Estates Healthcare and Rehabilitation Center

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for one of three residents (Resident #1) reviewed for supervision. Staff failed to ensure Resident #1 turned his smoking materials in to staff to be locked up, in order for him to only have use of them during scheduled, supervised smoking breaks. This failure could place residents at risk of injury.

Inspectors wroteBased on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 2 of 3 residents (Resident #1 and #2) reviewed for clinical records. The facility failed to have complete records for Resident #1 and #2 's wound care for June 2026. This failure could place residents at risk for incomplete and inaccurately documented medical records that included their progress treatment, services, and interventions that would lead to slowing on the healing of wounds .[

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program, including hand hygiene, designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for 1 of 5 residents (Resident #1) reviewed for infection control practices. While providing Resident #1, who was on EBP due to having a feeding tube and urinary catheter, with incontinence care, CNA A failed to wear a gown and failed to secure her identification lanyard badge, which resulted in the badge touching the resident's perineal area, buttocks, and feces. These failures could place residents at risk of cross-contamination and infections.

Inspectors wroteBased on interviews and record reviews the facility failed to ensure resident records were accurately documented for 17 of 86 residents (Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, and #17) reviewed for resident records. The facility failed to ensure on 06/03/26 CNA A did not use CNA B's log in credentials when she documented care provided for Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, and #17. This failure could place residents at risk of inaccurate reporting of their care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from abuse for 1 of 24 residents (Resident #17) reviewed for abuse. The facility failed to ensure CNA Z did not abuse Resident #17 on 04/30/2026 during incontinent care. An IJ (Immediate Jeopardy) was identified on 04/30/26. The IJ template was provided to the facility on [DATE] at 4:50 PM. While the IJ was removed on 05/01/26, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because all staff had not been trained on the plan of removal. This failure could place residents at risk for abuse, physical harm, mental anguish and emotional distress.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a private meeting space for the residents' monthly council meetings for 15 of 15 confidential residents reviewed for resident council. The facility failed to provide a private space for resident council meetings. This failure could place residents, who attended resident council meetings, at risk of not being able to voice concerns due to a lack of privacy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as is possible and each resident received adequate supervision to prevent accidents for 3 (Residents #7, #23, and #97) of 18 residents reviewed for smoking. The facility failed to follow their smoking policy when Residents #7, #23, and #97 were observed to be smoking on the patio without supervision. This failure placed residents at risk of harm and/or serious injury.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 (Resident #10) of 8 residents reviewed for comprehensive care plans. The facility failed to ensure Resident #10's care plan addressed resident's behavior of picking at her face. This failure could place residents at risk of not having their individual needs met, not receiving necessary care and services, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was fed by enteral means received appropriate treatment and services to prevent complications for 1 of 4 residents (Resident #11) reviewed for feeding tubes. RN D failed to follow physician orders and added the wrong amount of water during the flush to Resident #11's formula g-tube (device inserted through the belly into the stomach to deliver nutrition, fluids, and medications) during the feeding on 04/30/26. This failure could place residents at risk for a decline in health or adverse effects due to inappropriate management of G-tube care.

Inspectors wroteBased on observations, interviews and record reviews the facility failed to ensure all drugs and biologicals were stored in locked compartments and permit only authorized personnel to have access to the keys for 1 of 5 carts reviewed for medication storage. LVN-A failed to secure her medication cart prior to walking away from it on 04/28/26. This failure could place residents at risk of accessing medications not prescribed for them. Observation on 04/28/26 at 5:30 a.m. a medication cart located outside the only nurses' station was unlocked. All drawers were able to be opened, and multiple prescription and over the counter medications were in the drawers. In an interview on 04/28/26 at 5:33 a.m. LVN-A stated she had walked away for just a minute to talk with someone. [...]

Inspectors wroteBased on observations, interviews, 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 for 1 (Resident #4) of 8 residents reviewed for infection controlStaff left a graduated cylinder, used to measure urine output, on the resident's bedside table. This failure could cause cross contamination from an unclean item to the clean items on the bedside table.

Inspectors wroteBased on observation, interview, and record review, the facility failed to immediately consult with the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status for 1 of 5 residents (Resident #1) facility reviewed for nutrition. The facility failed to immediately notify the physician when Resident #1's weight showed a 15.9% loss from 02/10/26-03/09/26. This failure could place residents at risk for malnutrition or mismanagement of underlying medical conditions.

Inspectors wroteBased on interview and record review the facility failed to ensure the assessment accurately reflected the resident's status for 1 of 8 residents (Resident #1) reviewed for assessments. The MDS Nurse failed to ensure Resident #1's annual MDS assessment, updated on 03/15/26, was accurate and reflected the resident's recent significant weight loss. This failure could place residents at risk for missed care needs and continued decline in health.

Inspectors wroteBased on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 8 residents (Resident #1) reviewed for comprehensive care plans. The facility failed to develop a comprehensive care plan for Resident #1 to address the resident's recent significant weight loss. This failure could place residents at risk for missed care needs and continued decline in health.

Inspectors wroteBased on interviews and record review the facility failed to ensure, based on the comprehensive assessment of a resident, that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 10 residents (Resident #2) reviewed for quality of care. The facility failed to treat Resident #2's constipation as ordered by the physician. This failure could place residents at risk of developing an obstruction, or a rupture of the intestines.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that each resident maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrated that this was not possible or resident preferences indicated otherwise for 1 of 5 residents (Resident #1) facility reviewed for nutrition. The facility failed to recognize, evaluate and address Resident #1's weight loss when there was a documented 15.9 % loss from 02/10/26-03/09/26. This failure could place residents at risk for malnutrition or mismanagement of underlying medical conditions.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to establish and 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 for 1 of 5 residents (Residents #9) reviewed for environment. 1. LVN-W, CNA-R, and MA failed to ensure the linen cart located on the 100 hall was covered when not in use. 2. LVN-W and CNA-U failed to properly discard a red biohazard bag, after providing care when the bag was left in the hallway of Hall 300 outside Resident #9's room. This deficient practice placed staff and residents at risk for infections and human body fluids.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure the assessments accurately reflected the resident's status for 2 of 4 residents (Residents #1 and #2) reviewed for accuracy of assessments. The facility failed to ensure Resident #1 and Resident #2's MDS assessments were accurate and coded for behavior and mood. This failure could place residents at risk for receiving inadequate care and services based on an inaccurate assessment.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 2 of 4 residents (Residents #4 and #8) reviewed for respiratory care. 1. The facility failed to ensure Resident #4's nasal cannula and tubing were bagged when not in use. 2. The facility failed to ensure Resident #8's CPAP mask was bagged when not in use. These failures could place residents at risk for respiratory infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and 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, for 3 of 7 residents (Resident #1, Resident #2, and Resident #3) reviewed for infection control. The facility failed to ensure Residents #1, #2 and #3, who were on Enhanced Barrier Precautions, received proper care from staff donning and doffing personal protective equipment for infection control. This failure could place residents at risk for the spread of infections and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 8 residents (Resident #1) reviewed for quality of care. The facility failed to ensure Resident #1 received appropriate monitoring of his condition after the resident refused three consecutive dialysis treatments on 10/04/25, 10/07/25, and 10/09/25. This failure placed residents at risk of a delay in medical evaluation and treatment, which could result in worsening of conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from abuse for 5 of 6 residents (Residents #1, #2, #3, #8, and #9) reviewed for abuse. 1. The facility failed to ensure adequate supervision was provided to prevent a physical altercation between Residents #8 and #9 on the facility's memory care unit on 06/17/25 and failed to ensure the nurse on the unit, RN K, had visual access to the residents to be able to intervene timely. Resident #9 punched Resident #8 approximately eight times in the face/head resulting in Resident #8 having an abrasion and swelling on the left side of his face. 2. The facility failed to ensure Resident #1 was free from verbal abuse when he was verbally abused by CNA #1 on 09/04/25. 3. The facility failed to ensure Resident #3 were free from abuse on 05/13/25 when Resident #2 punched him in the face. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as is possible and each resident received adequate supervision and assistive devices to prevent accidents for 2 of 5 residents (Resident #8 and Resident #9) reviewed for supervision. The facility failed to ensure adequate supervision was provided to prevent a physical altercation between Residents #8 and #9 on the facility's memory care unit on 06/17/25 and failed to ensure the nurse on the unit, RN K, had visual access to the residents to be able to intervene timely. Resident #9 punched Resident #8 approximately eight times in the face/head resulting in Resident #8 having an abrasion and swelling on the left side of his face. The noncompliance was identified as a past non-compliance. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to incorporate the recommendations from the PASRR Level II determination and the PASRR evaluation report into a resident's assessment, care planning, and transitions of care for 2 of 4 residents reviewed (Residents #2 and #5) for PASRR assessments.1. The facility failed to submit a NFSS form, used to request specialized services for residents, request within 20 from interdisciplinary team meeting dated 03/18/25 for Resident #2. 2. The facility failed to submit a completed a NFSS in the LTC Online Portal within 20 business days of Resident #5's IDT meeting. This failure could place residents at risk of not receiving or benefiting from recommendations for services they may require.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that all alleged violations involving abuse were reported immediately to the Administrator of the facility for 1 of 3 residents (Resident #1) reviewed for reporting abuse and neglect. LVN B failed to report an allegation of verbal abuse to the Administrator, on 09/05/25 when CNA used profanity towards Resident #1. This failure could have resulted in psychological harm to residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from abuse for 3 of 6 residents (Resident #4, Resident #6, and Resident #7) reviewed for abuse. 1. The facility failed to ensure Resident #4 was free from emotional and mental abuse. Video footage identified CNA A antagonizing Resident #4 when she went to check on him on 02/18/25 . The noncompliance was identified as past noncompliance (PNC). The noncompliance began on 02/18/25 and ended on 02/19/25. The facility had corrected the noncompliance before the investigation began. 2. The facility failed to ensure Resident #6, and Resident #7 were free from abuse on 03/11/25 when Resident #6 verbally abused Resident #7 which cause Resident #7 to physically abuse Resident #6 by hitting him on the face. The noncompliance was identified as past noncompliance (PNC). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as possible and provide supervision to prevent avoidable accidents for 1 (Resident #5) of 3 residents reviewed for accidents. The facility failed to keep Resident #5 free of accidents after his anti-tippers were removed from his wheelchair during his dialysis treatment on 04/01/25 when he was on the van's lift and fell backwards, hitting his head on the grate of the lift and sustaining an injury. The noncompliance was identified as PNC. The noncompliance began on 04/01/25 and ended on 04/02/25. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of severe injury, hospitalization, and decline in quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate dispensing and administering of all drugs, to meet the needs of each resident for 2 of 3 residents (Residents #2 and #3) reviewed for pharmacy services. The facility failed to maintain accurate documentation regarding the administration of Resident #2 and Resident #3's PRN pain medication and failed to ensure LVN C checked the current physician's orders before administering the PRN pain medication, Hydrocodone/acetaminophen 10/325 mg, to Resident #2 on 01/06/25 when the resident had opioid restrictions. The failure placed residents at risk for possible drug overdose and complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for two of six residents (Resident #67 and Resident #99) reviewed for accidents. 1. The facility failed to provide adequate supervision to prevent Resident #99, who had cognitive impairment and resided on the secure unit, from eloping from the facility on 02/03/25 when the resident pried open the window in his room and made it 0.9 miles away from the facility. An Immediate Jeopardy was identified on 02/12/25 at 3:50 PM. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 of 4 residents (Resident #67) reviewed for quality of care. RN C failed to assess Resident #67 for a change in condition in a timely manner when he reported he was not feeling well on 02/09/25 at approximately 7:30 AM, and RN C noticed he did not look well and offered to send the resident to the hospital. An IJ was identified on 02/13/25. The IJ template was provided to the facility on [DATE] at 5:20 PM. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to provide the necessary treatment and services, based on the comprehensive assessment and consistent with professional standards of practice, to prevent development of pressure ulcers for 1 (Resident #67) of 2 residents reviewed for pressure ulcers with use of a wound vacuum. RN C failed to provide Resident #67 with wound care when he reported to her on 02/09/25 at approximately 7:30 AM that he was not feeling well and needed his dressing changed because his wound vac was leaking. RN C did not follow-up with Resident #67 for care until 5:30 PM at which time she discovered she did not have enough supplies to complete wound care. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 2 of 2 residents (Residents #9 and #63) reviewed for dialysis. The facility failed to ensure dialysis communication forms for Residents #9 and Resident #63 were received back from dialysis center after returning from dialysis treatment on the dates mentioned below. The missing communication forms for Resident #9 totaling to 10 days on the following dates: 01/01/25, 01/03/25, 01/06/25, 01/08/25, 01/10/25, and 01/17/25, 02/03/25, 02/05/25, 02/07/25 and 02/10/25. Resident #63 was missing communication forms totaling to 12 days on the following dates: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident on one of three medication carts (300) and 3 of 3 residents (Residents #7,#147, and #178) reviewed for pharmacy services. 1. The facility failed to ensure the 300 Hall nurses' medication cart contained accurate narcotic logs for Resident #7, #147 and #178 on 02/12/25. 2. The facility failed to ensure expired medications , 1 bottles of atropine 0.1% with expiration dates of August 2024 was removed and destroyed form 300 hall nurses cart on 02/12/25. These failures could place residents at risk for medication errors, drug diversion, and ineffective drug therapy.

Inspectors wroteBased on interviews and record review, the facility failed to immediately consult with the physician of a significant change in the resident's health status; or a need to alter treatment significantly for 1 (Resident #67) of 3 residents reviewed for notification of change. RN C failed to immediately notify the physician that Resident #67 came to the nursing station and stated to RN C that he was not feeling well. RN C stated Resident #67 looked pale, he looked sick. This failure could place residents at risk for delay in treatment, a negative outcome to a resident's physical, mental, and psychosocial health, well-being, or decreased quality of life.

Inspectors wroteBased on interviews, and record review the facility failed to ensure all alleged violations involving neglect were reported to the State Survey Agency in a timely manner for 1 (Resident #67) of three residents reviewed for abuse and neglect. The Administrator failed to report Resident #67 fell backwards in his wheelchair (which had not anti-tippers or brakes), hitting his head on the floor of the van during takeoff in the facility parking lot. Resident #67 was sent to hospital resulting in initial encounter with head injury and contusion of right hand. Resident #67 stated his wheelchair was not strapped down correctly and stated he blacked out. The failure could place residents at risk of serious harm or neglect.

Inspectors wroteBased on observations, interviews, and record review the facility failed to investigate and report allegation of neglect for 1 (Resident #67) of 3 residents reviewed for accidents and hazards. The Administrator failed to investigate and report the results of the investigation to the state agency when Resident #67 fell backwards in his wheelchair (which had not anti-tippers or brakes), hitting his head on the floor of the van during takeoff in the facility parking lot. Resident #67 was sent to hospital resulting in initial encounter with head injury and contusion of right hand. Resident #67 stated his wheelchair was not strapped down correctly and stated he blacked out. This failure could place residents at risk of harm and injuries related to neglect and a delay in investigating.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure all drugs and biologicals were stored securely and had acceptable labeling for one (Halls 200 nurses Medication Cart) of three medication carts reviewed for labeling and storage. The facility failed on 02/12/25 to ensure insulin vials were dated after they were opened and were not dated with wrong dates located on the medication cart for the 200 hall. This failure could place residents at risk of not receiving the therapy needed.

Inspectors wroteBased on interview, and record review the facility failed to provide specialized rehabilitative services for 1 (Resident #2) of 3 residents reviewed for specialized rehabilitative services. The facility failed to ensure Resident #2 received a speech therapy evaluation as per physician orders dated 01/28/25. This failure could place residents with orders for therapy at risk of not meeting their highest practicable well-being.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (Resident #1) reviewed for accidents. CNA A failed to get assistance from another staff member when providing Resident #1, who required two staff for assistance with all ADLs, a bed bath on 12/05/24. During the bed bath, CNA A asked Resident #1 to turn to her side. When the resident turned she fell to the floor, which resulted in the resident sustaining a fracture of her right femur (thigh bone). The noncompliance was identified as past noncompliance. The Immediate Jeopardy began on 12/05/24 and ended on 12/05/24. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for serious injury or harm, decline in health, and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 2 residents (Resident #1) reviewed for comprehensive care plans. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that each resident who was incontinent of bladder with an indwelling catheter received appropriate treatment and services for 1 of 2 residents (Residents #1) reviewed for incontinent care and for indwelling urinary catheters. The facility they failed to monitor and document signs and symptoms of dehydration, decreased or no urine output, for Resident#1. This failure could place residents at risk of not having their individual needs met, not receiving necessary care and services, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that drugs and biologicals were stored in locked compartments for 1 of 6 medication carts located on hall 200 observed for drug storage. 1. The facility failed to ensure one medication cart found on 200 hall was not left unlocked and unattended by LVN A on at 10/04/24 at 12:30 PM. 2. The facility failed to ensure one medication cart found on 200 hall was not left unlocked and unattended by LVN B on 10/05/24 at 9:26 PM. This failure could place residents at risk of access and ingestion medications.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure the resident had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 of 10 residents (Resident #2) reviewed for call lights. Resident #2's call light was not within reach. The call button was on the other side of the privacy curtain draped over a vacant bed. This failure could place residents at risk of not having their needs and preferences met and a decreased quality of life.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 10 residents reviewed for accidents. The facility staff failed to ensure Resident #1 was safe from accidents and hazards when she fell from her bed on 09/28/2024 and was found face down on the floor with a bruise on her forehead. Resident #1 did not have a fall mat placed on both sides of her bed. This failure could place residents at risk of injury and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for 1 of 4 residents (Resident #1) reviewed for accidents. Staff failed to ensure Resident #1 did not receive a burn blister to her left wrist on 08/09/24 when she was drinking coffee from the dining room and spilled it on herself. The noncompliance was identified as PNC. The noncompliance began on 08/09/24 and ended on 08/09/24. The facility had corrected the noncompliance before the survey began. This deficient practice could affect residents at the facility who drank hot liquids that could cause burns from the facility's kitchen.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 3 shower rooms (Shower room [ROOM NUMBER]) observed for accident and hazards. The facility failed to ensure two disposable razors in Shower room [ROOM NUMBER] were kept out of reach of residents. These failures could place residents at risk for injury.

Inspectors wroteBased on interview, the facility failed to designate a registered nurse to serve as the director of nursing on a full time basis for 53 of 65 days (04/13/24-06/05/24) reviewed for DON coverage. The facility failed to designate a RN to serve as DON on a full-time basis since 04/12/24. The failure placed residents at risk of not receiving necessary care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 9 residents (Resident #1) reviewed for quality of care. The facility failed to ensure hospital discharge orders were followed for Resident #1 to have a follow-up appointment with a primary care physician. This failure could affect residents who receive care from the facility and place them at risk for worsening conditions.

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 for 2 of 3 ice chests observed for infection control. 1. The facility failed to ensure the ice chests were maintained in a manner to prevent cross-contamination. 2. The facility failed to ensure staff personal food items were not stored in the facility's medication refrigerator in the facility's medication storage. These failures placed residents at risk for the development and spread of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and 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 for 1 (Resident #61) of 17 residents reviewed for dignity. The facility failed to ensure a WanderGuard device was not placed on Resident #61 when the resident was not an elopement risk. The failure placed residents at risk of decreased quality of life and lowered self-esteem.

Inspectors wroteBased on interview and record review, the facility failed to immediately consult with the physician of a significant change in the resident's health status; or a need to alter treatment significantly for 1 (Resident #168) of 4 residents reviewed for notification of change. The facility failed to notify Resident #168's physician that the resident's insulin had been discontinued by the hospital or that the resident had returned from the hospital and failed to follow-up with the physician to obtain new orders. The failure placed residents at risk of not having medical complications and deterioration.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 1 of 8 residents (Residents #166) reviewed for comprehensive care plans. The ADON failed to ensure Resident #166's care plan was updated to include her use of a Life Vest. This failure could place the residents at risk of deterioration and improper care.

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents received proper treatment and assistive devices to maintain vision abilities for 1 (Resident #45) of 23 residents reviewed for vision services. The facility did not address Resident #45's vision loss and ensure Resident #45 was seen by an ophthalmologist. This failure could place all residents with vision loss at risk of not receiving proper services, decreased ability to communicate and/or a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments for 1 (Resident #57) of 17 residents reviewed for drug storage. LVN A left two medications at the bedside of Resident #57. This failure could place residents at risk of taking medications not prescribed for them.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all mechanical, electrical, and patient care equipment was in safe operating condition for 1 (Resident #22) of 6 residents reviewed for safe, functional equipment. The facility failed to ensure Resident #22's bed was in proper working condition. This failure could place residents at risk for skin tears, injury, falls and discomfort during transfers.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents had the right to be free from abuse and neglect for 2 of 5 residents (Resident #1 and Resident # 2) reviewed for abuse and neglect. The facility failed to prevent Resident #3 from physically abusing Resident #2, when Resident #3 punched Resident #2 in the face on 08/24/23. The facility failed to ensure Resident #1 was free from abuse and neglect by not providing adequate supervision and services, when the facility allowed Resident #3, who had a history of physically assaulting residents and staff, to continue to reside in the facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents has the right to be free from abuse for one (Resident #1) of three residents reviewed for abuse. The facility failed to ensure LVN A did not verbally abuse Resident #1 during their interactions on 08/04/23. This failure placed the resident at risk of decreased feelings of self-worth.