Desert Canyon Post Acute, LLC

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignity by failing to ensure the resident's oxygen concentrator was inventoried in the Resident's Clothing and Possessions. This deficient practice had the potential to result in loss, misplacement, and replacement challenges.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respiratory care provided to residents was consistent with professional standards of practice for one of two sampled residents (Resident 1) reviewed for respiratory care, by failing to ensure there were physician orders for oxygen administration, documentation of when oxygen was administered, and monitored while in use. These deficient practices had the potential to place residents at risk for respiratory complications such as signs and symptoms of tracheal irritation, difficulty breathing, or slow, shallow rate of breathing of oxygen and toxicity (too much oxygen).

Inspectors wroteBased on interview and record review, the facility failed to provide the requested medical records to the responsible party of one of three sampled residents (Resident 1). The facility received the request to release Resident 1's medical records on 4/23/2026. The facility provided the requested medical records on 5/11/2026, 16 days after the date the requested medical records were supposed to be released. This deficient practice violated Resident 1's rights to secure medical records.

Inspectors wroteBased on observation, interview, and record review, the facility failed to honor the resident's right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and support for daily living safely for two of five sampled residents (Residents 46 and 85) reviewed under environment facility task by failing to ensure the hot water in the residents` bathroom sink was between 105 to 120 degrees Fahrenheit (F, a temperature scale commonly used in the United States to measure how hot or cold it is). The deficient practice had violated the resident's right to a safe, clean, comfortable and homelike environment that resulted to residents being unable to bathe comfortably.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignity including the right to be free from physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the resident's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) for five of five sampled residents (Residents 63, 41, 3, 76, and 56) reviewed for physical restraints by failing to ensure: 1. Resident 63's physician's order for Bilateral Bolsters ([often called roll-control bolsters or bed wedges] are long, firm, cushioned pads placed on both sides of a resident's body while they are in bed) had appropriate indication as a restraint and was not tucked under the sheets. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment was free of accident hazards for four of eight sampled residents (Residents 63, 77, 41, and 21) reviewed for accidents by failing to ensure: 1. Resident 63 did not have a furniture or equipment on top of the floor mat (specially designed mats provide cushioning and support to patients who are at risk of falling, helping to prevent serious injuries). 2. Resident 77 did not have medications or biologicals (medicines derived from living organisms-such as humans, animals, or microorganisms-rather than being created from chemicals) left at the bedside. 3. Resident 41 did not have frayed wires (a condition where electrical cables become worn or damaged, exposing the internal wires) on the resident's call light button. 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free of any significant medication errors (the observed or identified preparation or administration of medications or biologicals which are not in accordance with the prescriber's order, manufacturer's specifications, and accepted professional standards) by failing to: 1. Rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (sq, beneath the skin) insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) administration sites for one of one sampled resident (Resident 6). 2. [...]

Inspectors wroteThe facility failed to ensure sufficient kitchen staff had the appropriate skills and competencies to carry out the functions of the food and nutrition service when the Dietary Supervisor (DS), [NAME] 1, [NAME] 2, and [NAME] 3 did not demonstrate knowledge of and / or competency for following International Dysphagia Diet Standardization Initiative (IDDSI - a standardized framework used to classify food textures and liquid thickness for people with dysphagia) testing (methods to confirm the flow or textural characteristics of a particular food or liquid) of mechanically altered diets on 2/23/2026 for one of four residents (Resident 25) on puree diet (a texture modified diet that consists of smooth, pudding-like consistencies that are easy to swallow). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare food in a form designed to meet individual needs for: 1. One (1) of four (4) residents (Resident 25) on puree diet (a texture modified diet that consists of smooth, pudding-like consistencies that are easy to swallow) when the resident`s lunch plate did not contain broccoli that wept (release of moisture, forming liquid on the surface) because International Dysphagia Diet Standardization Initiative (IDDSI, a standardized framework used to classify food textures and liquid thickness for people with dysphagia) testing (methods to confirm the flow or textural characteristics of a particular food or liquid) was not performed to ensure appropriate texture standards for residents with dysphagia (difficulty swallowing). 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen reviewed during the Kitchen task by failing to: 1. Ensure used towels were stored in sanitation buckets or dirty towel bins and not left unattended in the sink, at the trayline (a specialized, assembly-line food service system), and in the dirty dish washing area. 2. Ensure food items in the Dry Food Storage Area were labeled with the date per facility policy and procedure (P&P). 3. Ensure perishable fruits and vegetables were stored in the refrigerator and according to facility P&P. 4. Ensure frozen items in the Ice Cream Freezer were labeled with the contents and date. 5. Ensure food items in the Dry Can Storage Area were properly covered with tight sealed lids. 6. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain documentation and demonstrate evidence of ongoing Quality Assurance and Performance Improvement (QAPI - a data driven proactive approach to improvement used to ensure services are meeting quality standards) program by: 1. Failing to provide documentation of the written QAPI plan (guides the nursing home's quality efforts and serves as the main document to support implementation of QAPI). 2. Failing to provide documentation of data collection and analysis at regular intervals to include falls, which was identified by the facility as a problem issue in the facility. These deficient practices had the potential for systemic failures to go uncorrected and no improvement to the facility's delivery of care for all residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases (a disease that is spread from one person to another through a variety of ways that include: contact with blood and bodily fluids; breathing in an airborne virus; or by being bitten by an insect), and infections by failing to ensure: 1. Resident 41's call light (a button, cord, or remote device in a hospital or nursing home room that allows a patient or resident to electronically alert nurses or staff that they need assistance) that was inside the trash can was sanitized before handing it off to the resident for use observed during random screening of residents. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep the call light (an alerting device for nurses or other nursing personnel to assist a patient when in need) within reach of the residents for two of four sampled residents (Residents 41 and 37) reviewed under environment task. The deficient practice had the potential for residents unable to summon health care worker for help as needed.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents rights to request, refuse, and / or discontinue treatment for one of two sampled residents (Resident 2) reviewed under the Advance Directives (AD - a legal document that outlines an individual's wishes regarding medical care in the event they become incapacitated and unable to communicate their preferences) care area by failing to ensure medical records were updated with a current copy of the resident's Durable Power of Attorney (DPOA or POA, a type of AD). This deficient practice had the potential to violate the resident's right to have their wishes honored regarding health care decisions.

Inspectors wroteBased on interview and record review, the facility failed to document a significant change of condition (COC, is the formal written record of any significant, non-temporary change in a resident's physical, mental, or emotional health [e.g., sudden confusion, falls, weight loss]) on a resident's physical condition that had deteriorated for one of one sampled resident (Resident 5) by failing to inform the resident's representative/family member when the resident fell at the facility on 10/31/2025. This deficient practice had violated the resident's responsible party's right to be informed of the resident's accident and the facility's intervention to mitigate the situation.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident's drug regimen was free from unnecessary drugs (any medication in excessive dose, excessive duration, without adequate indication for its use and monitoring) use of psychotherapeutic drug (any medication capable of affecting the mind, emotions, and behavior) in accordance with facility policy and procedures for one (1) of five (5) sampled resident (Resident 12) reviewed for unnecessary medications by failing to ensure there was a physician's order for the behavior manifestations monitoring, adverse side effects (unwanted or dangerous medication-related side effects) monitoring, and non-pharmacological approach attempted for the use of clonazepam (also known as Klonopin, a medication used to treat panic attacks and control seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause [...]

Inspectors wroteBased on interview and record review, the facility failed to follow its policy and procedure regarding transfers and discharge by failing to ensure that necessary medical information was communicated to the receiving hospital for one (1) of one (1) sampled resident (Resident 90) reviewed for hospitalization. This deficient practice placed Resident 90 at risk for a delay in the continuity of care and receiving the services and treatment the resident needed.

Inspectors wroteBased on interview and record review, the facility failed to ensure the PASRR was completed accurately for one of four sampled residents (Resident 10) reviewed under Preadmission Screening and Resident Review (PASARR - a federal assessment requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care) when Resident 10 was admitted with a serious mental illness and was taking a psychotropic medication (medication that alters brain chemistry to manage mental health conditions by affecting mood, thoughts, behavior, or perception). This deficient practice had the potential to result in inappropriate placement and unidentified specialized services for Resident 10.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan (is a tool that ensures residents receive personalized, comprehensive, and goal-oriented care in a nursing home setting) for one of 21 sampled residents (Resident 5) reviewed for accidents by failing to develop and implement a care plan when the resident fell on [DATE]. This deficient practice had the potential to result in a delay of nursing care and medical interventions for the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary services to maintain good grooming and personal hygiene for two of two sampled residents (Resident 13 and 19) by failing to: 1. Ensure Resident 13's nails were trimmed per family requests and plan of care. 2. Ensure Resident 19's right hand fingernails were cleaned as dirt and dead skin had accumulated under the free edge of the nails from the resident scratching himself. These deficient practices had the potential to result in resident infections caused by abrasions from long fingernails and uncleaned free edge fingernails.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were incontinent of bladder received services and assistance for one (1) of one (1) sampled resident (Resident 40) reviewed for urinary tract infection (UTI- an infection in the bladder/urinary tract) by: 1. Failing to ensure Resident 40's urinal bottle (portable container for collecting urine) was labeled with the name of the resident and the date it was last changed. 2. Failing to ensure Resident 40's urinal bottle was changed per facility practice. These deficient practices had the potential for the resident to experience cross-contamination (the physical movement or transfer of harmful bacteria from one person, object or place to another) and to develop UTI due to potentially contaminated urinal bottle and switching of urinal bottle with other residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the staff providing care and services to a resident who had a feeding tube (are soft plastic tubes through which liquid nutrition travels through the gastrointestinal tract [the series of organs that food and liquids pass through as they are digested, absorbed, and leave the body as feces]) were aware of, competent in, and utilized facility protocols regarding feeding tube nutrition and care for one of one sampled resident (Resident 6) reviewed for tube feeding by failing to ensure Resident 6's old piston syringe (is a large, reusable plastic syringe used to deliver formula, water, or medication directly into the stomach through a feeding tube) for gastrostomy tube (g-tube, a soft, flexible tube surgically inserted through a small opening in the skin of the abdomen directly into the stomach) medication [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure parenteral fluids (liquids, such as medication or nutrition, that are administered to the body by bypassing the digestive system) were administered consistent with professional standards of practice to one of one sampled resident (Resident 5) reviewed for hydration by failing to ensure that Resident 5's peripheral intravenous (IV, within a vein) line (a small, flexible plastic tube (catheter) inserted through the skin into a small vein-usually in the hand, arm, or foot-to deliver fluids and medications directly into the bloodstream) had the date and initials of the licensed nurse who inserted the IV line or changed the IV dressing. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respiratory care provided to residents was consistent with professional standards of practice for three of three sampled residents (Residents 83, 6, and 7) reviewed for respiratory care by failing to ensure: 1. Resident 83's Bilevel Positive Airway Pressure (BIPAP, a non-invasive device used to help people breathe more easily, typically while sleeping or in a hospital setting) tubing was labeled with the date it was provided or last replaced. 2. Resident 6's nebulizer (a typically, electric or battery-powered device that transforms liquid medicine into a fine, breathable mist) mask and tubing dated 2/10/2026 was discarded and replaced with a new nebulizer mask and tubing dated 2/23/2026. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide pain management consistent with professional standards of practice and the residents' goals and preferences for one of one sampled resident (Resident 11) by failing to ensure as needed pain medication was administered per physician's orders and according to parameters for Resident 11. These deficient practices had the potential to result in side effects from unnecessary administration of narcotics including constipation and mismanagement of resident pain resulting in limited resident participation in activities of daily living (ADLs - activities such as bathing, dressing and toileting a person performs daily), general activities, and mobility.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents who received hemodialysis (HD, process of removing waste products and excess fluid from the body) received treatment consistent with professional standards of practice for one of one sampled residents (Resident 86) reviewed under the Dialysis care area by failing to provide communication with the HD Center (a specialized outpatient facility that provides HD) and ensure that licensed nurses (LN) performed and documented assessments before and after Resident 86's hemodialysis sessions. These deficient practices placed the resident at risk for a delay in care and services and a delay in detecting complications resulting from HD.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately account for one dose of tramadol (a controlled medication used to treat pain) affecting Resident 95 in one of two inspected medication carts (Medication Cart 1). This deficient practice increased the risk of diversion (any use other than that intended by the prescriber) of controlled medications (medications with a high risk for diversion) and that Resident 95 could have received too much or too little medication due to lack of documentation resulting in serious health complications such as drug overdose (occurs when a substance is taken in quantities that pose severe health risks or death).

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare the menu to meet a resident`s nutritional needs for one of four residents (Resident 25) on puree diet (a texture modified diet that consists of smooth, pudding-like consistencies that are easy to swallow) by failing to have the puree broccoli recipe available and followed which indicated to perform International Dysphagia Diet Standardization Initiative (IDDSI, a standardized framework used to classify food textures and liquid thickness for people with dysphagia) testing (methods to confirm the flow or textural characteristics of a particular food or liquid) to ensure appropriate texture standards for residents with dysphagia (difficulty swallowing). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents receive food that accommodates their intolerances, preferences, and appealing options of similar nutritive value for one of six sampled residents (Resident 44) when during dining observation facility task on 2/25/2026, the resident was served two well done eggs out of three eggs instead of over easy per resident's preferences and two burnt toasts for breakfast. The deficient practice failed to accommodate the resident preference, which resulted in the resident becoming upset and delayed the resident's breakfast because the food had to be re-prepared correctly.

Inspectors wroteBased on interview and record review the facility failed to ensure the facility did not transfer or discharge a resident in an unsafe manner for one of three sampled residents (Resident 1) when Resident 1 was transferred to recuperative care (a short-term, supportive housing program for people experiencing homelessness who are recovering from an illness or injury but are not sick enough to need a hospital anymore) prior to confirming recuperative care would accept Resident 1. This deficient practice resulted in Resident 1's admission to the hospital after recuperative care did not accept Resident 1's transfer.

Inspectors wroteBased on interview and record review, the facility failed to provide the necessary treatment and services for one of five samples residents (Resident 3) at risk for developing pressure ulcers (a localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure, or pressure in combination with shear) to prevent pressure ulcers from developing, by failing to: 1. Perform the Wound Weekly Monitoring Assessment when Resident 4's wound was not assessed on the week of 9/23/2025.2. Wound care orders were not ordered for five (5) days when Resident 4 had a wound from 9/24/2025 to 9/28/2025.3. On 9/29/2025 Resident 4 was noted with a Change in Condition (COC) with wound increased in size and the Medical Doctor (MD) was not informed to provide an updated of treatment. These deficient practices had the potential for Resident 3's wound to worsen.

Inspectors wroteBased on interview and record review, the facility failed to inform the attending physician (MD) and the Responsible Party (RP) for one of five sampled residents (Resident 3) when Resident 3 was noted with a Change of Condition (COC) on 9/29/2025. This deficient practice had the potential for a delay in Resident 3's care and violated the RP's right to be notified.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a clean and sanitary environment for one of five sampled residents (Resident 4) when on 12/1/2025 Resident 4's bedside fan was noted with thick gray dust. This deficient practice had the potential to negatively impact Resident 3's well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary practices were followed for one of five sampled residents (Resident 4) for food brought from outside of the facility when: 1. Resident 4's food was not properly labeled with use by date. 2. Resident 4's food was not discarded after 48 hours per facility's policy and procedure (P&P). These deficient practices had the potential for Resident 4 to consume food that was unsafe and that can cause foodborne illness (any illness resulting from eating contaminated/spoiled foods). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement its infection control measures for three of three sampled residents (Residents 1, 2, and 3) during a respiratory virus season (a specific period, typically during the fall and winter months, when common respiratory illnesses like influenza [flu-a contagious {spread from one person to another by direct or indirect contact}-respiratory illness caused by influenza viruses], Coronavirus Disease 2019 [COVID-19-a highly contagious respiratory disease thought to spread from person to person through droplets], and Respiratory Syncytial Virus [RSV-common respiratory virus that primarily affects infants and young children, but can also cause illness in older adults and people with underlying health conditions] become more prevalent [widespread] and circulate widely in the population) by failing to wear a mask [...]

Inspectors wroteBased on interview and record review, the facility failed to implement its policy and procedure related to infection control program for three of three sampled Residents (Resident 1, 2, and 3), by failing to: 1. Implement surveillance and monitoring measures to prevent the recurrence and spread of bed bugs (a small, wingless, parasitic insects that hide in places like mattresses and furniture, feed on human blood, and their bites can cause itchiness and allergic reactions) in the facility when on 10/9/2025 bed bugs were found in Room A (Resident 1, 2, and 3's shared room). 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that the comprehensive care plan (a plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs) was reviewed and revised for three of three sampled residents (Residents 1, 2, and 3) by failing to ensure Residents 1, 2, and 3's care plans were revised after a bed bug (a small, wingless, parasitic insects that hide in places like mattresses and furniture, feed on human blood, and their bites can cause itchy welts on the skin) was found in Resident 1's bed mattress in Room A (Resident 1, 2, and 3's shared room) on 10/9/2025. This deficient practice had the potential to delay provision of person-centered care for Residents 1, 2, and 3.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide reasonable accommodation of resident needs and preferences by failing to ensure the call light (an alerting device for nurses or other nursing personnel to assist a patient when in need) was within reach for one of three sampled residents (Resident 1). This deficient practice had the potential to result in a delay of care and services and possible injury to Resident 1 when unable to call for assistance.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignity including the right to be free from physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the resident's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) for two (2) of three (3) sampled residents (Residents 1 and 2) reviewed for physical restraints during a random observation by:1. Failing to complete a restraint assessment quarterly for the continued use of the restraint bed against the wall according to the facility policy and procedure for Resident 1.2. Failing to ensure Resident 2 did not have pillows tucked under the fitted sheet on the right side of the bed. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a written notice indicating the reason for room changes for three of three sample residents (Resident 1, Resident 2, and Resident 3). This deficient practice resulted to Residents 1, 2, and 3 feeling violated their right to refuse for room changes. Cross reference F837.

Inspectors wroteBased on observation, interview, and record review, the facility failed to update the facility's policy and procedure for a room change affecting three of three sampled residents (Residents 1, 2, and 3). This deficient practice resulted to Resident 1, Resident 2, Resident 3 feeling their right to refuse for a room change was violated. Cross reference F559.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide dignity to one of five sample residents (Resident 4) by not fully covering Resident 4 and exposing his incontinence brief while walking with physical therapist in the hallway. This deficient practice could lead Resident 4 to feel uncomfortable, lose dignity, and lose modesty.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the facility's emergency exit was not blocked by a Hoyer lift (a device that helps caregivers safely lift and move people) and wheelchair, and an emergency cart was not parked in both sides of the hallway. These deficient practices had the potential for the delay of care during an emergency.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately document a Fall Risk Assessment for one of three sampled residents (Resident 1) after Resident 1 had a fall. This deficient practice had the potential for Resident 1 to have inaccurate assessment of the fall that can affect provision of nursing care.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident ' s right to be free from verbal abuse (at type of abuse that uses language) for two of two sampled residents (Resident 2 and Resident 3), when on 2/11/2025, both Resident 3 and Resident 2 called each other derogatory words (unflattering, unkind, or demeaning). This deficient practice resulted in Resident 2 and Resident 3 being subjected to verbal abuse while under the care of the facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to employ a qualified Activity Director (AD) that met the qualifications as per facility's job description for Activity Director for one of two staff. This deficient practice had a potential for residents residing in the facility not being assisted and receiving activity related necessary care to attain highest practicable well-being.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive care plan for one of three sampled residents (Resident 1) by failing to ensure care plan was developed on Resident 1's refusal of medication. This deficient practice had the potential for delayed provision of necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to provide an ongoing activity program that is resident centered for one of three sampled residents (Resident 2). This deficient practice had the potential to affect Resident 2's sense of self-worth and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to provide an ongoing activity program that is resident-centered for one of three sampled residents (Resident 1). This deficient practice had the potential to affect Resident 1's sense of self-worth and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its infection control measures for one of three sampled residents (Resident 1) who was on enhanced barrier precaution (EBP- wearing a protective gown and gloves whenever you are doing close-contact care with a patient who might be carrying these germs) by failing to ensure Treatment Nurse 1 (TN 1) wore protective gown while proving wound care. These deficient practice had the potential for cross contamination (unintentional transfer of bacteria or germs or other contaminant from one surface to another) of infection among residents and staff.

Inspectors wroteBased on interview and record review, the facility's licensed nursing staff failed to provide care in accordance with professional standards for three of three sampled residents (Residents 21, 43, and 28) investigated under insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) insulin administration sites. The deficient practices had the potential for adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin such as bruising, lipodystrophy (abnormal distribution of fat), and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin).

Inspectors wrote2. During a review of Resident 42's admission Record, the admission Record indicated the facility originally admitted the resident on 2/11/2022 and readmitted Resident 42 on 4/21/2023 with diagnoses including history of falling, difficulty in walking, and generalized muscle weakness. During a review of Resident 42's History and Physical (H&P) dated 5/15/2024, the H&P indicated the resident had the capacity to understand and make decisions. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were completely assessed for the use of bed rails for two of seven sampled residents (Residents 22 and 184) investigated under the accidents care area and for one of three sampled residents (Resident 44) investigated under bedrails care area when the facility failed to: 1. Indicate Resident 22's and Resident 184's recommendations for use of bed or side rails (adjustable metal or rigid plastic bars that attach to the bed that are available in a variety of types, shapes, and sizes, mattress, or bed frame) on their Bed/Side Rail Entrapment Assessment. 2. Indicate Resident 44's recommendation and the reason for use of grab bars (safety devices that help people maintain their balance, reduce fatigue, and prevent falls) on the Bed/Side Rail Entrapment Assessment. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure residents were free of any significant medication errors (means the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order, manufacturer's specifications, and accepted professional standards) for three of three sampled residents (Residents 21, 43, and 28)) investigated under insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) insulin administration sites. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections by failing to: 1. Ensure the Treatment Nurse (TN) performed hand hygiene after doffing (removing) used disposable gloves and prior to donning (putting on) new disposable gloves while providing wound care treatment for one of one sampled resident (Resident 16) reviewed during the Pressure Ulcer/Pressure Injury (PU or PI - localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) care area. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide reasonable accommodation of resident needs and preferences by failing to ensure the call light (an alerting device for nurses or other nursing personnel to assist a patient when in need) was within reach for one of two sampled residents (Resident 237) reviewed under the Environment facility task. This deficient practice had the potential to result in the delay of care and services and possible injury to residents when they are unable to summon health care workers.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents receiving enteral feeding (EF - also known as tube feeding, a method of supplying nutrients directly into the stomach) received appropriate care and services to prevent complications of enteral feeding for one (1) out of 1 sampled resident (Resident 43) investigated under the tube feeding care area by failing to ensure the licensed nurse (LN) hang the correct EF formula. This deficient practice had the potential for the resident to experience increase in blood sugar and gastrointestinal (GI) (relating to stomach and intestines) problems such as abdominal pain and diarrhea.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respiratory care provided to residents were consistent with professional standards of practice for one of two sampled residents (Resident 33) investigated under respiratory care by failing to ensure the nebulizer (a small machine that turns liquid medicine into a mist that can be easily inhaled) mask and tubing (this allows the medicine to enter the lungs directly) were kept in a plastic bag with the name of the resident and the date it was provided. The deficient practice had a potential for Resident 33 to develop complications such as respiratory infections of using a nebulizer caused by improper handling of the mask and tubing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe handling of medications and maintain a safe and secure storage by failing to discard one (1) of nine (9) sampled residents (Resident 35) medication in bubble pack (a packaged container with compartments that can contain medications) with a broken seal and covered with paper tape. This deficient practice had the potential for medication error and contaminate medications stored inside the medication cart.

Inspectors wroteBased on interview and record review, the facility failed to ensure the entire medication regimen of the resident was managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being for two of seven sampled residents (Residents 67 and 285) investigated under unnecessary medications review by: 1. Failing to monitor Resident 67's hours of sleep for two consecutive night shifts on 11/17/2024 and 11/18/2024 in relation to the use of Trazodone (antidepressant, a prescription medication used to treat depression [mood disorder that causes a persistent feeling of sadness and loss of interest] and other mental health conditions) for inability to sleep. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe provision of pharmaceutical services during the inspection of one (1) of two medication carts (Medication Cart 2) reviewed during the Medication Storage and Labeling task by failing to ensure one open bottle of glucose test strips was labeled with the date it was opened in accordance with the manufacturer's requirements. This deficient practice had the potential to result in inaccurate blood glucose readings on the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident receives and the facility provides drinks, including water and other liquids consistent with resident needs and preferences and sufficient to maintain resident hydration for one of five sampled residents (Resident 53) investigated during dining observation by serving regular milk that the resident indicated on his diet preference as a dislike. The deficient practice had the potential for Resident 53 who was on renal diet (a diet that limits the amount of sodium, protein, potassium, and phosphorus in the food) to develop excess phosphorus leading to low level of calcium levels causing bone fractures (a partial or complete break in the bone).

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents receive and consume foods in the appropriate form and/or the appropriate nutritive content as prescribed by a physician, and/or assessed by the interdisciplinary team to support the resident's treatment, plan of care, in accordance with his her goals and preferences for one of five sampled residents (Resident 53) investigated during dining observation by failing to follow the physician's diet order of double portions with all meal and serving regular milk that is listed as a dislike on the resident's meal ticket. The deficient practice had the potential for the resident for weight loss and increased phosphorus leading to low level of calcium levels causing bone fractures (a partial or complete break in the bone).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: 1. One tomato was found on the floor in the walk-in refrigerator. 2. A separate thermometer probe was not kept inside the reach-in freezers. 3. Three bags of cereal were not labeled with the receive date or expiration date in the dry storage area. 4. Food items that indicate to refrigerate after opening were stored in the dry storage area. 5. Drink pitchers were placed in the drying area stacked on top of other drink pitchers while wet. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident receives an accurate assessment, reflective of the resident's status at the time of the assessment: 1. For one of three sampled residents (Resident 82) investigated during closed record review, when Resident 82's Minimum Data Set (MDS, a resident assessment tool), did not indicate the resident was receiving hospice services (compassionate care for people who are near the end of life). 2. For one of two sampled residents (Resident 43) investigated under the tube feeding care area when Resident 43's MDS did not indicate the resident received tube feeding. 3. For one of one sampled resident (Resident 4) investigated under the unnecessary medication care area when Resident 4's MDS did not indicate the resident had a fall incident since the prior assessment. [...]

Inspectors wroteBased on interview and record review, the facility failed to prevent verbal abuse for two of four sampled residents (Resident 1 and Resident 2) when on 8/24/2024 Resident 2 had an exchange of verbal profanity with Resident 1. Resident 1 and Resident 2, who were roommates, were not separated until 9/6/2024. This deficient practice had the potential for further abuse for Resident 1 and Resident 2.

Inspectors wroteBased on interview and record review, the facility failed to implement its abuse prevention policy by failing to report the alleged abuse to the State Survey Agency no later than 2 hours after the allegation occurred for two of four sample residents (Resident 1 and Resident 2) when on 8/24/2024 Resident 2 had an exchange of verbal profanity with Resident 1. This deficient practice had the potential to result in unidentified abuse and placed Residents 1 and 2 at risk for further abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure 1 of 2 sampled residents ' right to be free from misappropriation of property was maintained by the facility. Resident 1 ' s cell phone was taken by another resident. This deficient practice resulted in Resident 1 to not have his personal phone and make calls to his family.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from physical abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish .includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology) by another resident for one of ten sampled residents (Resident 1). On 7/17/2024 at 5:15 a.m., Resident 2 poured lemon juice on Resident 1's face while Resident 1 was sleeping. This deficient practice resulted in Resident 1 feeling defenseless, hopeless, and verbalized not being able to sleep.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents receive the necessary care based on the assessed individual needs to prevent accidents and minimize injuries forone of ten sampled residents (Resident 3), who was identified as a high fall risk. The facility failed to: 1. Ensure Resident 3 was provided visual supervision while sitting on a Geri-chair (a padded reclining chair that was designed to help older adults with limited mobility) in the hallway. 2. Review and revise Resident 3's care plan interventions that were person-centered and were individualized based on the resident's risks, physical, and mental condition. 3. Implement the facility's policies and procedure on Fall Management Program and Free of Accident Hazards / Supervision / Devices. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure clinical records were complete and accurately documented for two of ten sampled residents (Resident 1 and Resident 3) by failing to: a. Ensure the Social Service Director (SSD) documented the correct date of Resident 1 and Resident 2's altercation in Resident 1's clinical record. The SSD also failed to document Resident 1's refusal of a psychologist (a person that specializes in helping treat people's cognitive, emotional, and social process and behaviors) and psychiatrist (a medical doctor that specializes in the field of psychiatry [field of medicine focused on the diagnosis, treatment, and prevention of mental, emotional, and behavioral disorders]) evaluation. b. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, and comfortable environment for seven of nine sampled residents (Residents 1, 2, 3, 4, 5, 6, and 7), by failing to monitor daily temperatures on 7/1/2024, 7/2/2024, and 7/3/2024. This deficient practice had the potential to result in unsafe temperatures related to summer weather, compromising the health & safety of the residents, staff, and visitors.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from verbal abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish .includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology) by staff. On 6/9/2024 at 1:30 p.m., the Admissions Coordinator (AC) stated the Facility [NAME] yelled at Resident 1 to shut up. This deficient practice resulted in Resident 1 feeling humiliated and verbalizing not feeling safe in the facility.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive care plan for one of three sampled resident (Resident 1) to address the following: 1. Resident 1 refused lactulose (medication used to constipation [when your bowel movements become less frequent, and stools become difficult to pass]) nine times from 5/4/2024 to 5/9/2024. 2. Resident 1 refused shower twice in a week from 5/3/2024 to 5/9/2024. These deficient practices had the potential for delayed provision of necessary care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control measures for one of three sampled residents (Resident 2) by: 1. Failing to ensure Certified Nursing Assistant 1 (CNA 1) wore protective gown during incontinent care (care provided to resident with no bladder and bowel control) and linen change. Residents 2's was on enhanced barrier precaution (expand the use of personal protective equipment and refers to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of multidrug resistant organisms [MDRO- are germs that are difficult to treat because they are resistant to many antibiotics]). 2. Failing to ensure Licensed Vocational Nurse 1 (LVN 1) was notified that Resident 2 was on enhanced barrier precaution. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to notify the Power of Attorney (POA-a person legally or non-legally appointed to make decisions on behalf of a patient who lacks capacity) of one of three sampled residents (Resident 1) regarding the progression of an abrasion (the surface layers of the epidermis [skin] has been broken) over Resident 1 ' s coccyx (the small bone at the end of the spine tailbone). As a result, Family Member 1 was not provided information to request additional care interventions. This deficient practice violated the resident ' s rights and/or the representative ' s right to be fully informed of Resident 1 ' s change of condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control measures for three of five sampled staff (Certified Nursing Assistant 1 [CNA 1], CNA 2 and Payroll Coordinator [PC]), while the facility had Coronavirus Disease 2019 outbreak (a sudden rise in the incidence of a disease) by failing to: 1. Ensure CNA 1 and PC wore the N95 (disposable respirators that can help reduce your exposure to airborne particulates of all sizes, from large visible dust to particles that cannot be seen, such as viruses) mask with lower strap secured behind the neck, while inside the facility. 2. Ensure CNA 2 wore a fit tested N95 mask while inside the facility. This deficient practice had the potential to result in the spread of COVID-19 infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light button was within reach of the resident for one of five sampled residents (Resident 1). This deficient practice had the potential to result in the resident not being able to call for facility staff assistance and delay in the provision of necessary care and services that can negatively affect the resident's comfort and well-being.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for one out of five sampled residents (Resident 4) by failing to ensure Resident ' s bathroom sink have running water. This deficient practice had the potential to result in an unsanitary and unhomelike environment for Resident 4 due to not having access to running water in the bathroom sink.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one of eight sampled residents (Resident 8) had a functional eyeglass. The facility was not able to provide a replacement for the Resident 8 ' s broken eyeglasses. This deficient practice had the potential to result in Resident 8 ' s decreased ability to read, write, and do activities safely. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program regarding Coronavirus disease 2019 (COVID-19, a viral infection that is highly contagious and easily transmits from person to person, causing respiratory problems and may cause death) for one of eight sampled residents (Residents 8), by failing to ensure Licensed Vocational Nurse 2 (LVN 2) perform hand hygiene (hand washing with soap and water or use of alcohol-based hand sanitizer) before and after changing gloves and after touching unclean surfaces. LVN 2 also did not disinfect the pulse oximeter (a device used to measure the saturation of oxygen carried in the red blood cells) used on Resident 8. These deficient practices placed other residents and staff at risk for exposure and contracting COVID-19.

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose garbage and refuse properly by not covering three of six green dumpsters (large trash container designed to be emptied into a truck) from 7:30 a.m. to 9:41 a.m. while waiting for trash to be picked up by the garbage truck. This deficient practice had a potential to attract birds, flies, insects, and pests, and possibly spread infection to all 88 facility residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accommodate the needs and preferences for six of 58 residents (Resident 2, 21, 68, 36, 5, and 64) by failing to: 1. Ensure the call light was within reach for Residents 2, 21, 68, and 36. 2. Ensure Resident 5 and Resident 64's call light was operative and within reach. These deficient practices had the potential for residents not being able to call for facility staff assistance, possibly delay necessary care and services, and increase the risk for injury or fall.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents had the right to receive mail for two of 16 sampled residents (Resident 74 and Resident 85). Resident 74 and Resident 85 stated they do not receive mail on Saturdays. This deficient practice violated the residents' right to receive mail on Saturdays and had the potential to negatively affect the resident's psychosocial well-being.

Inspectors wroteBased on interview and record review the facility failed to complete and transmit the Minimum Data Set (MDS - a standardized assessment and care screening tool) Discharge Assessments for three of three sampled residents (Resident 81, 82, and 83) investigated under the Resident Assessment task. These deficient practices had the potential to result in care that does not address the resident's specific care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for four of 58 residents (Resident 31, 33, 54, and 69) by failing to: a. Develop Resident 31's care plan for smoking that indicated interventions that are complete and specific, including addressing storage of Resident 31's smoking material (e.g., cigarettes, lighters). b. Develop and implement Resident 33 and 69's care plan on the use of insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood). c. Develop and implement Resident 54's care plan on the use of oxygen via nasal cannula (a device that gives additional oxygen through the nose). These deficient practices had the potential to result in inconsistent implementation of the care plan that may lead to a delay in or lack of delivery of care and services.

Inspectors wroteBased on interview and record review the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team (IDT) for two of 58 sampled residents (Resident 68 and Resident 65) by: 1. Failing to update Resident 68's care plan for fall after the resident had an unwitnessed fall on 8/30/2023, 9/1/2023, and 9/8/2023. The deficient practice had the potential for Resident 68 to have repeated falls that could result to injuries and even death. 2. Failing to revise Resident 65's care plan for nutrition. This deficient practice placed the resident at risk for complications related to nutritional and hydration status.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide the necessary care and services to ensure residents' abilities of daily living do not diminish to one of nineteen sampled residents (Resident 33) by failing to provide feeding assistance to Resident 33 who had hemiplegia (one-sided muscle paralysis or weakness) and hemiparesis (weakness or the inability to move on one side of the body) following cerebral infarction affecting left non-dominant side. This deficient practice placed Resident 33 at risk for complications related to nutritional and hydration status.

Inspectors wroteh. A review of Resident 7's Face Sheet indicated the facility admitted the resident on 12/19/2022 with diagnoses including chronic kidney disease, hypotension (low blood pressure), muscle weakness, and dependence on renal dialysis (blood is put through a filter outside the body, cleaned, and then returned to the person). A review of Resident 7's History and Physical dated 12/21/2022, indicated the resident has the capacity to understand and make decisions. A review of Resident 7's Minimum Data Set (MDS - an assessment and care screening tool) dated 9/20/2023, indicated the resident was cognitively intact (able to understand and make decisions) and required extensive assistance and one-person physical assistance with walking in room and corridor, dressing, toilet use, and personal hygiene. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide respiratory care consistent with professional standards for three of three sampled residents (Resident 11, 54, and 23) by: 1. Failing to apply Resident 11, 54, and 23's nasal cannula (a lightweight tube which on one end splits into two prongs which are placed in the nostrils to provide supplemental oxygen to the body) properly to ensure the residents receive oxygen as ordered by the physician. These deficient practices had the potential for Resident 11 and 54 not to get enough oxygen in the system causing shortness of breath leading to hypoxia (low levels of oxygen in the body). 2. Failing to ensure Resident 23's oxygen tubing was kept off the floor. This deficient practice had the potential for bacteria to grow in Resident 23's nasal cannula tubing resulting in respiratory infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide individual food preferences to two out of 2 sampled residents (Resident 18 and 86). This deficient practice had the potential to cause psychosocial harm to the residents and decrease food intake resulting to weight loss.

Inspectors wroteBased on observation, interview and record review, the facility failed to prepare food and drinks designed to meet individual needs when: 1. Two of 88 residents (Residents 6 and 16) did not receive fortified diet (adding foods such as butter, margarine, soup to the diet to increase calories and protein) during lunch meal. 2. One of one resident (Resident 65) on moderately thickened liquid's (a honey thick consistency, fluid slowly drips in dollops off the end of the spoon) was not thickened appropriately. These deficient practices had the potential to cause weight loss for Residents 6 sand 16; and may cause coughing, choking (to keep from breathing the normal way), and death to Resident 65.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: a. Two 400 pans (4-inch deep pans) four 600 pans (6-inch deep pans), and two carts for storing clean dishware had sticker and/or tape residues. b. Two freezer bottom shelves and gaskets (a rubber attached to outer edge of the refrigerator use for airtight seal) had dust and dirt residues. c. Freezer and refrigerator temperature logs were left blank on 11/12/2023. d. Clean pink pitchers were not protected from spill from the handwashing sink (issue of possible cross-contamination, the transfer of harmful bacteria from one place to another). e. Pots and pans were not air dried. f. Red buckets containing sanitizer and wipe cloths were not separated from food and clean kitchen utensils (issue of possible cross-contamination) g. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection prevention and control measures for seven of eight sampled residents (Resident 11, 63, 23, 46, 57, 500, and 28) and one of one linen cart (Linen Cart 1) by: 1. Failing to ensure the urinary catheter (a tube that is inserted into the bladder, allowing urine to drain freely) drainage bag (to collect urine) was not touching the floor for Resident 11. 2. Failing to ensure the oxygen tubing was not touching the floor for Resident 11. These deficient practices had the potential for contamination of residents' equipment and placed the residents at risk for infection. 3. Failing to ensure Linen Cart 1 was covered when not in use. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignity for one of 58 residents (Resident 65), when Certified Nursing Assistant (CNA) 10 was observed standing over Resident 65 while spoon-feeding the resident. This deficient practice had the potential to affect the resident`s sense of self-worth and self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's self-administration of medications was appropriate and safe for one of 58 sampled residents by failing to ensure Resident 39's Medication Self-Administration Assessment was completed prior to leaving medications at the resident's bedside. This deficient practice had the potential to result in unsafe medication administration or omission.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a resident written notice of bed hold (holding or reserving a resident's bed while the resident is absent from the facility for therapeutic leave or hospitalization) when the resident was transferred to a general acute care hospital (GACH) for one of three (Resident 32) residents reviewed under closed records. This deficient practice had the potential to result in Resident 32 and their representative being unaware of the bed hold policy and can lead to a transfer of the resident to another skilled nursing facility not of the resident's or responsible party's preference.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care in accordance with professional standards for two of 13 sampled residents (Resident 33 and Resident 11), by 1. Failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) insulin (a hormone that lowers the level of sugar in the blood) administration sites to Resident 33. This deficient practice had the potential for adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin such as lipodystrophy (abnormal distribution of fat). 2. Failing to provide Resident 33 a straw for drinking liquids. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who is unable to carry out activities of daily living (ADL) received the necessary services to maintain good nutrition for one of 58 sampled residents (Resident 65) by failing to Ensure Resident 65 was not in a reclined position while being assisted with feeding by Certified Nursing Assistant (CNA) 10. This deficient practice resulted in Resident 65 coughing after eating a spoonful of food and drinking the provided beverage; and had the potential for Resident 65 to aspirate (breathe in foreign objects, such as liquid or food, into the lungs) and possibly result in aspiration pneumonia (inflammation and infection of the lungs or large airways that occurs when food or liquid is breathed into the airways or lungs, instead of being swallowed).

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections (UTI, common infections that happen when bacteria, often from the skin or rectum, enter the urethra [duct that transmits urine from the bladder to the exterior of the body during urination], and infect the urinary tract) to one out of thirteen sampled residents (Resident 21) by failing to: 1. Attach a leg strap/statlock (a device to secure the catheter to prevent tugging and pulling) to secure the urinary catheter (a procedure used to drain the bladder and collect urine, through a flexible tube called a catheter) of the resident. 2. Keep the urinary catheter bag (collects urine from the catheter) off the floor. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a performance review (also known as performance evaluation [PE] - a formal and productive procedure to measure an employee's work and results based on their job responsibilities) at least once every 12 months for one of three sampled Certified Nursing Assistants (CNA) (CNA 11) reviewed under sufficient and competent nurse staffing task. This deficient practice had the potential to result in missed opportunities to address CNA 11's performance issues that could impact resident safety and satisfaction.

Inspectors wroteBased on observation, interview and record review the facility failed to administer medications in accordance of professional standards of practice for one of three sampled residents (Resident 11) by failing to consult with the pharmacist before opening the tamsulosin (Flomax, medication used to help relax the muscles in the prostate and the opening of the bladder) timed-release capsule (designed to release medication over a sustained period, usually 8 to 24 hours) and administering it to Resident 11. This deficient practice had the potential to result in alteration of the drug's absorption and cause adverse consequences including stomach lining irritation and sudden drop in the blood pressure, which could lead to dizziness or fainting

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure safe provision of pharmaceutical services by failing to label the date of when Anoro Ellipta (a brand of prescription medication used to treat chronic obstructive pulmonary disease [COPD - refers to a group of diseases that cause airflow blockage and breathing-related problems] administered by inhalation) was opened for one out of nine residents (Resident 56) during investigation of Medication Storage and Labeling. This deficient practice placed the Resident 56 at risk for medication errors.

Inspectors wroteBased on interview and record review, the facility failed to evaluate the overall number of facility staff available to meet the resident care needs by failing to determine sufficient staffing ranges for the provision of quality care. This deficient practice had the potential to result in a delay of necessary care and services to the residents.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the licensed nurse documented the notification to the physician and dialysis center (a hospital-based or independent unit approved and licensed to provide outpatient dialysis services) of a resident's refusal for dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) treatment for one out of three residents (Resident 32) investigated for closed records. This deficient practice had the potential to result in the medical records containing inaccurate documentation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a functioning call light system (device used to alert facility staff assistance as needed by residents) was provided for two of 58 sampled residents (Residents 5 and 64) when their call light was not functioning after pressing the call light button to activate the call light system. This deficient practice resulted in Resident 64 feeling helpless and had a possibility to delay provision of care to the residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the facility met the data requirements for staffing information by failing to: 1. Ensure that the reflected total number and the actual hours worked of the Restorative Nursing Assistants (RNA) on 11/14/2023 were accurate. 2. Post the current nurse staffing data daily. As a result, the total number of staff and the actual hours worked by the staff was not readily accessible to residents and visitors.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three Certified Nursing Assistants (CNA 10) received the dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) in-services (training) as indicated in the Facility Assessment (determines the resources necessary to care for residents competently during the day-to-day operations and emergencies). This deficient practice had the potential to result in reduced quality of care, as without proper training CNAs may lack the necessary knowledge and skills to effectively communicate with and care for residents with dementia.