Elevate Care Windsor Park

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain building temperatures within the regulated range to provide a homelike environment for residents and failed to obtain building humidity levels to accurately assess building temperatures. This failure affected all 198 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to evaluate its resident population to prioritize its most vulnerable residents prior to a facility emergency. This failure has the potential to affect all 198 residents that reside in the facility.

Inspectors wroteBased on interview and record review the facility failed to safely warm up food in the microwave for one resident (R4) out of four residents reviewed for accidents and supervision. This failure resulted in the resident sustaining a second degree burn measuring 15.0 cm (Centimeter) x 17.0 cm x 0.10 cm after hot noodles were spilled in her lap.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain a safe, functional, sanitary, comfortable environment. The facility failed to maintain and repair water leaks in the kitchen timely. The facility also failed to maintain an adequate supply of dining ware resulted in residents being served meals using disposable Styrofoam items. These deficient practices have the potential to affect all 189 residents receiving food prepared in the facility's kitchen. Findings Include:1.) On 6/9/26 at 9:50AM, V7 (Dietary Manager) and surveyor toured the kitchen. Observed an active ceiling leak over the handwashing sink. There were no mold or discolored areas observed in the kitchen. Observed discolored area on the ceiling tile in the dishwashing area in the kitchen. [...]

Inspectors wroteBased on interview and record review the facility failed to report an incident of a resident burn to the state agency in a timely manner for one (R4) resident that sustained a second degree burn. Findings Include:R4 was admitted to the facility with diagnosis not limited to Essential (Primary) Hypertension, Gastro-Esophageal Reflux Disease, Kyphosis, Cerebral Palsy, Burn of Second Degree of Right Thigh. R4's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 15 indicating intact cognitive response. Progress note dated 04/14/26 2:34 PM document in part: Wound Care Note Text: R4 had a recent report of a new skin condition. There has been an additional report of a change in pain level since the event. Progress note dated 04/14/26 3:06 PM document in part: Wound Care Note Text: Wound care assessed resident post spill with a cup of noodles. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident dependent on incontinent care was provided incontinent care in a timely manner for one (R9) of four residents reviewed for quality of care/treatment. Findings Include:R9's diagnoses include but not limited to History of Falling, Chronic Diastolic (Congestive) Heart Failure, Malignant Neoplasm of Prostate, Atrial Fibrillation, Hypertensive Heart Disease with Heart Failure, Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, Absolute Glaucoma, Right Eye, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side, Type 2 Diabetes Mellitus with Diabetic Neuropathy, , Peripheral Vascular Disease, Gastro-Esophageal Reflux Disease, Diseases of Anus and Rectum, Pressure Ulcer of Sacral Region, Stage 3, Pressure Ulcer of left Buttock, Stage 2. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure staff wore the proper PPE (Personal Protective Equipment) while providing care for one (R9) resident on Enhanced Barrier Precautions. Findings Include:R9's diagnoses include but not limited to History of Falling, Chronic Diastolic (Congestive) Heart Failure, Malignant Neoplasm of Prostate, Atrial Fibrillation, Hypertensive Heart Disease with Heart Failure, Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, Absolute Glaucoma, Right Eye, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side, Type 2 Diabetes Mellitus with Diabetic Neuropathy, , Peripheral Vascular Disease, Gastro-Esophageal Reflux Disease, Diseases of Anus and Rectum, Pressure Ulcer of Sacral Region, Stage 3, Pressure Ulcer of left Buttock, Stage 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure there are no more than 14 hours between the evening meal and breakfast the following day with a substantial bedtime snack available/offered to everyone. These failures have the potential to affect all 190 residents receiving oral diets from the facility's kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to (a) ensure a resident received the correct oxygen flow rate, (b) obtain physician order for oxygen use, (c) ensure oxygen in use signage was posted, (d) develop comprehensive care plan for oxygen use, (e) ensure oxygen nasal cannula was labeled and dated and (f) ensure nebulization tubing mask was properly stored. These failures affected five (R41, R89, R105, R173, R207) of seven residents reviewed for respiratory care in a sample of 35.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a) medications were discarded when expired, b) ensure medications were labeled with the resident's name and c.) ensure medications were dated when opened in 4 of 4 medication carts reviewed during the medications labeling and storage observation. Findings Include:On 04/01/26 at 09:34 PM V9 (Licensed Practical Nurse) handed the surveyor a zip lock bag containing Budesonide-Formoterol Fumarate Inhalation Aerosol 160-4.5 MCG/ACT with 135-1 and the date of 03/18/26 written in marker on the inhaler. There was no label or resident name on the inhaler. V9 stated I don't know what happened to the box, I will order a new inhaler. On 04/01/26 at 12:11 PM the second-floor team 1 medication cart was reviewed with V11 (Licensed Practical Nurse). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a) food items were properly labeled and dated, b.) food is rotated using First In, First Out (FIFO) guidelines, c.) kitchen equipment is sanitized based on manufacturers' procedure directions. These failures have the potential to affect all 190 residents receiving food prepared in the facility's kitchen.

Inspectors wroteBased on observation, interview and record review the facility failed to (a) ensure staff cleaned and disinfected reusable equipment between resident use, (b) perform hand hygiene during medication administration for five (R53, R56, R112, R119, R215) residents, (c) ensure proper Personal Protective Equipment (PPE) were worn during wound care treatment, (d) ensure Enhanced Barrier Precautions (EBP) signage was posted, (e) develop comprehensive care plan for one (R7) resident on Enhanced Barrier Precautions (EBP). These failures have the potential to affect six (R7, R53, R56, R112, R119, R215) residents reviewed for infection control in a sample of 35.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the call light was within reach for two (R1 and R13) of two residents reviewed for reasonable accommodation of needs in a sample of 35.

Inspectors wroteBased on interview and record review, the facility failed to obtain a physician order for a code status for two (R10, and R12) out of eight residents reviewed for advance directive in a total sample of thirty-five. Findings Include: R10's Minimum Data Set (MDS) dated [DATE] noted she is moderately cognitively impaired. R10's Electronic Medical Record (EMR) noted she was admitted to the facility on [DATE]. She is [AGE] years old with diagnoses not limited to type 2 diabetes mellitus without complications, dementia, obstructive and reflux uropathy, myocardial infarction, and chronic kidney disease. 2. R12's Minimum Data Set (MDS) dated [DATE] noted she is cognitively intact. R12's Electronic Medical Record (EMR) noted she was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a clinical contraindication for gradual dose reduction (GDR) for residents receiving psychotropic medications. This failure resulted in three residents (R3, R11, R70) not having a gradual dose reduction (GDR) attempted/completed for medications they receive.

Inspectors wroteBased on interviews and record reviews, the facility failed to refer a resident (R11) who was later identified with a mental disorder to the appropriate state-designated authority for a Level II PASARR (Preadmission Screening and Resident Review) evaluation and determination for one out of a total sample of 35 residents.

Inspectors wroteBased on interview and record review, the facility failed to refer a resident to the appropriate state-designated authority for a PASARR Level II Screen evaluation and determination with known mental illness for one (R35) out of eight residents reviewed for Pre-admission Screening and Record Review (PASARR) in a total sample of 35.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nail care was provided for one (R126) resident who requires supervision in grooming reviewed for Activities of Daily Living (ADL) out of eight residents in total sample of thirty-five. Findings Include: R126's Minimum Data Set (MDS) dated [DATE], Brief Interview Score (15) indicates he is cognitively intact. R126 Electronic Health Record/EHR noted an active diagnosis of hemiplegia and hemiparesis affecting right dominant side, contracture of right hand, acquired absence of left leg below knee, acquired absence of other right toes, chronic kidney disease, and type 2 diabetes mellitus with diabetic nephropathy. R126's Minimum Data Set (MDS) dated [DATE] functional abilities assessment noted R126 requires partial/moderate assistance with personal hygiene. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to assist a resident (R78) out of bed for 1 out of a total sample of 35 residents reviewed for Activities of Daily Living (ADLs).

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the controlled substances were counted and documented correctly in one of 4 medication carts reviewed during the medication storage and labeling observation. Findings Include:On 04/01/26 at 12:28 PM the third-floor medication cart 2 was reviewed with V25 (Licensed Practical Nurse). During review of the controlled substance a Controlled Substances Proof of Use sheet dated 03/19, amount received 15 ml (milliliter) was observed with no name documenting in part: Morphine Sulfate 100 mg (milligram) per 5 ml (milliliter). Take 0.25 ml (5mg) by mouth or under tongue every 2 hours as needed for shortness of breath. A box with R75's name was observed in the narcotic drawer. V25 stated the sheet has 15 ml but there is about 13 ml in the bottle. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident (R78) was up-to-date with their pneumonia vaccine series for 1 out of 5 residents reviewed for immunizations.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the dumpsters were covered with lids to prevent the harborage and feeding of pests, insects, and rodents. This deficient sanitation practice has the potential to affect all 202 residents who reside in the facility.

Inspectors wroteBased on interview and record review, the facility failed to provide adequate nursing staff to ensure resident needs are being met in a timely manner and medications are being administered as ordered by the physician. This had the potential to affect residents assigned to V31 (Licensed Practical Nurse) on 03/21/26 and residents residing on the 2nd and 3rd floor on 03/21/26, residents residing on the 3rd floor on 03/22/26 and residents assigned to V46 (Licensed Practical Nurse) on 03/26/26.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow physician orders for administering medications to eight (R1, R6, R7, R10, R11, R12 R13, R14) of eight residents reviewed for Improper Nursing Care.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents are free of any significant medication error for two (R12 and R13) of eight residents reviewed for improper nursing care.

Inspectors wroteBased on interview and record review the facility failed to follow their fall prevention policy and safely transfer for one resident (R4). The facility failed to check the mechanical lift sling to ensure that the sling was safe for resident transfers. This failure resulted in R4 falling to the ground from a mechanical lift, causing R4 pain and being frightened every time the staff have to transfer R4. This failure affected one resident (R4) reviewed for falls. This past noncompliance occurred from 10/26/25 to 11/4/25.

Inspectors wroteBased on interview, and record review the facility failed to update a resident's (R1) care plan intervention post resident fall. This failure affected 1 of 3 residents reviewed for falls.

Inspectors wroteBased on interview, and record review the facility failed to investigate a resident (R1's) fall. This failure affected 1 of 3 residents reviewed for fall accidents/incidents.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide wound care treatment and change wound dressing as ordered by physician to one (R1) resident identified as a high risk for development of pressure ulcer. This failure affected one (R1) out of three residents reviewed for improper nursing care. As a result of this failure, R1 had worsening/deterioration and infection of pressure ulcer.

Inspectors wroteBased on observation, interview and record review, the facility failed to (a) implement transmission-based precautions, (b) ensure staff wear proper PPE (Personal Protective Equipment), (c) post precaution sign to alert staff for instructions prior to entering the room, and (d) provide PPE supplies accessible to staff for 1 (R1) of 3 residents reviewed for improper nursing care. These failures have the potential to cross contaminate 15 residents assigned to V7 (Certified Nursing Assistant/CNA).

Inspectors wroteBased on interview and record review the facility failed to keep two residents (R2 and R5) free from abuse of three reviewed for abuse in a total sample of nine residents.

Inspectors wroteBased on observation, interviews and record review, the facility failed to make prescribed anticonvulsant medication (Dilantin/ Phenytoin) available for one a resident (R444), who is diagnosed with seizure disorder, had sub- therapeutic (low levels) of Dilantin in his blood according to lab-work, and missed a dose of his anticonvulsant medication; the facility failed to administer medication for one resident (R15) who has seizure disorder. This failure has affected R444, who had two episodes of seizures within five minutes of each other and resulted in R15 having sub- therapeutic levels Dilantin medication in the blood.

Inspectors wroteBased on interviews and record review, the facility failed to provide restorative services for four physically impaired residents: R445, R59, R88 and R85. This failure has affected four of four residents reviewed for restorative services and has resulted in R445 becoming visibly emotional while expressing her fear of deteriorating in bed.

Inspectors wroteBased on observation, interviews and record review, the facility failed to provide continuous supplementary oxygen to one resident (R19); failed to provide the correct concentration of oxygen for R73; and failed to ensure that oxygen tubing for one resident (R544) was dated. This failure has resulted in R19 having an oxygen saturation of 89% and has the potential to affect 30 Residents using oxygen in the facility.

Inspectors wroteBased on observation, interview and record review, the failed to ensure residents are free from unnecessary psychotropic medication use; failed to ensure that gradual dose reductions were completed. This failure caused harm to R58, causing R58 to exhibit symptoms of sedation. On 3/3/2025 at 10:37 AM, R58 was observed in semi-Fowlers position resting in bed. Resident was difficult to arouse by voice and appeared lethargic. When being interviewed, R58's voice was unclear when speaking and was falling asleep mid conversation. Record review of R58's minimum data set (dated 12/19/2024) documents in part that R58 has clear speech, is able to make self understood, able to express ideas and wants; has a brief interview of mental status summary score of 10, indicating R58 has cognitive impairment; [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure foods in the refrigerator and freezer were labeled with a date indicating when the item was placed into the refrigerator/freezer and labeled with a use by date. These failures have the potential to affect all 194 residents in the facility who are receiving an oral diet.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the outside trash dumpsters were not missing lids to cover the tops of the trash dumpsters. This failure has the potential to affect all 199 residents residing at the facility.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure a clean linen cart was not stored inside the restroom of a resident on Enhanced Barrier Precautions (EBP) and failed to ensure the plastic bag used for containment of soiled linen were securely tied prior to conveyance via a chute. These failures affected 2 (R7 and R89) reviewed for infection control and have the potential to affect all the residents residing at the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to conduct care plan conferences, allowing residents/their families exercise the right to participate in the development/implementation of their plan of care; failed to follow their comprehensive care planning policy. These failure affects 4 residents (R9, R58, R163, and R48).

Inspectors wroteBased on observation, interview and record review, the facility failed to provide assistance with grooming. These failures affected 1 (R46) of 3 residents (R46, R73, R148,) reviewed for ADLs (activities of daily living) in a sample of 65. Findings Include: On 3/3/2025 at 12:04 pm, R46's fingernails were long and contained brown matter under all 10 fingernails. R46 stated that she did not like her nails long and wanted her nails trimmed. [...]

Inspectors wroteBased on Observation, interview, and record review, the facility failed to ensure that residents' Low Air Loss Mattresses (LALM) for pressure ulcer prevention are set at the correct weight settings. This failure affected five residents (R38, R40, R113, R148, R170) out of nine residents reviewed for pressure ulcer prevention and treatment in a sample of 33 residents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the personal refrigerator temperatures were monitored daily, failed to ensure expired food items were discarded, and failed to ensure personal refrigerator has temperature log form in an effort to prevent foodborne illnesses. These failures affected 5 (R7, R71, R77, R124, and R145) residents reviewed for personal refrigerator in a total sample of 65 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents' call lights are functional and in good working order. This failure has the potential to affect 4 residents, R32, R97, R645, and R646, reviewed for functioning call lights, in a total sample of 65 residents.

Inspectors wroteBased on interview and record review, the facility failed to obtain informed consent for psychotropic medication. This failure affects 1 resident (R58) in a sample of 65.

Inspectors wroteBased on observation, interview and record review, the facility failed to store a bottle of lorazepam in accordance to manufacturer's instructions. This failure affects 1 resident (R32) in a sample of 65.

Inspectors wroteBased on interview and record review, the facility failed to implement their fall prevention policy to ensure the safety of a resident by failing to assess for the risk for falls and implement appropriate fall prevention interventions. The facility also failed to provide supervision and assistive devices to utilize as necessary for one of three residents (R1) reviewed for falls. These failures resulted in R1 falling, requiring transport to the local emergency department where R1 was diagnosed with a closed fracture of the neck of the left femur, requiring surgical repair.

Inspectors wroteBased on observation, interview and record review the facility failed to provide residents with a home-like environment, clean and sanitary shower rooms. This failure has the potential to affect 195 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the availability of adequate clean bed linen due to inadequate supply of new bed linens and laundry equipment malfunction. This has the potential to affect all 197 residents who reside in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement their Enhanced Barrier Precaution (EBP) policy and procedures by failing to place a resident with a pressure wound on EBP to prevent the potential spread of multidrug resistant organisms. This failure affects one resident (R5) and the potential to affect three additional residents (R9, R10, R11) on the sample list of 11.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure low air loss mattress was set appropriately for one (R7) resident reviewed for pressure ulcer/injury treatment in the total sample of 11 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the nurse call system was properly working for four of eight residents (R5, R6, R7, R8) reviewed for call lights on the sample list of eight.

Inspectors wroteBased on interviews and records review, the facility failed to investigate, and report alleged mental abuse for one (R1) of three residents reviewed.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to a.) ensure food items were properly labeled, dated, and stored, b.) kitchen staff wearing hair/beard coverings These failures have the potential to affect all 181 residents receiving food prepared in the facility's kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure dumpster was covered to prevent the harborage and feeding of pests, insects, and rodents. This deficient sanitation practice has the potential to affect all 185 residents who reside in the facility.

Inspectors wroteBased on observation, interviews, and review of records the facility failed to ensure all policies related to infection control were reviewed in a timely manner. And failed to follow policy on handling clean linen to avoid contamination. These failures have the potential to affect all 185 residents using linens and ensuring that facility policies and procedures are updated to address present infection related concerns.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy to develop a comprehensive person-centered care plan that directs the care team, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs. This failure affects 7 (R20, R45, R61, R91, R125, R129, R136) residents reviewed for comprehensive care plan in a sample of 35.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to follow their policy and procedure for medication storage and labeling to ensure medication was secured in a locked storage area for 1 (R182) resident and failed to properly date opened multi-dose inhalers and insulins for 6 residents (R144, R104, R123, R18, R76, R48) from two of four medication carts inspected for medication storage and labeling. Findings Include: On 1/16/24 at 10:17 AM, 2nd floor medication cart 2 was inspected with V33 (Licensed Practical Nurse). The following were noted: - R144's opened Tiotropium 18MCG inhaler without the date opened written on the label. - R104's opened Symbicort inhaler without the date opened written on the label. - R123's two opened Lispro insulin pen without the date opened written on the label. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to follow the pureed menu spreadsheets for five residents (R16, R21, R77, R87, R101) out of 8 residents receiving pureed diets in a total sample of 35 residents.

Inspectors wroteBased on record review and interview the facility failed to follow policy on documenting influenza and pneumococcal vaccination on residents record for 5 out of 10 residents (R531, R233, R24, R182, and R181) reviewed for vaccination / immunization.

Inspectors wroteBased on review of records and interviews the facility failed to show documentation of 5 out of 10 residents (R531, R233, R24, R182, and R181) Covid-19 vaccination status. Failed to provide staff documentation that Covid-19 was screened and offered and failed to provide Covid-19 vaccination policy for both residents and staff. This also affects 5 residents (R531, R233, R24, R182, and R181) determination of Covid-19 vaccination and to avail the benefit of Covid-19 vaccine.

Inspectors wroteBased on observation, interview, and review of records the facility failed to follow their policy on feeding and assisting residents to eat. Failures include facility staff was standing and not giving attention to 3 out of 3 residents (R2, R101, R16) during mealtime. These failures affects 3 residents (R2, R101, R16) socializing experience during mealtime.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy to ensure that call light was within easy accessibility to resident at the bedside and failed to monitor defective and/or non-functioning call light. These failures affect 2 (R114 and R531) residents to call for assistance and receive care in a sample of 35.

Inspectors wroteBased on interview and record review the facility failed to obtain a Physician's order with the code status for 1 (R24) of 6 residents reviewed for Advance Directives in a sample of 35. Findings Include: R24 was admitted to the facility on [DATE] with diagnosis not limited to Peripheral Vascular Disease, Seizures, Essential (Primary) Hypertension, Polyneuropathy, Major Depressive Disorder, Anemia, Gastritis, Gastro-Esophageal Reflux Disease, Symptomatic Epilepsy and Epileptic Syndromes with Complex Partial Seizures, Generalized Epilepsy and Epileptic Syndromes, Altered Mental Status, Extended Spectrum Beta Lactamase (ESBL) Resistance. Review of R24 Physician orders, Progress Notes and Care Plan has no orders or documentation for Advance Directives. On [DATE] at 11:39 AM, R24 was observed sitting in a wheelchair in his room in no distress. [...]

Inspectors wroteBased on interview and record review, the facility failed to obtain a resident's blood glucose as ordered, this failure affected 1 resident (R42) in a sample of 35 residents. On 1/16/24 at 11:55 AM, R42 was sitting on R42's wheelchair in R42's room. R42 was alert and able to verbalize needs. R42 stated that R42 receives insulin injections, but the staff has not checked R42's blood glucose since Friday. R42 stated that R42 is diabetic, and no one checked R42's blood glucose this morning either. At 12:01 PM, Surveyor checked R42's electronic health record (EHR) with V5 (Registered Nurse/3rd Floor Unit Manager). R42's current physician order sheet (POS) shows an order for blood glucose monitoring two times a day scheduled at 9:00 AM and 6:00 PM. R42's blood glucose results show R42's blood glucose was last taken on 12/12/23 at 4:40 PM with a result of 331 mg/dl. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their policy to ensure that intervention was documented or initialed in the electronic treatment administration record (ETAR) for 1 (R94) resident with presence of pressure ulcer in a sample of 35.

Inspectors wroteBased on observation, interview and record review the facility a.) failed to provide services to treat and prevent a decline of Range of Motion (ROM) for a resident with contractures to the left hand, b.) failed to assess a resident with contractures and c.) failed to implement a care plan to address the resident contractures. This deficient practice was identified for 2 (R70, R172) of 2 residents reviewed for ROM in a sample of 35. Findings Include: 1. R172 was admitted to the facility on [DATE] with diagnosis not limited to Adult Failure to Thrive, Single Subsegmental Pulmonary Embolism Without Acute Cor Pulmonale, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Dominant Side, Essential (Primary) Hypertension, Paraplegia, Hyperlipidemia, Emphysema, Long Term (Current) use of Anticoagulants, Abnormalities of Gait and Mobility, Weakness and Lack of Coordination. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policies and procedures to ensure a resident received the correct oxygen flow rate as ordered by the physician and to ensure oxygen tubing was properly labeled when it was changed for 1 (R65) of 2 residents receiving oxygen therapy in a sample of 35 residents reviewed for respiratory care. Findings Include: On 1/16/24 at 12:38 PM, R65 was sitting in R65's geriatric chair alert and awake but unable to answer surveyor's questions. R65 was noted receiving oxygen (O2) via nasal cannula that was set to 4 liters per minute (LPM). R65's O2 tubing was also noted with no date labeled when it was last changed. On 1/18/24 at 9:54 AM, V2 (Director of Nursing) stated that a resident's oxygen should be administered per physician's order. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to follow facility policy for personal refrigerators by not labeling food items with a date and discarding expired food items from resident's personal refrigerators for 1 (R45) resident reviewed in the sample of 7 for safe personal food storage.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that call lights are within reach for 9 residents (R2, R3, R4, R5, R6, R10, R11, R12, and R13) reviewed for call lights in the sample.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that beverages were served in sanitary way to prevent contamination and prevent the spread of food borne illnesses. This failure has the potential to affect all 69 residents on the 3rd floor of the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that resident room TV's are in good working condition for two residents (R1 and R15) in the sample reviewed for homelike environment.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that the resident environment remained free of accidental hazards by not leaving sharp items, disposable shaving razor that could harm the residents. This failure affected R3 who had a disposable shaving razor stored on the over bed side table visible to the hallway unsupervised and has the potential to affect all 69 residents residing on the 3rd floor of the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that inhaler medication was stored in a locked medication cart when not in use and not in visual proximity of the nurse for two residents (R8 and R18) in the sample reviewed for medication storage.

Inspectors wroteBased on interviews and record reviews the facility failed to follow their discharge policy to ensure R1 was safely discharged home with the necessary durable medical equipment [DME] in a sample of 6 residents. This failure resulted in R1 with an increase in pain to the surgical right hip, and emotional distress leaving R1 feeling upset, afraid, sometimes crying scared that R1 was going to fall and hurt herself.

Inspectors wroteBased on interviews and record reviews the facility failed to provide on-site social worker coverage on a full-time basis for 12 days, resulted in [R1] to discharge home without the durable medical equipment needed for safe mobility. This failure has the potential to affect all 195 residing in the facility.