Dunbar Center

Inspectors wroteBased on record review, resident and family interviews, and staff interviews, the facility failed to ensure residents received timely assessment, intervention, and treatment for acute changes in condition. Specifically, the facility failed to ensure a resident exhibiting signs and symptoms consistent with sepsis, respiratory distress, hypoxia, hypotension, tachycardia, and acute clinical deterioration received timely emergency medical evaluation and transfer to the hospital; failed to follow physician orders for skin and wound care; and failed to provide pain management as ordered. This failed practice placed residents at risk for serious injury, harm, impairment, or death and had the potential to affect all residents requiring timely assessment, treatment, and intervention for changes in condition. Resident Identifiers: #123, #129, and #4. Facility census: 118. [...]

Inspectors wroteBased on record review and staff interviews, the facility failed to designate one or more qualified Infection Preventionists responsible for the facility's Infection Prevention and Control Program in accordance with regulatory requirements. Specifically, the facility failed to ensure the individual(s) responsible for infection prevention had completed specialized infection prevention training while overseeing the Infection Prevention and Control Program. This failed practice had the potential to affect all residents residing in the long-term care facility. Facility census: 118. Findings Included:During the facility entrance conference the Administrator reported the facility did not have an official Infection Preventionist at this time. The Administrator indicated that the Clinical reimbursement Coordinator held an Infection Preventionist certification. [...]

Inspectors wroteBased on direct observation and interview with the Facility Maintenance Director (#119), the facility failed to consistently maintain ambient temperatures within the required range in the 100/200 Nurses' Station and the 300/400 Nurses' Station. This was a random opportunity for discovery and had the potential to affect more than a limited amount of residents. Facility census: 118.

Inspectors wroteBased on record review, resident interviews and staff interviews, the facility failed to ensure all food was temped before leaving the kitchen, to ensure safe and appetizing temperatures of the food and to prevent foodborne illness. The facility failed to ensure all foods were palatable, hot foods were served hot, and cold foods were served cold. This failed practice was also true for one (1) of one (1) meal tray's tested throughout the survey process. This failed practice had the potential to affect more than a limited number of residents. Facility census: 118. Findings Included: a) Healthcare Services Group (HCSG) Policy #6 titled, Food Quality and Palatability states: -Food will be prepared by methods that conserve nutritive value, flavor and appearance. [...]

Inspectors wroteBased on observation and staff interviews, the facility failed to store, prepare, distribute and serve food in accordance with professional food safety standards. Additionally, the facility failed to follow proper sanitation practices for the kitchen. This practice had the potential to affect more than a limited number of residents. Facility census: 118. Findings Included: a) Department Staffing Policy Healthcare Services Group (HCSG) Policy #2 titled, Department Staffing states: -The Dining Services will employ sufficient staff, with appropriate competencies and skill sets to carry out the functions of food and nutrition services in a manner that is safe and effective. -Adequate staffing will be provided to prepare and serve palatable, attractive, nutritionally adequate meals, at proper temperatures, at appropriate times and to support proper sanitary techniques being utilized. [...]

Inspectors wroteBased on observation and staff interviews, the facility failed to store and dispose of garbage and refuse properly. This was a random opportunity for discovery. The failed practice had the potential to affect more than a limited number of residents at the facility. Facility census: 118. Findings Included: a) Environment Policy The Healthcare Services Group (HCSG) Policy #28 titled Environment states: -All food preparation areas, food service areas, and dining areas will be maintained in a clean and sanitary condition.-All trash will be contained in covered, leak-proof containers that prevent cross-contamination. b) Garbage and Refuse Policy The HCSG Policy #30 titled Dispose of Garbage and Refuse states: -All garbage and refuse will be collected and disposed of in a safe and efficient manner.-The Dining Services Director will ensure that: [...]

Inspectors wroteBased on observation, record review and staff interview, the facility failed to maintain an infection control program during medication administration. These were random opportunities for discovery and had the potential to affect more than a limited amount of residents. Resident Identifiers: #90, #105, and #29. Facility Census: 118. Findings Include: a) Medication Administration On 07/02/26 at 8:35 AM, Registered Nurse (RN) #154 was observed during medication administration. RN #154 did not complete hand hygiene prior to preparing the medication for Resident #90. After preparing the medication, hand hygiene was not completed before entering the resident's room. RN #154 sat the Spiriva Inhaler box on the over-the-bed table without using a barrier. After medication administration to Resident #90, hand hygiene was not completed prior to preparing Resident #105's medication. [...]

Inspectors wroteBased on observation and staff interview, the facility failed to ensure an effective pest control program was in place. This was discovered throughout the completion of the kitchen pathway during the Long-Term Care Survey Process. This failed practice had the potential to affect more than a limited number of residents. Facility census: 118. Findings Included: a) Pest Control Policy Healthcare Services Group (HCSG) Policy #29 titled Pest Control states: -A program will be established for the control of insects and rodents for the Dining Services Department.-The Dining Services Director coordinates with the Director of Maintenance to arrange pest control services on a monthly basis, or as needed.-All food preparation, service, and storage areas will be monitored regularly for any signs of pest / vermin. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to obtain informed consent for psychotropic medication for Resident #1 . This was true for two (2) of five (5) residents reviewed under the care area of unnecessary medications. Resident Identifier: #1 . Facility Census: 118. Findings Included: a) Resident #1 On 07/01/26 at 2:15 PM, a record review was completed for Resident #1. The review found the resident had been admitted to the facility on [DATE]. The resident was prescribed Cymbalta, an antidepressant. The facility did not obtain informed consent for the psychotropic medication. The resident did have medical-decision making capacity. On 07/02/26 at 9:35 AM, the Corporate Registered Nurse (RN) #175 confirmed the consent for Cymbalta had not been completed. The Corporate RN stated, We will get the consent right now.

Inspectors wroteBased on record review and staff interview, the facility failed to provide the required Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF-ABN) form and/or the Notice of Medicare Non-Coverage (NOMNC) form to two (2) of three (3) residents reviewed for the facility's beneficiary protection notification practice throughout the Long-Term Care Survey Process. This failure placed the residents at risk of not being informed of their rights prior to the end of Medicare Part A covered services. Resident identifiers: #128 and #29. Census: 118.

Inspectors wroteBased on record review and staff interview, the facility failed to provide evidence that it conveyed the required information to the hospital at the time of transfer. The facility was unable to provide documented evidence that the receiving health care institution received, at a minimum, residents' advance directives, physician orders, and comprehensive care plan upon transfer to a hospital as required for a safe transition of care. This was true for two (2) of two (2) residents reviewed under the hospitalization pathway throughout the Long-Term Care Survey Process. Resident Identifiers: #98 and #115. Facility census: 118.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure an accurate Preadmission Screening and Resident Review (PASARR) was maintained to reflect a resident's diagnosed serious mental illness for one (1) of one (1) residents reviewed for PASARR requirements. Resident identifier: #28. Facility census: 118.

Inspectors wroteBased on record review and staff interview, the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident. This was a random opportunity discovered during the completion of the Hospitalization and Discharge pathways conducted throughout the Long-Term Care Survey Process. Resident Identifiers: #115 and #117. Facility census: 118.

Inspectors wroteBased on record review and staff interview, the facility failed to develop care plan regarding the diagnosis of depression and the use of a psychotropic medication. This was true for one (1) of five (5) residents reviewed under the care area of unnecessary medications. Resident Identifier: #1. Facility Census: 118. Findings Included: a) Resident #1 On 07/01/26 at 2:15 PM, a record review was completed for Resident #1. The resident had been admitted to the facility on [DATE]. The review found the care plan had not been developed regarding the diagnosis of depression and the use of an antidepressant, Cymbalta. On 07/02/26 at 9:35 AM, the Corporate Registered Nurse (RN) #175 confirmed the care plan had not been developed regarding the diagnosis of depression and the use of an antidepressant, Cymbalta. The Corporate RN #175 stated, We will get this taken care of now.

Inspectors wroteBased on record review and staff interview, the facility failed to follow the physician's order regarding a monthly pharmacy recommendation for Resident #1. This was true for one (1) of five (5) residents reviewed under the care area of unnecessary medications. Resident Identifier: #1. Facility Census: 118. Findings Included: a) Resident #1 On 07/01/26 at 2:15 PM, a record review was completed for Resident #1. The review covered monthly pharmacy recommendations from 03/11/26 through 05/08/26. The monthly pharmacy review dated 03/11/26 included two (2) separate recommendations. The second recommendation concerned an alternate treatment using a Beta-3 agonist (Vibegron) instead of an anticholinergic medication for overactive bladder. The facility physician agreed to switch the therapy to the Beta-3 agonist Vibegron. [...]

Inspectors wroteBased on observation, record review and staff interview, the facility failed to ensure freedom of significant medication errors during medication administration for Resident #105. This was true for one (1) of three (3) residents reviewed under the care area of medication administration. Resident Identifier: #105. Facility Census: 118. Findings Included: a) Resident #105On 07/02/26 at 9:00 AM, an observation of medication administration by Registered Nurse (RN) #154 for Resident #105. Resident #105 takes her medication crushed in applesauce. Upon preparation of Resident #105's medication, the resident received Cardizem CD (controlled dose) 120mg (milligrams) by mouth every day. The extended release medication cannot be crushed due to the special time-release mechanism causing the entire dose to hit the bloodstream at once. [...]

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to prepare food in the form to meet the individual needs of Resident #62 as ordered by the physician. Resident #62 was ordered an Advanced Dysphagia diet and was served a regular diet. This was a random opportunity for discovery. Resident Identifier: #62. Facility Census: 118. Findings Included:a) Resident #62 Healthcare Services Group (HCSG) Policy #6 titled, Food Quality and Palatability states:-Food will be prepared by methods that conserve nutritive value, flavor, and appearance. Food will be palatable, attractive, and served at a safe and appetizing temperature.-Food and liquids are prepared and served at a safe and appetizing temperature.-The Dining Services Director and [NAME] are responsible for food preparation. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure quarterly smoking safety assessments were completed in accordance with the facility's smoking policy for one (1) of one (1) residents reviewed for smoking safety. This failed practice had the potential to place residents at risk for smoking-related accidents and injuries. Resident Identifier: #38. Facility census: 118. Findings Included:a) Resident #38Record review, completed on 06/29/26, of the facility's smoking policy revealed, All residents upon admission, readmission, and with change in condition should have a smoking assessment completed if they wish to smoke in the facility. This assessment cannot have any missing documentation and must match the clinical admission assessment also completed upon admission. If they remain in the facility this will be done quarterly. [...]

Inspectors wroteBased on observation, resident interviews and staff interview, the facility failed to ensure hydration was available at bedside for Resident #11, Resident #31, Resident #88 and Resident #108. This was true for four (4) residents residing on the 300 and 400 halls. Resident Identifiers: #11, #31, #88 and #108. Facility Census: 110. Findings Include: a) 400 Hall On 05/27/26 at 11:40 AM, an initial interview was held with Resident #11. Resident #11 was asked, do you have any water? Resident #11 stated, no, I don't have any ice water. On 05/27/26 at 11:44 AM, Resident #31 was unable to be interviewed, however, no water was observed at bedside. On 05/27/26 at 12:00 PM, Nurse Aide (NA) #81 stated, I have passed some water but I haven't been able to finish, I have been doing showers. On 05/27/26 at 12:03 PM, Registered Nurse (RN) #39 stated, they didn't tell me they needed water. [...]

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure liquids were distributed and served in accordance with professional standards for food service safety. This failed practice had the potential to affect more than a limited number of residents. Facility Census: 110.

Inspectors wroteBased on observation, resident interview and staff interview, the facility failed to ensure accommodation of needs were provided for a call light within reach for Resident #75 and a pull cord for a light for Resident #58. These were random opportunities for discovery. Resident Identifiers: #75 and #58. Facility Census: 110.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure appropriate notices were given to residents prior to discharge from the facility. This failed practice had the potential to affect a limited number of residents. Resident identifier: #47. Facility Census: 110.

Inspectors wroteBased on resident interviews, record review and staff interviews, the facility failed to report allegations of abuse between Resident #62 and Resident #113 as well as Resident #62, Resident #13 and Nurse Aide (NA) #3. This is true for two (2) of two (2) residents reviewed under the care area of abuse. Resident Identifiers: #62, #113, and #13. Facility Census: 110. Findings Include: a1) Resident #62 On 05/27/26 at 1:00 PM, an interview was held with Resident #62 regarding a complaint of alleged abuse. Resident #62 stated, I have told staff about Resident #113 constantly threatening me and trying to intimadate me. I told Social Worker (SW) #162. He doesn't work here anymore. But SW #162 would say, There is nothing I can do .just stay away from her. I told different staff members .they knew what she was doing and no one would do anything. [...]

Inspectors wroteBased on observation, record review and staff interview, the facility failed to ensure the Annual Minimum Data Set (MDS) was correct regarding tobacco use for Resident #23. This was true for one (1) of two (2) residents under the care area of smoking. Resident Identifier: #23. Facility Census: 110. Findings Include: a) Resident #23 On 06/01/26 at approximately 3:00 PM, Resident #23 was observed smoking with staff present. On 06/01/26 at 3:10 PM, a record review was completed for Resident #23. The Annual MDS dated [DATE] section J Health Conditions was reviewed. Under J1300, current tobacco user, the code entered was 0 (zero). Zero (0) indicates the resident does not smoke. On 06/01/26 at 3:30 PM, an interview was held with the Clinical Reimbursement Coordinator (CRC) #65. The CRC #65 confirmed the MDS dated [DATE] was incorrect regarding tobacco use. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to develop and implement the care plan for Resident #69. This was true for one (1) of one (1) residents reviewed under the care area of pressure ulcers. Resident Identifier: #69. Facility Census: 110. Findings Include: a1) Resident #69 On 06/01/26 at 12:15 PM, a record review was completed for Resident #69. The care plan was reviewed and found multiple blank areas under the interventions of the focus area of risk for decreased ability to perform ADL(s) (activities of daily living) in: bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, toileting related to limited mobility. The following interventions were left blank: --Provide resident/patient with _____(specify: set-up, supervision, partial/moderate, substantial/maximal, dependent assistance) assist of (specify #) for bed mobility. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to revise and review a comprehensive care plan for a long term care resident. This failed practice had the potential to affect a limited number of residents. Resident Identifier: #47. Facility Census: 110.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure pressure ulcer prevention was in place. This was true for one (1) of two (2) residents reviewed under the care area of pressure ulcers. Resident Identfier: #69. Facility Census: 110.a) Resident #69 On 06/01/26 at 12:15 PM, a record review was completed for Resident #69. The care plan was reviewed and found an intervention, under the focus area of risk for skin breakdown, were not being implemented. The interventions states, Assist resident in turning and repositioning every 2-3 hrs. (Typed as written.) Therefore, the pressure ulcer prevention was not in place. At this time, a review under the tasks tab was completed. The following dates did not include documentation regarding turning and repositioning each shift: [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure an accurate and complete medical record for Resident #111. This was true for one (1) of two (2) residents reviewed under the care area of falls. Resident Identifier: #111. Facility Census: 110. Findings Include: a) Resident #11 On 06/01/26 at 2:00 PM, a record review was completed for Resident #111. The review found the fall risk evaluation dated 03/31/26 was not complete. The following sections were left blank: Section Gait/balance Gait/balance: Observe the Resident's gait/balance, have them/they stand on both feet without holding onto anything, if safe to do so. If assistive devices are required, provide the device and then proceed. Walk straight forward, walk through a doorway; and make a turn. Check the response below that best describes the resident abilities. [...]

Inspectors wroteBased on observation and staff interview, the facility failed to maintain an infection control program regarding disposal of a soiled brief and linen. This was a random opportunity for discovery. Resident Identifier: #69. Facility Census: 110. Findings Include: a) Resident #69 On 06/02/26 at 4:23 AM, an observation was made of a soiled brief and soiled wash cloth laying on the floor at the foot of Resident #69's bed. On 06/02/26 at 4:25 AM, Nurse Aide (NA) #160 approached the resident's room and removed the soiled brief and wash cloth. NA #160 stated, let me take care of this. At this time, Licensed Practical Nurse (LPN) #18 observed the NA picking up the items and confirmed the soiled brief and wash cloth should have been disposed of correctly. On 06/02/26 at approximately 5:00 AM, the Director of Nursing (DON) was notified and confirmed the items should have been disposed of properly.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure confidentiality of medical records. This was a random opportunity for discovery. Facility census: 116.

Inspectors wroteBased on record review and staff interview the facility failed to ensure medications were administered in a timely manner as ordered. This was true for 1 (one) of 6 (six) residents reviewed for medication administration. Resident identifier: #84. Facility census: 116.

Inspectors wroteBased on observation and staff interview, the facility failed to store clorox wipes in an area to maintain a safe environment in room [ROOM NUMBER]. This was a random opportunity for discovery. Facility Census: 116. Findings Include:a) room [ROOM NUMBER]Upon the initial tour of the facility on 01/28/26 at 11:55 AM, a container of clorox wipes was observed sitting on the bathroom sink in room [ROOM NUMBER]. On 01/28/26 at 11:58 AM, Licensed Practical Nurse (LPN) #21 confirmed the container of clorox wipes should not be in the resident's bathroom. LPN #21 stated, Let me get these out of here. On 01/28/26 at 12:20 PM, the Administrator was notified and confirmed the clorox wipes should not be in a resident's bathroom.

Inspectors wroteBased on observation and staff interview, the facility failed to maintain infection control standards for storage of a bed pan in room [ROOM NUMBER]. This was a random opportunity for discovery. Faciltiy Census: 116. Findings Include:a) room [ROOM NUMBER]Upon the initial tour of the facility on 01/28/26 at 11:55 AM, a bed pan was observed laying on top of trash can in the bathroom, which was not bagged or labeled in room [ROOM NUMBER]. On 01/28/26 at 11:58 AM, Licensed Practical Nurse (LPN) #21 confirmed the bed pan was not labeled or stored in a storage bag. On 01/28/26 at 12:20 PM, the Administrator was notified and confirmed the bed pan should have been labeled and stored in a storage bag.

Inspectors wroteBased on observation, record review, caregiver interview and staff interview, the facility failed to ensure each resident maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible. This was true for four (4) of four (4) residents reviewed. This failed practice resulted in actual harm for Resident #64 who since the time of her admission has lost a severe amount of weight. The facility failed to track her consumption of meals, provide assistance at mealtimes and failed to implement the dietician's recommendation for a house supplement and the resident continued to lose weight. [...]

Inspectors wroteBased on observation, record review and staff interview the facility failed to ensure all residents were treated with dignity and respect. This was true for five (5) residents and were random opportunities for discovery. Resident Identifiers: #69, #11, #62, #64, and #52. Facility Census: 115. Findings Include: a) Resident #64 Observation of the morning meal on 07/23/25 beginning at 8:08 AM found the resident sitting in her recliner in her room. The nurse aid took her a cup of cranberry juice and told the resident she had brought her a cup of juice. The resident was observed feeling around on her bedside table. She did not find the juice, nor did she take a drink. At about 8:15 AM Registered Nurse (RN) #112 went into the room and asked her how she was doing. The resident stated, I am just hungry. I am starved. [...]

Inspectors wroteBased on observation, record review and staff interview, the facility failed to keep the resident as free from neglect as possible. This failed practice had the potential to affect more than a limited number of residents. This was a random opportunity of discovery. Resident Identifiers: #11 and #96. Facility Census: 115.

Inspectors wroteBased on observation, record review and staff interview, the facility failed to develop and/or implement the care plan regarding Resident #11's need for meal assistance and cueing for meals, Resident #117's negative pressure wound therapy (wound vac) and turning and repositioning for Resident #122, #21, #63, #7, and #104. This was true for seven (7) of 16 residents reviewed during the survey process. Resident Identifiers: #11, #117, #122, #21, #63, #7 and #104. Facility Census: 115.a) Resident #7 On 07/22/25 at 9:00 AM, a record review found that Resident #7 has multiple pressure ulcers, including his glutes and thighs. He had a Braden Scale for Predicting Pressure Score Risk dated 07/08/25 with a score of fifteen (15) which indicated he was at risk for pressure ulcers. [...]

Inspectors wroteBased on observation, record review and staff interview, the facility failed to provide ADLs to dependent residents. This was true for five (5) of seven (7) residents reviewed for the care area of ADL care during the complaint survey. Resident Identifiers: #11, #96, #21, #119, and #16. Facility Census: 115. Findings Included: a) Resident #21 On 07/23/25 9:00 AM record review of showers for this dependent resident were reviewed. Review of the shower schedule indicates that Resident #21 is scheduled for showers Tuesday and Friday evenings. He was scheduled for a shower but did not receive one on the following dates (six (6) days) 06/24/25, 07/04/25, 07/11/25, 07/15/25, 07/15/25 and 07/18/25. This was confirmed with the Corporate Resource Nurse #106 on 07/23/25 at 2:00 PM at which time she agreed the resident missed several of his showers. [...]

Inspectors wroteBased on record review and staff interview the facility failed to perform wound treatments as ordered by the physician. This was true for three (3) of five (5) residents reviewed for wound treatments. Resident Identifiers: #21, #63 and #117. Facility Census: 115Findings include:a) Resident #21On 07/21/25 at 1:03 PM a record review of the Treatment Administration Record (TAR) for July, 2025 shows that Resident #21 did not have wound treatments as ordered by the physician. On 07/04/25 a wound care order was not complete for Skin tear right elbow cleanse with hydrating form cleanser Sure prep wound cover with adhesive foam dressing every day shift for wound care. On 07/20/25 a wound care order was not complete for Sure prep left elbow cover adhesive foam dressing for comfort per resident request every day shift. [...]

Inspectors wroteBased on record review and staff interview the facility failed to ensure residents received treatment or services to prevent or heal pressure ulcers. This was true for four (4) of five (5) residents reviewed for turning and repositioning. Resident Identifiers: #7, #104, #117 and #122. Facility Census: 115. Findings Included:a) Resident #7On 07/22/25 at 9:00 AM record review found that Resident #7 has multiple pressure ulcers, including his glutes and thighs. He has a Braden Scale for Predicting Pressure Score Risk dated 07/08/25 with a score of fifteen (15) which indicates he is at risk for pressure ulcers. Review of his care plan states under the focus of skin breakdown that he is to be turned and repositioned every 1-2 hours. [...]

Inspectors wroteBased on record review and staff interview the facility failed to ensure all nursing staff possess the competencies and skill sets necessary to provide nursing and related services to meet the residents' needs safely and in a manner that promotes each resident's rights, physical, mental and psychosocial well-being. This was true for two (2) of five (5) personnel records reviewed during the extended survey. Employee Identifiers: Nurse Aide (NA) #86 and NA #13. Facility Census: 115. Findings Include: a) Nurse Aide #13 A review of NA#13's competency check offs for the calendar year of 2024 found she had only completed two (2). One (1) for hand hygiene and one (1) for Putting on and taking of personal protective equipment. During an interview with the Nursing Home Administrator (NHA) at 3:12 PM on 07/28/25 confirmed NA #13 only had these two (2) check offs completed. [...]

Inspectors wroteBased on record review and staff interview the facility failed to ensure all nurse aides received an annual performance evaluation. This was true five (5) for five (5) employee personnel records reviewed. This failed practice has the potential to affect more than an isolated number of residents. Employee Identifiers: #86, #13, #21, #5, and #95. Facility Census: 115. Findings Include: a) Performance Reviews On 07/28/25 in the early afternoon the yearly performance evaluations were requested for Nurse Aide (NA) #86, #13, #21, #5 and #95. On 07/28/25 at 2:41 PM during an interviedw with Corporate Resource Nurse (CRN) #106 it was revealed that the facility did not have any of the five (5) performance evaluations requested.

Inspectors wroteBased on medical record review and staff interview the facility failed to ensure a complete and accurate medical record. The facility failed to document meal percentages in the Tasks portions of medial records for Resident #121. Facility Census: 115Findings included: a) Resident #121A review of Resident #121's tray cards revealed that the resident was scheduled to receive meal tray on the day of 05/31/25. A review of Resident #121's task documentation for meals had no information for the one day he was present in the facility on 05/31/25. Nurse Aide #43 was interviewed on 07/24/25 at 3:14 PM and reported that Resident #121 was admitted to the facility and left the facility against medical advice the same day as 05/31/25. She stated that he had been arguing with his family because he wanted to go home and they wanted him to stay for treatment. [...]

Inspectors wroteBased on observation, record review and staff interview, the facility failed to provide a safe, clean, homelike environment for Resident #11 and #96. This was a random opportunity for discovery. Resident Identifiers: #11 and #96. Facility Census: 115. Findings Include:a) Resident #11 On 07/22/25 at 10:45 AM, an observation of room [ROOM NUMBER] was made. The observation found Resident #11 sitting in a geri-chair with dried food and other debris on it. The resident was found facing the wall. There was no television or music playing. The resident appeared disheveled, and the room was noted with a foul odor of urine. The resident's fall mat was observed with a tear on the corner. The floor was sticky and food from breakfast as well as a plastic spoon were on the floor. The resident's clothes were dirty and were noted with a foul body odor. Her hair was disheveled. [...]

Inspectors wroteBased on record review, staff interview and family interview, the facility failed to complete a thorough investigation regarding an allegation of neglect for Resident #123. This was true for one (1) of seven (7) residents reviewed under the care area of neglect. This failed practice had the potential to affect more than a few residents. Resident Identfiers: #123 Facility Census: 115. Findings Include:a) Resident #123On 07/23/25 at 11:00 AM, a review of a facility-reported incident regarding Resident #123 was completed. The review found the allegation of waiting over a one (1) hour wait time for the resident to receive assistance. The five (5) day follow-up was reviewed at this time as well. The following was documented: [...]

Inspectors wroteBased on record review and staff interview the facility failed to ensure Resident #59's care plan was revised to reflect the residents history of falls. This was true for one (1) of seven (7) residents reviewed in regards to Facility Reported Incidents during a complaint survey. Resident Identifiers: #59 . Facility Census:115. a) Resident #59A review of a facility reported incident (FRI) found Resident #59 suffered a fall on 08/10/24. A review of the facility's five-day follow-up report found the following, .He does have fall precautions in place, and secondary to this incident, his bed will now be placed against the wall to prevent falling from the bed. A review of the resident's current care plan on 07/22/25 found the resident had no care plan focus statement, goals, or interventions related to being at risk for falls and/or a history of falls. [...]

Inspectors wroteBased on observation, record review and staff interview the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible to prevent injury to the residents. Nurse Aide (NA) #12 transferred Resident #56 from the tilt shower chair to her bed using a stand and pivot method. The residents care plan, Kardex and physician orders all indicated Resident #56 was to be transferred via a total lift with the assistance of two (2) staff members. Resident Identifier: #56. Facility Census: 115. Findings Include: a) Resident #56 On 07/28/25 at 10:48 AM NA #12 was observed transporting Resident #56 back to her room from the shower room. The resident was in a tilt back shower chair at this time. NA #12 was observed taking Resident #56 into her room. No other staff members were observed in the room. At 10:51 AM another NA entered the room. [...]

Inspectors wroteBased on observation, record review and staff interview the facility failed to ensure a resident who is fed by enteral means receives the appropriate treatment and services to prevent complications of enteral feeding including but not limited to weight loss and dehydration. This was true for one (1) of one (1) resident reviewed for the care area of Feeding Tubes during a complaint survey. Resident Identifier: #52. Facility Census:115. Findings Include: a) Resident #52 A review of Resident #52's medical record found a physician's order which read: Enteral feed order one time a day Glucerna:1.5 cal at 70 ML (Milliliters) per hour for 20 hours This order was current at the time of this review and began on 07/15/25. The resident was to be started on the feeding at 2:00 PM and unhooked at 10:00 AM the following day. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to protect the resident's right to be free from neglect. The facility failed to care for the resident's skin conditions and percutaneous endoscopic gastrostomy (PEG). The facility also failed to ensure the resident received bathing activities. The resident was hospitalized for a wound infection. The resident's PEG tube was adhered to her skin. This caused actual harm to the resident. Resident Identifiers: #110. Facility census: 109. a) Resident #110 Resident #110 was discharged from the hospital and returned to the facility on [DATE]. On 03/25/25, Resident #110 was transferred back to the hospital. Hospital records stated upon admission to the hospital, the resident was generally soiled with dirt and feces in her skin folds. She also had yeast appearing exudate. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to provide care and services for pressure ulcers in accordance with professional standards of practice. This deficient practice had the potential to affect three (3) of three (3) residents reviewed for pressure ulcers. Pressure ulcers were not assessed weekly for Residents #110, #58, and #90. Additionally, Resident #110's pressure ulcers were not treated as ordered. This deficient practice caused actual harm to Resident #110, who was admitted to the hospital with a pressure ulcer infection. The hospital physician also diagnosed the resident with septic shock, believed to be caused by a combination of pneumonia and sacral pressure ulcer wound infection. Resident identifiers: #110, #58, #90. Facility census: 109.

Inspectors wroteBased on resident representative interview, record review, observation, and staff interview, the facility failed to treat each resident with respect and dignity and to care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility failed to ensure Resident #13 was wearing her glasses and also failed to ensure Resident #13's legs were covered when she was in a public area. Additionally, the facility failed to honor Resident #65's right to vote. This failed practice was true for one (1) of three (3) residents reviewed in the area of dignity throughout the complaint process and one (1) of five (5) residents reviewed in the area of activities and voting. Resident identifiers: #13 and #65. Facility census: 109.

Inspectors wroteBased on observation and staff interview, the facility failed to secure and keep confidential residents personal and medical information. The facility failed to safeguard private information that was placed in a clear acrylic wall file holders located in the hallway outside of the Medical Records office and the Physician's office. These were random opportunities for discovery. Facility census: 109.

Inspectors wroteBased on record review and staff interview, the facility failed to provide care and services for skin tears in accordance with professional standards of practice. This deficient practice had the potential to affect four (4) of four (4) residents reviewed for skin tears. Resident identifiers: #110, #26, #58, #90. Facility census: 109.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure percutaneous endoscopic gastrostomy (PEG) tube care in accordance with professional standards of care for one (1) of three (3) residents reviewed for PEG tube care. Resident identifier: #110. Facility census: 109.

Inspectors wroteBased on resident interviews, anonymous nursing staff interviews, and hours per patient day review, the facility failed to ensure sufficient qualified nursing staff were available to provide nursing and related services to meet the residents' needs safely and in a manner that promoted resident rights, physical, mental and psychosocial well-being. The low staffing had the potential to affect all residents in the facility. Facility census: 109.

Inspectors wroteBased on food tray temperatures and staff interview, the facility failed to serve food to residents that was at an appetizing temperature. This failed practice was true for one (1) of one (1) hallway tested for food tray temperatures throughout the complaint survey process. This had the potential to affect more than an isolated number of residents. Facility census: 109.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. Facility staff failed to follow contact precautions and enhanced barrier precautions. Staff also failed to perform appropriate hand hygiene during a dressing change. This deficient practice had the potential to affect more than a limited number of residents. Resident identifiers: #9 and #26. Facility census: 109.

Inspectors wroteBased on observation and staff interview, the facility failed to provide a safe, clean, comfortable, and homelike environment. The facility failed to keep the 100 Hall hallway at a comfortable temperature level. Additionally, the facility failed to keep the Maple Dining area at a comfortable temperature level. These were random opportunities for discovery. These practices had the potential to affect more than an isolated number of residents. Facility census: 109.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure a complete and accurate Minimum Data Set (MDS) assessment in the area of pressure ulcers. This was a random opportunity for discovery during the investigation. Resident identifier: #7. Facility census: 109.

Inspectors wroteBased on record review, and staff interview the facility failed to send a copy of transfer/discharge notifications to a representative of the Office of the State Long-Term Care Ombudsman. This failed practice was found true for six (6) of seven (7) seven residents reviewed for hospitalizations/discharges during the Long-Term Care Survey Process. Resident identifiers #105, #114, #36, #24,#68, and #5. Facility census: 115.

Inspectors wroteBased on resident interview, record review, staff interview and observation, the facility failed to ensure dependent residents received showers according to schedule/preference for Resident #14, #111, #62, and #42. Facility census: 115.

Inspectors wroteBased on record review and staff interview the facility failed to follow the Physicians order for wound care and providing immunizations as required. This was true for one (1) of five (5) residents' wounds reviewed and three (3) of five (5) immunizations records reviewed. Resident Identifiers: #84, #12, #83, #87. Facility Census: 115.

Inspectors wroteBased on interview with the resident, staff interview and record review, the facility failed to honor resident's choices for food. This was true for 1 (one) of 4 (four) residents reviewed in this annual survey. Resident identifier: #42. Facility census: 115.

Inspectors wroteBased on record review and [NAME] interview, the facility failed to provide a written notice of bed hold to the resident or resident representative. This was true for 2 (two) of 7 (seven) residents reviewed during the survey process. Resident identifiers: #36 and #24. Facility census:

Inspectors wroteBased on record review and staff interview, the facility failed to coordinate the PASARR's diagnosis of dementia, with the MDS assessment. This was found to be true for 1 (one) of 1 resident reviewed during the survey process. Resident Identifier: #42. Facility census: 115.

Inspectors wroteBased on observation, record review and staff interview the facility failed to provide a program of activities to support residents one on one and sensory stimulation needs. This failed practice was found true for (1) one of (2) two residents reviewed for Activities during the Long-Term Care Survey Process. Resident identifier #43. Facility Census 115. Findings Include: a) Resident #43 The initial observation on 03/31/25 at 1:53 PM, found Resident #43 lying in bed, staring at the wall. No television or music was on in the residents room. An observation on 04/01/25, at 9:30 AM, found Resident #43 lying in bed, with her head at the foot of her bed, she was rolling the sheet in her fingers. No television or music was on in the residents room. [...]

Inspectors wroteBased on observation and staff interview the facility failed to properly store locked controlled medications and permit only authorized personnel to have access to the keys and medications. This was a random opportunity for discovery. Facility census: 115 Findings Include: a) On 04/02/25 at 03:10 PM it was observed that the medication storage refrigerator had a narcotic medication storage box. The separately locked, permanently affixed box in the facility medication refrigeration was affixed to a removable shelf, however, the shelf was easily slid out of the refrigerator making it easy to remove the shelf and box from the facility. Also, the key to the box was placed (stored) in the lock itself. [...]

Inspectors wroteBased on observation, record review and staff interview, the facility failed to provide appropriate assistive devices to residents who need them to maintain or improve their ability to eat or drink independently, by not ensuring Resident #36 was served lunch on a three (3) compartment plate. Facility census: 115.

Inspectors wroteBased on observation, staff interview and review of documentation, the facility failed to ensure trash was properly contained in the dumpster. Dumpster door broken, another open. Medical Supplies (gloves, wipes, chuck pads) on the ground surrounding area. Facility census: 115.

Inspectors wroteBased on record review and interview, the facility failed to ensure orders were being monitored by having an order for medicine to be taken orally for Resident #64 who is NPO (nothing by mouth). This was a random opportunity for discovery and had the potential to affect a limited number of residents residing in the Long-Term Care Facility. Resident identifier: #64 Facility Census:

Inspectors wroteBased on observation and staff interview the facility failed to establish and maintain an infection prevention and control program during medication pass and by not properly disposing of urine. These were random opportunities for discovery. Resident Identifier: #63. Facility Census: #115 Findings Include: a) Resident #63 On 04/01/25 at 7:40 AM during medication administration observation with Licensed Practical Nurse (LPN) #69 it was observed that the LPN placed a 50 milligram Tramadol pill in her ungloved hand and then placed it in the medication cup and administered to Resident #63. This was confirmed immediately with the LPN and then with the Administrator and Corporate Registered Nurse #134 on 04/01/25 at 8:45 AM.

Inspectors wroteBased on record review and staff interview the facility failed to educate, offer and obtain declination or consent for influenza and pneumococcal immunizations. This was true for one (1) of five (5) Residents screened for immunizations. Resident I\identifier: #83 Facility Census: 115 Findings Include: a) Resident #83 (Influenza and Pneumococcal) On 04/03/25 at 09:54 AM during record review of resident immunizations it was found that Resident #83 is a [AGE] year old that was admitted on [DATE]. There is no documentation of any past influenza (flu) or pneumococcal (pneumonia) immunizations education, consents or declinations. The influenza vaccination is marked Not eligible due to being admitted after flu season. The resident was admitted on [DATE]. According to the Centers for Disease Control and Prevention (CDC) guidelines, the flu season runs from October through May. [...]

Inspectors wroteBased on record review and staff interview the facility failed to educate, offer and obtain declination or consent for COVID-19 2024-2025 immunizations. This was true for one (1) of five (5) Residents screened for immunizations. Resident Identifier: #83 Facility Census: 115 Findings Include: a) Resident #83 (COVID 19) On 04/03/25 at 09:54 AM during record review of resident immunizations it was found that Resident #83 is [AGE] years old and was admitted on [DATE]. There is documentation that the resident received the following COVID 19 vaccinations prior to admission to the facility: COVID 19 Vaccine dose 1 03/06/21 COVID 19 Vaccine dose 2 04/10/21 Vaccine additional dose 10/27/21 Vaccine additional dose 05/16/22 There is no documentation that Resident #83 or the MPOA was educated or offered a COVID 19 2024-2025 updated vaccination. [...]

Inspectors wroteBased upon record review and staff interview, the facility failed to provide 12 (twelve) hours of education for the past year for nursing aides (NA). This was true for 5 (five) of 5 (five) records reviewed during the annual survey process. Employee iIdentifiers: NA #24, NA #37, NA #48, NA #75, and NA #66. Facility census:

Inspectors wroteBased on record review, staff interview, and resident interview, the facility failed to consider the views of the resident counsel and act promptly upon the grievances and recommendations of the group concerning issues of resident care and life in the facility. This has the potential to affect more than a limited number of residents at the facility. Resident identifiers: #27, #95, #15, #29, #103, #16 and #58. Facility census: 118.

Inspectors wroteBased on record review, observation and staff interview, the facility failed to develop and/or implement care plans for six (6) of 38 residents reviewed during the long term care survey. Residents #17, #88 and #117 did not receive care and treatment for pressure ulcers as directed by the care plan. Resident #71 was not care planned for advanced directives. Resident #108's care plan was not implemented for the prevention of edema. Resident #63 did not have care plan interventions in place for the prevention of falls. Resident identifiers: #17, #63, #117, #108, #88, and #71. Facility census: 118.

Inspectors wroteBased on record review and staff interview the facility failed to revise comprehensive care plans as needed. This was true for three (3) of thirty-eight (38) care plans reviewed during the Long Term Care Process. Resident Identifiers: #93, #77 and #51. Facility Census:

Inspectors wroteBased on record review, resident interview and staff interview, the facility failed to follow or obtain physician's orders regarding medication administration, obtain a weight and a physician's order for advance directives. This is true for seven (7) of 38 residents reviewed during the survey process. Resident identifiers: #88, #9, #108, #112, #103 and #71. Facility Census: 118. Findings Included: a) Resident #88 On 03/17/24 at 11:40 AM, a physician's order was found stating, Extremity Protectors to be in place to bilateral arms. Remove every shift and prn (as needed) for bathing/skin inspections. (Typed as written. On the following dates and times, observations were made to show the extremity protectors were not in place: [...]

Inspectors wroteBased on observation, record review, resident interview and staff interview, the facility failed to ensure three (3) of four (4) residents reviewed for the care area of pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. Resident identifiers: #17, #117, and #33. Facility census: 118. a-1) Resident #17 - Treatments During an interview with the resident on 03/17/24 at 12:07 PM, the resident stated she developed a pressure ulcer on her backside while at the hospital, she still has it, but believes the area is getting better. Record review found the resident was admitted to the facility on [DATE] with an unstageable pressure ulcer to the right gluteus. [...]

Inspectors wroteBased on observation and staff interview, the facility failed to ensure all medical supplies stored in the medication storage room were stored in accordance with currently accepted professional principles. This was a random opportunity for discovery and had the potential to affect more than a limited number of residents. Facility Census:

Inspectors wroteBased on observation and staff interviews, the facility failed to post accurate menus prior to meal times. This was a random opportunity for discovery. This has the potential to affect more than a limited number of residents. Facility census: 118.

Inspectors wroteBased on observation, record review, and resident interview, the facility failed to serve food at palatable temperatures for resident consumption. There were a total of 18 complaints of cold food during the survey process. This had the potential to affect more than a limited number of residents. Resident identifiers: #224, #223, #117, #33, #12, #51, #82, #59, #103, #73, #71 #55, #27, #95, #15, #29, #16 and #58 complained of cold food during the long term care survey. Facility census: 118.

Inspectors wroteBased on observation, record review and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections due to not wearing protective protection equipment (PPE) in an enhanced barrier room and touching the surroundings with soiled glove for Resident #88, for proper storage of a nebulizer mask for Resident #62, no hand hygiene completed before meals for room [ROOM NUMBER], 408 and 411 and by placing a dirty meal tray on a clean dining cart. These were random opportunities for discovery. Resident Identifiers: #88 and #62 . Facility Census: 118. Findings Included: a1) Resident #88 On 03/18/24 at 12:40 PM, Nurse Aide (NA) #107 was observed completing incontinence care for Resident #88 without wearing proper PPE (gown). [...]

Inspectors wroteBased on observation and staff interview, the facility failed to provide a dignified and respectful existence for Resident #88 and #104. These were random opportunities of discovery. Facility Census: 118.

Inspectors wroteBased on observation, record review, and resident and staff interview, the facility failed to provide a safe, comfortable, and homelike environment by failing to ensure water temperatures in the shower room were comfortable for Resident #73. This was a random opportunity for discovery. Resident identifiers: #73. Facility census: 118.

Inspectors wroteBased on observation and resident and staff interview, the facility failed to provide activities of daily living (ADL) care to a dependent resident by not providing proper nail care to Resident #104. This was true for one (1) of two (2) residents reviewed for ADL care. Resident identifier: 104. Facility census: 118.

Inspectors wroteBased on observation, resident interview and staff interview, the facility failed to maintain a safe and accident-free environment as possible. These were a random opportunities for discovery. Resident identifiers: #87 and #73. Facility Census: 118. Findings Included: a) Resident #87 On 03/17/24 at 11:47 AM, an interview with Resident #87 was held. During the interview, an observation of two (2) medication cups with a clear cream inside was found sitting on the over-the-bed table by the bed. The resident was asked, do you know what is in the medication cups? The resident responded, I think they use that for my wound on my leg. On 03/17/24 at 11:50 AM, Licensed Practical Nurse (LPN) #135 was notified regarding the two medication cups with a clear cream inside. LPN #135 stated, let me get rid of that .I'm not sure what it is .it looks like Aquaphor. [...]

Inspectors wroteBased on observation and staff interview, the facility failed to maintain professional standards of care for residents receiving dialysis. This was true for one (1) of one (1) residents reviewed under the care area of dialysis. Resident Identifier: #51. Facility Census: 118. Findings Included: a) Resident #51 On 03/19/24 at 10:36 AM, a record review was completed for Resident #51. The review found the dialysis communication book was incomplete. On the following dates the hemodialysis communication book was missing information: [...]

Inspectors wroteBased on record review and staff interview, the facility failed to complete performance reviews for Nurse Aides at least once every twelve months. This was true for one (1) of five (5) employees reviewed for performance reviews during the long term care survey process. Facility census: 118.

Inspectors wroteBased on record review and staff interview the facility failed to identify a diagnoses for psychotropic medications. This was true for one (1) of five (5) residents reviewed for unnecessary medications. Resident Identifier: #93 Facility Census:

Inspectors wroteBased on record review and staff interview the facility failed to maintain complete and accurate medical records. This was true for one (1) of three (3) resident records reviewed for discharge during the Long-Term Care Survey Process. Resident #120 was discharged and the physician did not complete the recapitulation of the resident's stay. Resident identifier: #120. Facility census:

Inspectors wroteBased on observation and staff interview, the facility failed to ensure a resident's call light was accessible. These were random opportunities for discovery and affected only a limited number of residents. Resident identifiers: #4 and #63. Facility census: 118.