in the comprehensive care planned interventions. This failure placed Resident 2 at risk for a decline in functional and psychosocial health (complications related to the dynamic interplay between psychological well-being -thoughts, emotions, identity- and social environment -relationships, cultural context, and societal influences).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure services provided met professional standards of practice for 1 of 6 sampled residents (Resident 1) when the facility failed to follow up on a referral from 1/15/26 from the optometrist (an eye care professional who provides primary vision care) and make arrangements for an appointment/transportation for Resident 1 to be seen by an ophthalmologist (a medical doctor (MD) who specializes in eye and vision care. They are qualified to perform eye surgery, diagnose and treat complex eye diseases, and prescribe vision correction tools like glasses and contact lenses). This failure had the potential to place Resident 1 at risk for functional decline and complications from delayed treatment.

Inspectors wroteBased on interview and record review, the facility failed to ensure the appropriate discharge process was followed for one of two sampled residents (Resident 1) when;1. The facility did not provide a copy of the 30-day Notice of Transfer/Discharge (a written document given to residents or their representative when a facility plans to move them to another location or end their stay) to Resident 1;2. The facility failed to provide a copy of Resident 1's discharge notice, dated 4/9/26, to a representative of the Office of the State Long-Term Care (LTC) Ombudsman (advocates for residents of nursing homes to protect resident rights);3. The contents of the discharge notice signed by Resident 1 on 4/9/26 did not include the discharge location; and 4. An updated discharge notice when a discharge location was identified on 4/20/26 was not given to Resident 1 until the day of discharge on [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility failed to review and revise the comprehensive person-centered care plan (a step-by-step guide for staff to make sure a person gets the right care in the right way) as necessary to reflect changes in one of two sampled residents (Resident 1) related to discharge planning. This failure had the potential to result in an uncoordinated discharge that did not adequately address Resident 1's discharge needs and preferences.

Inspectors wroteBased on interview and record review, the facility failed to implement safety measures to prevent accidents for one of three sampled residents (Resident 1) when on 3/31/26 while Certified Nursing Assistant (CNA) 1 was providing care alone to Resident 1 on a low air loss mattress (LAL -low air loss mattress, a specialized therapeutic surface featuring air-filled bladders with tiny holes that release a constant, gentle flow of air), Resident 1 fell off of the bed onto the concrete ground. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to practice appropriate infection prevention and control measures for a census of 116, when on 4/14/26: 1. Licensed Nurse (LN) 4 did not perform hand hygiene (the action of cleansing hands to remove germs, dirt, and microorganisms (bacteria/viruses) includes washing with soap and water or a alcohol-based hand sanitizer) between glove changes while providing tracheostomy (a surgical procedure that creates an opening in the neck and directly into the windpipe to create an alternative airway) inner cannula tube (a removable, hollow liner that fits inside the main body (outer cannula) of a tracheostomy tube) care and suctioning to Resident 1 (procedure that uses a vacuum-connected hollow tube to remove mucus, saliva, and secretions from a patient's breathing tube); and, 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 2) received medications as ordered by the physician and was free of significant medication errors (one which could jeopardize the residents health and safety) when on 4/1/26 Resident 2 was given two of Resident 4's medications in error. This failure may have contributed to Resident 2 being sent out to a hospital for vomiting blood on 4/6/26. In addition, this failure had the potential to interact with Resident 2's other medications causing additional harm to Resident 2's health and safety.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure medications were stored safely and securely for a census of 116, when on 4/14/26 Licensed Nurse (LN) 5 left medications on top of a medication cart (a mobile cart containing medication used for administration of medication to residents) and left the medication cart unlocked when she walked away from it. These failures had the potential for medication diversion (medication taken by someone it was not intended for), and unsafe medication use in the facility.

Inspectors wroteBased on interview, and record review, the facility failed to ensure resident Interdisciplinary Team Care Conferences (IDT, a care plan meeting with the resident and family members where interdisciplinary team members from different healthcare disciplines discuss, identify, address, implement and review plans to meet needs regarding the resident's care) were conducted quarterly for three of three sampled residents (Resident 1, Resident 2 and Resident 3) when IDT Care Conferences were not documented quarterly in 2025 for Resident 1, Resident 2, and Resident 3. These failures had the potential for unmet care needs for Resident 1, Resident 2 and Resident 3.

Inspectors wroteBased on interview, and record review, the facility failed to report to the Department an injury of unknown source in accordance with the facility's abuse policy and procedure (P&P) for one of one resident (Resident 1) when on 2/2/26, Resident 1 was found with an unexplainable left shoulder dislocation (an injury that occurs when the upper arm bone pops out of the cup shaped socket near the shoulder blade). This failure denied the Department the ability to conduct a timely investigation and placed Resident 1 at risk for abuse. In addition, the facility failed to comply with federal and state reporting regulations.

Inspectors wroteBased on interview, and record review, the facility failed to investigate an injury of unknown origin for potential abuse for one of one resident (Resident 1) when Resident 1 was found with an unexplainable left shoulder dislocation (an injury that occurs when the upper arm bone pops out of the cup shaped socket near the shoulder blade) on 2/2/26. This failure placed Resident 1 and other residents in the facility at risk for unidentified abuse and had the potential to hinder protection from ongoing abuse.

Inspectors wroteBased on interview, and record review, the facility failed to complete and document a significant change in status assessment (Significant Change in Status Assessment, SCSA, refers to a comprehensive assessment that must be completed when the Interdisciplinary Team [IDT, a team of professional staff or a care team consisting of different disciplines who work together towards the goals of their residents] has determined that a resident meets the significant change guidelines for either major improvement or decline) for one of one resident (Resident 1) when Resident 1 was found with a left shoulder dislocation (an injury that occurs when the upper arm bone pops out of the cup shaped socket near the shoulder blade) on 2/2/26. This failure had the potential to result in unmet care needs for Resident 1 when the plan of care for Resident 1 was not current. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide adequate care and supervision (an intervention and means of mitigating the risk of an accident) for one out of two sampled residents (Resident 1) to ensure resident safety when, the facility staff did not take immediate action to locate Resident 1 when Resident 1 left the facility for more than four hours past his expected return time for a medical appointment on 10/16/25. This failure resulted in Resident 1 eloping from the facility on 10/16/25 and Resident 1 did not return to the facility until approximately 29 hours later. Resident 1 was transferred to hospital, was positive for illicit drug use (use of illegal drugs (e.g., heroin, cocaine) and/or inappropriate use of prescription medications), and missed scheduled intravenous (IV; [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure a comprehensive person-centered care plan (a structured document that outlines a patient's healthcare needs, goals and the nursing interventions needed to achieve them), was developed for 1 of 3 sampled residents (Resident 2) when, an elopement care plan was not developed for Resident 2 after Resident 2 was identified as at risk for elopement on 12/24/25. This failure put Resident 2 at risk for elopement.

Inspectors wroteBased on interview and record review, the facility failed to provide comprehensive pain management, for one of three sampled residents (Resident 1) when, Resident 1 had not been given the appropriate pain medication as per the pain assessment scale (a tool used to assess the level of pain) and provided pain medication as ordered by the physician. This failure resulted in Resident 1's pain not being effectively managed and Resident 1's pain not being treated per the physician's orders.

Inspectors wroteBased on interview and record review, the facility failed to refer one of two sampled residents (Resident 1) to a psychiatrist (a medical doctor who can diagnose and treat mental health conditions) as recommended by the Interdisciplinary Team (IDT, a group of professionals who have a role in the Resident's care) and ordered by the physician after Resident 1 had a behavioral manifestation of agitation during an altercation with another resident (Resident 2) on 10/24/25. This failure could potentially result in increased agitation episodes for Resident 1 and a risk of getting involved in another altercation incident. A review of Resident 1's admission RECORD, indicated Resident 1 was admitted with diagnoses which included muscle weakness and difficulty walking. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure garbage and refuse was properly disposed of when 1 of 2 outside garbage dumpster lids were observed not adequately closed for a census of 112. This failure had the potential to expose the residents' environment to pests, odors, or diseases.

Inspectors wroteBased on interviews, and record reviews the facility failed to provide a safe discharge process for one resident (Resident 1) when:1. Resident 1 was discharged home without a clear plan of care to support his activities of daily living (ADL, tasks of everyday life including eating, dressing, bathing, or showering, and using the bathroom; activities related to daily care) needs;2. Resident 1 was discharged home while facing foreclosure (the action of taking back the property that was bought with borrowed money because the money was not being paid back as formally agreed);3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents' rights to be treated with dignity and respect were honored for seven of 35 sampled residents when:1. Staff were observed standing over Resident 25 and Resident 90 while assisting them to eat their lunch meal on 9/29/25; and,2. Resident 23, Resident 46, Resident 86, Resident 56, and Resident 4 who required the use of incontinent briefs (a type of absorbent material worn to soak up urine and/or contain feces) were told by unidentified nursing staff to urinate and/or defecate (feces) in their bed, due to the lack of available incontinent briefs during the weekend of Saturday 9/27/25 and Sunday 9/28/25. These failures had the potential to negatively impact Resident 25, Resident 90, Resident 23, Resident 46, Resident 86, Resident 56, and Resident 4's psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe and hazard free environment when:1. Safe water temperatures were not maintained in 2 of 4 sampled resident bathrooms; and,2. Resident 10's post mobility assessment was not done after she fell in the bathroom. These failures had the potential to cause physical injuries to residents who resided in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide medications which met the needs of 1 of 35 sampled residents (Resident 46) when on 10/2/25 the following medications were not administered and left on the residents bedside table:Nephro-Vite 1 tablet (used to treat vitamin deficiencies in people with kidney disease),Senna 1 tablet (used to treat constipation); and,Sevelamar - 2 tablets (used to treat high phosphate in the blood in people with kidney disease). This failure had the potential for Resident 46 to experience worsening kidney disease (a decline in kidney function over time), hyperphosphatemia (medical condition characterized by elevated levels of phosphate in the blood in people with kidney failure), and constipation (a condition in which there is difficulty in emptying the bowels or hard feces).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe medication storage and labeling practices in two out of three medication rooms and four out of five medication carts when:1. An external air-conditioning (ac) unit that had a filter with grayish colored dust and debris, was placed on top of a medication refrigerator in Medication Storage room [ROOM NUMBER],2. Two bottles of Drug Buster (an eco-friendly, liquid solution designed for safe and effective disposal of unwanted or expired medications. It dissolves pills, tablets, capsules, and other forms of medication on contact, rendering them non-toxic and safe for disposal in regular trash) were found soiled and in active use in two different medication carts,3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, and serve food per safety standards when:1. Three tomatoes were found with mold and a discolored, flattened, and mushy apple were in the walk-in refrigerator,2. Frozen fish fillets, beef patties, meatballs, and veggie patties were left open to the environment in the reach in meat freezer,3. Small wares (three bowls and a cutting board) were not replaced when worn,4. The cool down log was not followed; and,5. The two-compartment sink did not have an air gap (a break in the plumbing to prevent unsanitary water from flowing back into the sink). These failures had the potential to lead to cross-contamination and food borne illness for the 85 residents eating facility prepared meals.

Inspectors wroteBased on observation, interview, and record review, the facility failed to practice appropriate infection prevention and control measures for a census of 104, when:Urinals were found inside the trash can instead of being placed in the provided urinal receptacle and were not replaced with a clean urinal for Resident 62; and,Flying pests were found inside Resident 65's room; and,Licensed Nurse (LN) 4 did not clean, sanitize, and disinfect a glucometer (device used to measure blood sugar) per manufacturer guidelines. These failures had the potential to spread infections to residents residing in the facility, negatively impacting their health and well-being.1. [...]

Inspectors wroteBased on interview, and record review, the facility failed to develop a baseline care plan within 48 hours of admission as required, to address resident-specific care needs for 1 of 35 sampled residents (Resident 76). This failure placed Resident 76 at risk for not receiving effective person-centered care, and preventing to reach the highest potential for mental, emotional, and/or psychosocial health and well-being.

Inspectors wroteBased on interview, and record review, the facility failed to provide a resident centered care plan for 2 of 35 sampled residents (Resident 65 and Resident 76) when:1. Resident 65 was taking a blood thinner medication and there was no care plan developed to monitor for potential side effects or risk of bleeding; and,2. Resident 76 did not have a care plan for blood thinning medications. These failures placed Resident 65 and Resident 76 at risk for potentially serious complications and not receiving effective and person-centered care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate treatment and services were provided when one of 35 sampled residents (Resident 97) did not receive the appropriate range of motion (ROM - the distance and direction a joint can move) services. This failure had the potential to result in decreased ROM, further functional decline, and/or pain and discomfort for Resident 97.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure proper hydration (process of providing fluid to the body) for one of 35 sampled residents (Resident 5) when Resident 5's water was out of reach. This failure placed Resident 5 at risk of dehydration (condition where your body loses more fluid than it takes in, resulting in insufficient water for its normal functions).

Inspectors wroteBased on interview, and record review, the facility failed to provide medically- related social services for 1 of 35 sampled residents (Resident 19) when the facility failed to honor Resident 19's requests and wishes to be transferred to a facility closer to home. This failure placed Resident 19's health and psychosocial well-being at risk for potentially serious complications which could have impacted his quality of life and could have lowered his self-esteem (confidence in one's own worth or abilities).

Inspectors wroteBased on interview, and record review, the facility failed to ensure safe monitoring and assessment of blood pressure (BP -the force of your blood pushing against the walls of your arteries as your heart pumps blood and was measured as two numbers: systolic [when the heart beats] and diastolic [when the heart rests between beats]) and heart rate (HR -frequently of your heart beats per minute) for a medication used to treat low (hypotension) BP for two of six sampled residents (Resident 17 and Resident 80), when:1. Resident 17's physician prescribed hold parameters (a set of numbers that guide the nursing staff when to not give [hold] a medication) for Midodrine (a medication used to treat low blood pressure) were not followed 13 times between 8/15/25 and 10/1/25; and,2. Resident 80's physician prescribed hold parameters for Midodrine were not followed 13 times between 8/1/25 and 9/30/25. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe medication administration practices when the medication error rate was more than 5% ( % percentage - number or ratio expressed as a fraction of 100) with a resident census of 104. Medication administration observations were conducted over multiple days, in random locations throughout the facility. The facility had a total of 2 errors out of 32 opportunities which resulted in a facility wide medication error rate of 6.25% for 2 of 6 residents (Resident 68 and Resident 17) observed for medication administration. These failures had the potential to result in unsafe medication use and medication errors affecting the resident's health and well-being.

Inspectors wroteBased on interview and record review, the facility failed to offer, obtain informed consent and provide education to a resident or resident 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 and pneumococcal (a serious bacterial infection that can cause respiratory illness) vaccine for two out of five sampled residents (Resident 13 and Resident 65) when:1. Resident 13 was not offered the flu vaccine for 2 years.2. Resident 65 was not offered the pneumococcal vaccine within 30 days of admission. [...]

Inspectors wroteBased on interview, and record review, the facility failed to provide COVID-19 vaccine, for one out of five sampled residents (Resident 65) when:1. Resident 65s' clinical record did not contain documented evidence that the COVID-19 vaccine was administered within 30 days upon admission.2. Resident 65's COVID-19 vaccine information history was not obtained and documented in the medical record. This deficient practice put Resident 65 at risk to be infected with COVID-19 virus that could lead to severe illness, hospitalization, and/or death. During a concurrent interview and record review on 10/1/25, at 12:49 PM, with the Infection Preventionist (IP), the IP stated the facility offered a COVID-19 vaccine to all residents upon admission. The IP stated that the admitting nurse is the one responsible for offering the COVID-19 vaccine and obtaining consent upon admission. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure interventions (actions, treatments, procedures, or activities designed to meet a residents goals) listed on a resident centered comprehensive care plan (a list of resident specific problems, goals, and interventions) were specific to the care and services that would be implemented for two of three sampled residents (Resident 1 and Resident 3) when, Resident 1 and Resident 3's gastrostomy tube (G-tube; a thin tube surgically inserted into the stomach area to provide a direct route for delivering nutrition, medications, and fluids) care plan intervention indicated to provide dressing to the g-tube site as ordered, however there was no physician order for Resident 1 or Resident 3 in regards to g-tube skin care and dressing instructions and/or frequency. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure appropriate treatment and services were provided to prevent potential further decline in range of motion (ROM; the extent to which a joint can move through its entire range of motion without pain or restrictions) for one of three sampled residents (Resident 1), when Resident 1's ordered Restorative Nursing Program (program to help ensure that residents retain the skills gained in physical therapy and prevent declines that can impact the quality of a resident's life) to provide passive range of motion (PROM; when another person or a machine moves a patient's limb or joint through its full range of motion without the patient's active muscle contraction or effort) to Resident 1's bilateral lower extremities (BLE; both legs) was discontinued on 2/5/25 without an updated referral from the therapy department. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a physician order was in place to indicate the appropriate care of a gastrostomy tube feeding (G-tube; a thin tube surgically inserted into the stomach area to provide a direct route for delivering nutrition, medications, and fluids) for 2 of the 3 sampled residents (Resident 1 and Resident 3) to prevent potential complications of the feeding tube when, Resident 1 and Resident 2 did not have a physician treatment order to indicate the care needed for the G-tube site. This failure had the potential for Resident 1 and Resident 3 to experience skin breakdown and infection at the G-tube site.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly prevent the spread of COVID-19 when one direct care staff member, (Certified Nursing Assistant [CNA] 1) did not wear the required personal protective equipment (PPE, includes gowns, gloves, eye protection, face masks, or respirators worn to prevent the spread of germs and infection) prior to entering the room of residents who were COVID-19 positive (Resident 1 and Resident 2). This failure had the potential for CNA 1 to become infected with COVID-19 and to spread COVID-19 to other facility residents, staff, and visitors. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure adequate supervision and monitoring were maintained for one of six sampled residents (Resident 1) when staff did not verify Resident 1's Wanderguard (a monitoring device that alerts staff when a resident approaches a restricted area and attempts to exit a designated zone) placement every shift. This failure potentially contributed to Resident 1 leaving the facility on 4/7/25 without staffs' knowledge and placed Resident 1 at risk for injury.

Inspectors wroteBased on interview and record review, the facility failed to submit the investigation report of an allegation of abuse involving two of three sampled residents (Resident 1 and Resident 2) to the Department, within 5 days of the incident. This failure had the potential to result in the inability to protect Resident 1 and Resident 2 from further abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate supervision was provided for a census of 103 when several nursing staff were on their personal cellphones during work hours. This failure had the potential to cause psychosocial harm and/or potential injury to all residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) who was dependent on staff for activities of daily living (ADLs-routine tasks/activities such as bathing, dressing, grooming a person performs daily to care for himself or herself) received services to maintain personal hygiene when Resident 1 was not provided showers as scheduled from 1/9/25 through 3/11/25. This failure had the potential to cause discomfort, skin impairment, infection, and a decline in emotional and psychological well-being.

Inspectors wroteBased on interview and record review the facility failed to ensure one of three sampled residents (Resident 1) was free from physical abuse when Resident 2 was alleged to have hit Resident 1 on the chin and stomach on 3/16/25 and was witnessed hitting Resident 1 on the face on 4/1/25. This failure caused Resident 1 to suffer emotional distress and had the potential to negatively affect her physical and psychosocial wellbeing.

Inspectors wroteBased on interview, and record review, the facility failed to provide the proper notice for discharge for 2 of 2 sampled residents (Resident 1, and Resident 2) when a written notice of discharge for Resident 1 and Resident 2 was not sent to the State Long-Term Care Ombudsman's office (a government appointed person who actively supports the rights of the long term care residents). These failures violated Resident 1 and Resident 2's rights from the Ombudsman being informed of the discharge decisions and removed the opportunity for the Ombudsman to advocate on behalf of Resident 1 and Resident 2 with the potential of having an inappropriate discharge.

Inspectors wroteBased on interview, and record review, the facility failed to provide adequate supervision for one of five sampled residents (Resident 1) when Resident 1's physician order to monitor every 15 minutes for suicidal ideation (thinking about, considering, or being preoccupied with the idea of death and suicide) was not followed. This failure resulted in Resident 1 causing harm to himself by cutting his arms and legs multiple times with a razor blade on 8/8/24 and being admitted to an acute care hospital for treatment.

Inspectors wroteBased on interview and record review, the facility failed to ensure care provided to one of three sampled residents (Resident 1) met professional standards when, Resident 1's medication ordered upon discharge from the hospital, insulin lispro (fast acting insulin to control the levels of sugar in the blood), was not continued at the skilled nursing facility upon admission. This failure had the potential for Resident 1 to have complications related to high blood sugar (normal fasting blood sugar range is 70 to 100).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe use of a resident lifting machine for one of three sampled residents (Resident 2) when Certified Nursing Assistant (CNA) 1, used the lifting machine for Resident 2 without another CNA present to assist. This failure placed Resident 2 at risk for injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide medications which met the needs of one of three residents (Resident 2) when the following medications due at 9 a.m. were not administered and left at the bedside: Aldactone (used to treat heart failure), Digoxin (used to treat heart failure), Flagyl (an antibiotic used to treat infection), Furosemide (used to treat excess fluid in the body), and Tradjenta (used to treat diabetes - issues with blood sugar control) This failure had the potential for Resident 2 to experience elevated blood pressure, increased work of the heart, fluid retention, elevated blood sugar, and a worsening of her infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain its infection prevention control program for one of three sampled residents (Resident 2), when Certified Nursing Assistant (CNA) 1: a. Did not use personal protective equipment (PPE) during care of Resident 2 who required contact precautions (protective measures taken for infections which spread by means of contact with the resident or their environment); b. Transported Resident 2 to the physical therapy room; and, c. Did not clean and sanitize the equipment used to lift Resident 2, which was shared with other residents. This failure had the potential to expose other residents and staff to Clostridium difficile (C. diff. is a communicable illness that can cause diarrhea and colitis, an inflammation of the colon, and can be life threatening) infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide reasonable accommodation of needs for 1 of 9 sampled residents (Resident 1) when Resident 1's call light (a device used to call for assistance) was not within reach. This failure had the potential to result in Resident 1 being unable to ask for needed assistance and placed Resident 1's safety at risk.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide one of nine sampled residents (Resident 1) with twice weekly scheduled bathing. This failure had the potential to negatively impact Resident 1's personal hygiene and psychosocial well-being as well as promote infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services that meet professional standards of quality for one of nine sampled residents (Resident 1) when Certified Nursing Assistant (CNA) 3 applied a discontinued, prescription (ordered by a physician) cream on Resident 1. These failures decreased the potential to provide safe, effective care and services to Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe infection prevention and control practices were implemented for one of 9 sampled residents (Resident 7) when three bedpans (a container used to collect urine or feces, and it is shaped to fit under a person lying or sitting in bed) in Resident 7's shared bathroom, were soiled and unlabeled with a resident name and were left on the floor in a plastic storage basket. These deficient practices could contribute to the spread of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to practice appropriate infection prevention and control measures for a census of 104, when: 1. Multiple staff members did not wear the appropriate Personal Protective Equipment ([PPE] clothing and equipment that is worn or used in order to provide protection against hazardous substances or environments) while giving patient care, 2. Staff did not dispose of used PPE in an appropriate manner for Resident 2 and Resident 3; and, 3. Four resident rooms had trash cans that had garbage inside of them without liners being placed in the trash cans. These failures had the potential to spread infections to residents residing in the facility, negatively impacting their health and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe, clean, and comfortable living environment for one of seven sampled residents (Resident 1), when Resident 1 did not have a trash can in his room to dispose his trash. This failure had the potential to negatively impact Resident 1's homelike environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure professional standards of quality care were met for three of three sampled residents (Resident 1, Resident 2, and Resident 3) when, Resident 1 and Resident 3 ' s blood sugars (finger prick blood test to check blood sugar level) were not monitored before meals; and Resident 1, Resident 2, and Resident 3 ' s scheduled medications were not administered in a timely manner. These failures had the potential to negatively affect the therapeutic benefits of the medications prescribed to Resident 1, Resident 2, and Resident 3; and for Resident 1 and Resident 3 to receive unnecessary insulin (injectable medication used to manage blood sugar) doses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their infection control policies and procedures for 1 of 30 subacute (require special medical equipment, supplies, and treatments) residents (Resident 1) when licensed nurse (LN) 6 was observed suctioning (a procedure that removes excess secretions from a patient's respiratory tract when they are unable to do on their own to clear the airway and improve breathing) Resident 1 on Enhanced Standard Precautions (EBP- set of infection control measures to reduce the transmission of resistant germs through gown and glove use during high-contact resident care activities) without the required personal protective equipment (PPE- gowns, gloves, eye protection, facemasks or respirators used to prevent the spread of germs). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety when: 1. A dented can was found in canned foods storage, 2. Expired foods were not discarded and available to be served to residents, 3. Cereal in dry storage was not covered, 4. Food preparation and service items were found dirty, 5. Food items were mislabeled, 6. Rental coffee machine had not been recently serviced and filter was more than three years old, 7. Nursing staff did not protect resident food and beverage during meal service, 8. Adequate utensils were not available during meal service, 9. Custard did not undergo the cool down process, 10. Staff unable to state manual dish washing process, and, 11. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure four of 37 sampled residents had accommodations in place to have their needs met when: 1. Resident 11's call light was not within reach, and 2. Resident 37's side rails were not in the correct position for self-adjustment in bed, and 3. Resident 62's call light was not within reach, and 4. Resident 16's call light was not within reach. These failures could have resulted in injury, loss of physical function, and residents' needs not being met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respiratory care practices were consistent with professional standards of practices for five residents using oxygen in a sample of 37 when, 1. Resident 47's oxygen tubing was not changed and dated per facility standards of practice; 2. Resident 53's doorframe did not contain signage that indicated oxygen was in use; and, 3. Resident 84 and Resident 106's oxygen concentrator [a machine which converts room air to oxygen] filters contained a large amount of dust and debris; and Resident 64's oxygen concentrator had no filter, and the air intake contained a large amount of dust and debris. These failures put vulnerable residents ar risk for infection, and placed Resident 53 at risk for injury related to use of a flammable gas.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide medication to meet the needs of 2 of 37 sampled residents (Resident 50 and Resident 67), when: 1. Resident 50's medications were signed off as given prior to administering to Resident 50, and were administered late; and, 2. Resident 67's medication to keep blood pressure from being too low was not administered per physician orders. These failures had the potential to result in Resident 50 experiencing increased pain and a drop in her blood pressure, and Resident 67 not receiving the therapeutic effect of her medication with a potential for abnormal blood pressure

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect residents from significant medication errors when: 1. Resident 53 was given medication that was not ordered by the physician; and, 2. Resident 114's medications, including controlled substances, were left at Resident 114's bedside. These deficient practices had the potential for Resident 53 to suffer serious effects from a narcotic overdose, and had the potential for Resident 114 to miss or take her medications late, or for another resident to take them with the risk of serious effects.

Inspectors wroteBased on interview and record review, the facility failed to ensure implementation of their policy regarding personal food storage when there was not a microwave or refrigeration unit for the residents of the facility. This failure had the potential to limit resident rights and enjoyment of food brought by family and visitors as well as decrease the safety of food from both inside and outside the facility when proper storage and reheating was not available.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure safe infection prevention practices were used for a census of 118 when: 1. A bedpan (a container used to collect urine or feces, and it is shaped to fit under a person lying or sitting in bed) in Resident 43's shared bathroom was unlabeled with a resident name and was left on the floor, and 2. Resident 96's room contained clutter, unknown items, and trash. These failed practices could contribute to the spread of infection by cross-contamination in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 2 of 37 sampled residents (Resident 71 and Resident 100) were treated with dignity when, 1. Dentures were not provided in a timely manner for Resident 71, and; 2. Certified Nursing Assistant (CNA) 4 stood over Resident 100 while assisting him with his meal. These failures resulted in Resident 71 having feelings of sadness, and not wanting to smile due to not having dentures and Resident 100 not receiving his meal with dignity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a homelike environment for 1 of 37 sampled residents (Resident 43), when the facility did not ensure Resident 43's personal belongings were stored per the resident's preference. This failure placed Resident 43 at an increased risk for falls/accidents and potentially psychosocial distress.

Inspectors wroteBased on interview and record review, the facility failed to ensure that 1 of 37 sampled residents (Resident 30) was free from verbal abuse by facility staff when Certified Nursing Assistant (CNA) 7 called Resident 30 derogatory names. This failure caused an unsafe environment for Resident 30 in the facility, made her feel uncomfortable, and resulted in psychosocial distress.

Inspectors wroteBased on interview and record review, the facility failed to implement its abuse policy for one resident (Resident 30) who alleged verbal abuse by a staff member, in a sample of 37, when the facility did not initiate a timely investigation of the alleged verbal abuse incident which occured on 7/13/24, and did not send the results of the investigation to the Department within five working days of the incident. This failure placed Resident 30 and other residents in the facility at risk for unidentified abuse and hindered protection from potential ongoing abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Preadmission Screening and Resident Review (PASRR- to ensure that individuals with mental illness receive specialized services) Level ll (2) was completed for 1 of 37 sampled residents (Resident 89). This failure had the potential for Resident 89 to not receive adequate services to prevent mental health decline.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a document describing agreed goals of care, and outlining planned medical, nursing and health activities for a resident) for 1 of 37 sampled residents (Resident 95) when Resident 95's mobility care plan interventions did not include items to assist Resident 95 to reach the care plan goal of using bedrails for mobility, and there were no bedrails present on Resident 95's bed. This failure placed Resident 95 at risk for loss of independence, falls and injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure activities of daily living (ADL) were provided to maintain good hygiene for one of thirty-seven sampled residents (Resident 40) when Resident 40's fingernails were long with sharp edges and contained a black substance under the fingernails. This failure resulted in Resident 40's nails not being well groomed, and the potential for injury due to sharp edges, and infection due to harboring microorganisms (bacteria, virus, or fungus).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a living environment free from the potential of accidents and hazards for 2 of 37 sampled residents (Resident 95 and Resident 96), when: 1. Resident 96's room was full of clutter; and 2. Resident 95 was not provided a bed rail to assist with transfers and enhance mobility. These failures placed Resident 95 and Resident 96 at an increased risk for falls and possible injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain acceptable parameters of nutritional status when care planned interventions and food preferences were not provided for one of four sampled residents (Resident 37) who had a history of unplanned weight loss. This failure had the potential for Resident 37 to have further weight loss, skin breakdown, and malnutrition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide treatment and care in accordance with professional standards of practice for one of two sampled residents (Resident 375) with a peripherally inserted central catheter (PICC, a type of long catheter that is inserted through a peripheral vein, often in the arm, passed through to larger veins near the heart and used to give fluids, nutrition, drugs, or other treatments), when Resident 375's PICC line dressing was not changed for 12 days. This failure increased the risk of Resident 375 developing infection (the invasion and growth of germs in the body) and/or sepsis (a serious condition that happens when the body's immune system has an extreme response to an infection).

Inspectors wroteBased on interview and record review, the facility failed to ensure 1 of 37 sampled residents (Resident 178) was administered PRN (as needed) pain medication when Resident 178 requested the medication. This failure resulted in Resident 178's pain being unrelieved, negatively impacting Resident 178's health and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a respiratory therapy treatment cart and a medication cart, in the facility's sub-acute area (offers more intensive care than what is provided in a skilled nursing facility) were locked and secured, for a census of 118, when: 1. A respiratory therapy treatment cart was left unlocked and unattended; and a medication cart was left unlocked and unattended in the sub-acute area of the facility. 2. The medication refrigerator for Station's 3/4 contained a basin with medications that were submerged or partially submerged in a clear liquid substance. These failures had the potential residents or unauthorized persons could access respiratory treatment supplies and medications they were not prescribed, with the potential for harmful effects; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 of 37 sampled residents (Resident 71) was provided dental services to meet her needs when Resident 71 was not fitted for dentures in a timely manner. This failure resulted in Resident 71 not having dentures, and had the potential to impact Resident 71's quality of life and self esteem.

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of five sampled residents (Resident 1), received quality of care (health services for individuals and populations increase the likelihood of desired health outcomes) according to professional standards of practice (a set of principles, goals, and expectations that describe the rights and responsibilities of professionals in a specific practice) when a tourniquet (a band of rubber wrapped tightly around the arm for a short period of time to more easily visualize the veins for blood removal needed for testing) was left around Resident 1's right arm for approximately three days and the nursing staff did not perform a detailed skin assessment of Resident 1's skin. [...]

Inspectors wroteBased on interview, and record review, the facility failed to notify the physician when a change of condition occurred after one of five sampled residents (Resident 2) complained of chest pain. This failure resulted in Resident 2 not receiving medical tests or a higher level of care and could have resulted in serious injury (heart attack - heart stops beating).

Inspectors wroteBased on interview, and record review, the facility failed to meet the needs of its residents in regards to the quality of laboratory services provided by failing to ensure the contracted (an agency hired by the facility to provide a service) laboratory technician provided quality of care (the degree to which health services for individuals and populations increase the likelihood of desired health outcomes) to one of five sampled residents (Resident 1), when a tourniquet (a band of rubber wrapped tightly around the arm for a short period of time for easier visualization of the veins during blood removal for testing) was not removed after the blood draw (removal of blood from the resident's vein to be tested for abnormalities) was completed. This failure resulted in the tourniquet remaining around Resident 1's arm for approximately three days and led to a skin injury.

Inspectors wroteBased on interview, and record review, the facility failed to take timely action aimed at performance improvement after one of five sampled residents (Resident 1), received substandard (falling short from the norm) quality of care (the degree to which health services for individuals and populations increase the likelihood of desired health outcomes) according to professional standards of practice when a tourniquet (a band of rubber wrapped tightly around the arm for a short period of time for easier visualization of the veins during blood removal for testing) was left around Resident 1's right arm for approximately three days. This failure resulted in a delay in the identification of systemic failures and the implementation (putting a plan into effect) of new safety measures following laboratory blood draws (removal of blood from the vein for testing of abnormalities).

Inspectors wroteBased on interview, and record review, the facility failed to allow one of three sampled residents (Resident 1) to obtain a copy of his medical records in a timely manner. This failure violated Resident 1's right to access his personal and medical records. This failure also could have resulted in a delay of care for Resident 1 regarding the removal of his Gastrostomy Tube (G-Tube- a tube inserted through the wall of the abdomen directly into the stomach which allows for the administration of drugs, medications, and liquid food) to be given to the patient).

Inspectors wroteBased on interview, and record review, the facility failed to ensure two of two residents (Resident 2 and Resident 3) were assessed for risk of falls after a fall occurred and regularly (with a constant or definite pattern, especially with the same space between individual items) per the facility policy and procedure, when a fall risk assessment had not been documented as completed for Resident 2 and Resident 3 after a fall occurred, nor on a regular basis. This failure had the potential for a census of 117 residents in the facility to not be identified as a risk for falls and/or had fall risks measures and/or interventions be put in place, changed and/or modified based off of identified fall risk assessment factors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were in place for one of twenty-eight residents on enhanced barrier precautions (infection control interventions to help stop the spread of germs resistant to medication treatment) when, there was no signage placed outside of Resident 1's room to indicate the type of personal protective equipment (PPE; such as gloves and gowns) for staff to put on prior to specific high contact resident care activities (such as but not limited to bathing, toileting, and wound care). This failure had the potential to spread MDRO's (Multidrug-Resistant Organisms; bacteria that have become resistant to certain antibiotics (medication to treat infections), and these antibiotics can no longer be used to control or kill the bacteria) to Resident 1 and to other residents residing within the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure supervision to prevent accidents for one of seven sampled residents (Resident 4), when Resident 4 eloped (when a resident leaves without the facility ' s knowledge or supervision) and a wander management bracelet (WMB- a wearable device which alerts staff if a resident leaves the building) was placed on 3/22/24, but was not monitored for placement or functionality until 4/27/24. This failure increased the risk Resident 4 could leave the facility without staff knowledge and sustain injury or harm.

Inspectors wroteBased on interview, and record review, the facility failed to ensure that mandatory abuse training was provided to all facility staff when 62 out of 186 staff members did not complete their mandatory abuse training. This failure had the potential to result in an increased risk of failing to recognize and properly handle instances of abuse or neglect towards all the residents in the facility.

Inspectors wroteBased on interview, and record review, the facility failed to ensure an allegation of physical abuse was reported for one of five sampled residents (Resident 1) when the facility failed to report Resident 1's allegation of physical abuse. This failure resulted in a delay in the abuse investigation process and had the potential to affect Resident 1's physical and psychosocial well- being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the needs of four of six sampled residents (Resident 2, Resident 3, Resident 4, Resident 5) were accommodated when call lights (a device used by residents to call for assistance) were not within reach for Resident 2, Resident 3, and Resident 4. These failures had the potential to result in Resident 2, Resident 3, and Resident 4 being unable to ask for needed assistance and to negatively impact their physical and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the needs of three of six sampled residents (Resident 2, Resident 3, Resident 5) were accommodated when water pitchers were not available at the bedside. These failures had the potential to result in potential health problems related to dehydration for Resident 2, Resident 3 and Resident 5.

Inspectors wroteBased on interview and record review, the facility failed to ensure dignity and respect was maintained for one of 3 sampled resident (Resident 1) when the facility failed to notify her family to collect her personal belongings after she was hospitalized and later died. This failure had the potential to prolong the grieving process for Resident 1 ' s family when their loved one's belongings were disposed of without being notified.

Inspectors wroteBased on observation and interview the facility failed to ensure the needs of three of three sampled residents (Resident 1, Resident 2, and Resident 3) were met, when the facility failed to provide the appropriate size of incontinence briefs. This failure resulted in Resident 1, Resident 2, and Resident 3 wearing ill-fitting and uncomfortable briefs.

Inspectors wroteBased on interview and record review, the facility failed to ensure continuing education was provided to certified and licensed staff on the sub-acute unit (a level of care that is defined as a level of care needed by a patient who does not require hospital acute care but who requires more intensive licensed skilled nursing care than is provided to most patients in a skilled nursing facility). This deficient practice had the potential for harm for twenty-six residents on the sub-acute unit when; 1. Four out of eleven Certified Nursing Assistants (CNA), ten out of twenty Licensed Nurses (LN), and seven out of seven Registered Respiratory Therapists (RRT) did not attend the OXYGEN DELIVERY in-service which was offered from 1/29/24 to 2/3/24. 2. [...]

Inspectors wroteBased on interview and record review the facility failed to provide sufficient nursing staff to meet residents' needs when a Registered Nurse (RN) was not scheduled to work on 12/25/23 during the night shift (12 AM- 7:30 AM) or the day shift (7 AM - 3 PM) for a census of 109. This failure had the potential to put the health and safety of clinically compromised residents at risk.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow and maintain an effective infection prevention and control program for a census of 111 residents when: 1. A facility staff entered a room requiring use of gown, N95 mask respirator (a type of mask that filters up to 95% of particles in the air), eye protection, and gloves wearing only an N95 mask on top of a surgical mask (a type of mask that protects the mouth and nose from splashes, sprays, and large droplets that may include microorganisms). 2. Three out of three sampled facility staff did not have a current N95 mask fit test (a test protocol conducted to verify that the specific type and model of N95 mask is both comfortable and provides the wearer with the expected protection) done. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to promote personal hygiene for 1 of 6 sampled residents when Resident 1's showers were scheduled on a day when she went out for dialysis (a treatment for removing wastes products and excess fluids from the blood when the kidneys have failed) treatment. This failure resulted in Resident 1 not being given an opportunity to have a shower for 16 days in the 123 days reviewed.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care in a manner that promoted dignity and respect for 3 of 4 sampled residents (Resident 1, Resident 2, and Resident 3) in the subacute unit when residents who were incontinent of bowels and/or urine were double briefed for staff convenience. This failure had the potential risk to minimize the resident's self-esteem and negatively impact their skin integrity.

Inspectors wroteBased on interview and record review, the facility failed to provide the necessary respiratory care and services in accordance with professional standards of practice, when: 1. Ventilators (machines that act as bellows to move air in and out of your lungs) for Resident 1 and Resident 2 were not checked according to the facility policy; and, 2. Two of seven sampled Licensed Nurses (LN 2 and LN 3) competencies were not current. These failures increased the risk of respiratory distress and unsafe practices.

Inspectors wroteBased on interview and record review the facility failed to meet professional standards of quality when: 1. A physician's order to monitor resident's (Resident 71) fluid intake was not followed; 2. A physician's order was not obtained when Resident 63 was administered oxygen; 3. Facility staff borrowed medication from another resident's supply to give to Resident 2; and, 4. Resident 39 was given Alprazolam (medication used to treat anxiety and panic disorders) without a physician's order. These failures had the potential for residents to receive inaccurate and inadequate care for a census of 108.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure timely provision of assistance with activities of daily living (ADLs, which includes nail care and showers) for two of 30 sampled residents (Resident 39 and Resident 70) when: 1. Resident 70's nails were dirty and long; and, 2. Resident 39's skin was flaky and itchy, and she complained of not receiving her showers as scheduled. These failures had the potential to negatively impact the psychosocial well-being of Resident 70 and Resident 39 as well as promote infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide rehabilitative care and services for two residents (Resident 10 and Resident 48) of 30 sampled residents, when: 1. Resident 48 was not quarterly re-assessed for splint (device that maintains in position a displaced or movable part) use and Restorative Nursing Assistant (RNA) program as indicated in the care plan and progress notes; and, 2. Physical Therapy did not follow-up on Resident 10's RNA referral. These failures decreased the facility's potential to maintain or improve the residents' range of motion (ROM) and prevent contractures (shortening and hardening of muscles, tendons, or tissues).

Inspectors wroteBased on interview and record review, the facility failed to complete the annual performance reviews for five of six sampled certified nursing assistants (CNAs; CNA 4, CNA 5, CNA 6, CNA 7, and CNA 8). This failure increased the residents' potential to receive poor quality of care from CNAs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure accurate accountability and effective storage of controlled medications (those with high potential for abuse or addiction) when random controlled medication audits for one out of four residents (Resident 39) did not reconcile. The medications were signed out of the Controlled Drug Record (CDR, an inventory sheet that keeps record of the usage of controlled medications) but were not documented accurately on the Medication Administration Record (MAR) to indicate they were given to the residents. 2. Have an efficient system in place to accurately document and secure emergency medications (E-Kit) for a census of 108. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility had a 12% error rate when three medication errors out of 25 opportunities were observed during a medication pass for three of seven residents (Residents 2, 3 and 65). These failures resulted in medications not given in accordance with the prescriber's orders which resulted in residents not receiving the full therapeutic effect of the medications or worsening of their medical conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of seven sampled residents (Resident 2) was free of a significant medication error when she was not administered multiple doses of amlodipine (a medication to treat high blood pressure), then was administered medication from another resident's supply for two doses and was administered an incorrect dose of the same medication. These deficient practices had the potential for causing headaches, nausea, nervousness, increased heart rate from not receiving scheduled doses, potential for receiving incorrect medication that was not prescribed for her and worsening of her medical condition due to not receiving the correct dose.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were stored and labeled appropriately when: 1. Medications did not have an open date, or did not have a patient-specific label; and, 2. Medication Storage Room temperatures exceeded acceptable limits for extended periods of time. These failures had the potential for medication errors and/or medications being used past its effective date, and potential for loss of medications and loss of drug potency due to high temperatures.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain the cleanliness of the coffee percolator in the kitchen when it was observed to to have a build up of greyish dust adhering to the the coffee machine. This failure increased the potential for spreading food-borne illnesses by dust contamination of the food preparation area of the residents. The facility census was 108 residents.

Inspectors wrote2. A review of Resident 7's admission record indicated he was last admitted in Summer of 2022 with diagnoses including aphasia (a language disorder that affects a person's ability to communicate), depression (a persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and anxiety (a feeling of fear, dread, and uneasiness). A review of Resident 7's Activities of Daily Living (ADL) care plan, revised 6/15/22, indicated, BATHING: The resident is totally dependent on staff to provide a bath (3x a week) and as necessary .The resident requires (1) staff participation with bathing. A review of Resident 7's MDS, dated [DATE], indicated Resident 7 was cognitively intact and totally dependent on assistance for bathing. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the QAPI (Quality Assurance Performance Improvement) Committee met at least quarterly when documentation of quarterly meetings could not be provided. This failure had the potential to negatively impact the quality of resident care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when: 1. Resident 39's suction equipment was left at the bedside undated with a full suction canister and covered in dust; 2. Sharps containers on medication carts were filled above the fill line; and, 3. Licensed Nurse (LN 3) did not sanitize and disinfect a blood pressure cuff between resident use. These failures had the potential to expose residents and staff to infectious agents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the needs of residents were accommodated for three of 30 sampled residents (Resident 14, Resident 45, and Resident 106) when call lights were not within reach for Resident 14, Resident 45 and Resident 106. These failures had the potential to result in residents being unable to ask for needed assistance and to negatively impact their physical and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review the facility failed to accommodate one of 30 sampled residents (Resident 31) choice for a shower time based on the resident's preference. This failure resulted in Resident 31's preferences and choices not being honored and respected.

Inspectors wroteBased on interview and record review, the facility failed to revise a care plan for one of 30 sampled residents (Resident 70) when the resident had a g-tube (gastrostomy tube, a tube inserted through the belly that brings nutrition directly to the stomach) inserted and was NPO (nothing by mouth). This failure had the potential to result in unmet nursing needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of 30 sampled residents' (Resident 25, Resident 84, and Resident 73) tube feedings (TF, nutrition delivered directly to the stomach using a tube) were not set to the administer the correct volume of formula. This failure increased the residents' potential for not receiving the appropriate amount of nutrition to meet their dietary needs and goals.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 30 sampled residents (Resident 14) was free of unnecessary medications when the resident was prescribed a psychotropic medication (any drug that affects behavior, mood, thoughts or perception) without adequate indication. This failure had the potential to result in the use of an unnecessary psychotropic medication that could cause adverse consequences.