Extended Care Hospital of Westminster

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure a safe and secure environment for one of three sampled residents (Resident 1). * Resident 1 eloped from a facility outing where he was required to be under close supervision. The resident was not located until approximately 14 hours later by the law enforcement in the community and returned to the facility approximately 18 hours later after being medically cleared from the acute care hospital. This failure placed the resident at risk for injury while unsupervised in the community without medications and medical care.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure five of 19 final sampled residents (Residents 5, 10, 25, 68, and 81) were free from the unnecessary psychotropic medications. * The facility failed to ensure nonpharmacological interventions were implemented when Residents 5, 10, and 25 exhibited behaviors related to the use of the psychotropic medications. In addition, the nonpharmacological interventions were not included into the residents' plan of care. * The facility failed to ensure nonpharmacological interventions were implemented when Resident 68 exhibited behaviors related to the use of the Ativan (antianxiety), Seroquel (antipsychotic), and Geodon (antipsychotic) medications. [...]

Inspectors wroteBased on observation, interview, and medical record review, and facility P&P review, the facility failed to ensure the recommendations from the PASARR Level II determinations were followed up and incorporated into the resident care for three of three final sampled residents (Residents 10, 25, and 81) reviewed for PASARR. * The facility failed to ensure the recommendations for PASARR Level II determination were followed up and incorporated into Residents 10, 25, and 81's plan of care. These failures had the potential to prevent residents from receiving necessary services identified by the state-designated PASARR authority, affecting their physical, mental, and psychosocial well being.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the menus were followed when:1. The pureed diet peas and carrots recipe was not followed;2. The minced and moist diet peas and carrots recipe was not followed; and3. The minced and moist diet glazed meat loaf recipe was not followed. These failures had the potential to not meet the residents' nutritional needs for the 18 of 87 residents (Residents 2, 7, 18, 20, 24, 26, 34, 44, 45, 52, 59, 63, 65, 66, 67, 74, 88, and 93) who received a pureed diet and nine of 87 residents (Residents 16, 21, 37, 61, 64, 76, and 84) who received a minced and moist diet.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure food safety and sanitation guidelines were followed for 87 of 93 residents who received meals from the facility's kitchen. * The facility failed to ensure facial hair was covered in the food preparation area. * The facility failed to ensure the ice machine was not dirty. * The facility failed to ensure open food items were dated. These failures increased the risk of foodborne illness for the highly susceptible resident population of 87 residents who received meals prepared in the facility's kitchen.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the infection control practices were followed. * The facility failed to ensure Room A's door frame had no yellow discoloration. * The facility failed to ensure Room A's toilet seat was in good repair. * The facility failed to ensure the floor tiles in hallways throughout the facility and in the laundry room were intact and cleanable. * The facility failed to ensure the laundry room vents and surfaces were free of dust and cobwebs. * The facility failed to ensure clean towels used for residents were stored covered and protected from contamination. * The facility failed to ensure the clean PPE gowns were stored properly and not adjacent to a lint producing machine. * The facility failed to ensure eye protection was available for staff to use while sorting soiled laundry. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the residents or their representatives were informed in advance of the proposed treatments regarding the use of the psychotropic medications (medications affecting brain activity) for two of five final sampled residents (Residents 68 and 81) reviewed for psychotropic medication use. * The facility failed to ensure the informed consent for Geodon (antipsychotic medication) and Seroquel (antipsychotic medication) included the diagnosis for which medications were prescribed for Resident 68. * The facility failed to ensure informed consent for Zoloft (antidepressant medication) and Zyprexa (antipsychotic medication) included the benefits and the manifested behaviors for Resident 81. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain a homelike environment for the residents. * Yellow stains observed ceiling tiles in multiple areas throughout the facility. * Cracks and peeling paint observed on the lobby ceiling. These failures posed the risk of the residents not being able to enjoy a clean, well-maintained interior environment.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the comprehensive person-centered care plan was revised to reflect the residents' current care needs and interventions for three of 19 final sampled residents (Residents 7, 10, and 77). * The facility failed to ensure the care plan for pain and pain medication was revised to include nonpharmacological interventions prior to administration as ordered, for Residents 10 and 77. * The facility failed to ensure the care plan was updated to reflect the current use of wheelchair alarm for Resident 7. These failures increased the risk that residents would not receive individualized and person centered care in accordance with their assessed needs.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to meet the resident's care needs for one of 19 final sampled residents (Resident 81). * The facility failed to ensure side effects of the psychotropic medication (any drug that affects brain activity associated with mental processes and behavior) were monitored, documented and reported to the physician for Resident 81. This failure had the potential to cause avoidable complications, delayed interventions, worsening health conditions, and overall compromised residents' well being.

Inspectors wroteBased on observation, interview, medical record review, and facility document, the facility failed to ensure the necessary care and services were provided to prevent the development of pressure injuries for one of three final sampled residents (Resident 1) reviewed for pressure injuries. * The facility failed to ensure Resident 1's LAL mattress was not set in a static mode while the resident was in bed. This failure had the potential to result in the development of pressure injuries or the worsening of existing pressure injuries.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of two final sampled residents (Resident 7) reviewed for weight loss received the necessary services to maintain acceptable nutritional status. * The facility failed to notify Resident 7's physician and resident's responsible party, when Resident 7 experienced significant weight loss upon readmission to the facility. This failure had the potential to delay needed medical intervention, contribute to further nutritional decline, and increase the resident's risk for adverse health outcomes related to unaddressed significant weight loss.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure appropriate care and services were provided for the residents with GT for two of three final sampled residents (Residents 3 and 87) reviewed for the tube feeding management. * The facility failed to ensure LVN 3 administered diluted medications via GT by gravity flow as required, for Resident 3. * The facility failed to ensure Resident 87's enteral feeding formula and water feeding bag were changed within 24 hours per facility P&P and accepted standards. These failures placed the residents at risk for complications related to GT use, including tube dislodgement, gastrointestinal injury, contamination, or infection.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to provide the necessary care for one of one resident reviewed for respiratory care (Resident 7). * The facility failed to ensure Resident 7's suction canister, tubing, and opened Yankauer suction was labeled. This failure had the potential for Resident 7 to not receive appropriate respiratory care and increase risk of infection.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure one licensed nurse reviewed for competency had specific competencies and standard of practice skill sets needed to provide safe and efficient nursing care. * The facility failed to ensure LVN 3 was able to competently administer the medications via GT (gastrostomy tube, a small tube placed through the abdominal wall into the stomach, used to provide enteral feedings and/or administer medications) to Resident 3. This failure had the potential to put the resident at risks for the care not provided in a safe and competent manner.

Inspectors wroteBased on observation and interview, the facility failed to provide the necessary pharmacy services to ensure proper storage of the medications in one of one medication storage room inspected. * The facility failed to ensure over the counter medications were stored in a locked compartment. This failure resulted in unauthorized staff having access to the medications.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure food safety and sanitation guidelines were followed for 87 of 93 residents who received meals from the facility's kitchen. * The facility failed to ensure facial hair was covered in the food preparation area. * The facility failed to ensure the ice machine was not dirty. * The facility failed to ensure open food items were dated. These failures increased the risk of foodborne illness for the highly susceptible resident population of 87 residents who received meals prepared in the facility's kitchen.

Inspectors wroteBased on interview, facility document review, and facility P&P review, the facility failed to ensure residents in the TRC were offered suitable alternate meal choices in accordance with their food when refusing a planned meal. * The residents in the TRC were offered only nutritional supplement drinks when planned meals were refused. This failure had the potential to prevent the 45 TRC residents receiving meals from the facility's kitchen from meeting the residents' nutritional needs.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the medical record was complete and accurate for one of 19 final sampled residents (Resident 8). * The facility failed to ensure Section D of the POLST, and the Advance Directive Acknowledgement form were completed accurately for Resident 8. This failure had the potential to result in unmet care needs for the resident due to inaccurate medical information.

Inspectors wroteBased on interview and facility document review, the facility failed to ensure the Facility Assessment addressed or included the following:1. A plan to maximize recruitment and retention of direct care staff; and2. A contingency plan for staffing needs. These failures had the potential not to meet the residents' care needs if the assessed population's needs and resources were not comprehensively identified and addressed.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to properly obtain the informed consents for the use of bed exit alarms from the resident or responsible party for three of three sampled residents (Residents 1, 2, 3). * The facility failed to ensure Residents 1, 2, 3 had informed consent for the use of the bed alarm. This failure posed the risk for the residents and their responsible parties to not be informed of their treatment plan and the potential risks.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the staff provided care and promoted dignity and respect for two of 21 final sampled residents (Residents 31 and 45) and five nonsampled residents (Residents 17, 27, 28, 33, and 84). * CNA 1 was observed assisting Residents 31 and 84 with meals at the same time. In addition, CNA 1 was observed assisting Resident 31 and 17 with meals at the same time. * CNA 2 was observed assisting 27 and 28 with meals at the same time. * CNA 3 was observed assisting Residents 33 and 45 with meals at the same time. These failures had the potential to negatively impact the residents' feelings of self-worth and well-being.

Inspectors wrote4. Medical record review for Resident 397 was initiated on 6/24/25. Resident 397 was admitted to the facility on [DATE]. Review of Resident 397's admission Summary note dated 6/26/25 showed Resident 397 was admitted to the facility with diagnoses including bipolar disorder, anxiety disorder, and substance use disorder. Resident 397 had conservators to make medical decisions for him. Review of Resident 397's June 2025 Order Summary Report showed Resident 397 had the following orders dated 6/20/25: [...]

Inspectors wrote6. Review of the facility's P&P titled Psychiatric Pharmacy Policy dated 7/2/20, showed a standing order for Haldol (antipsychotic medication) 10 mg IM when residents refused to take any PO psychotropic medications. However, the policy did not mention nonpharmacological interventions that would be attempted prior to this standing order of residents refusing to take any PO psychotropic medications. Medical record review for Resident 397 was initiated on 6/24/25. Resident 397 was admitted to the facility on [DATE]. Review of Resident 397's admission Summary note dated 6/26/25, showed Resident 397 was admitted to the facility with diagnoses including bipolar disorder, anxiety disorder, and substance use disorder. Resident 397 had conservators to make medical decisions for him. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to develop the care plan problems for the residents' plans of care as evidenced by: * The care plans were not developed for 23 of 23 residents in the TRC unit who smoked. * The facility failed to develop the comprehensive person-centered care plans for two of 21 final sampled residents (Residents 1 and 67) addressing the disputes on closing and leaving their door open. These failures had the potential risk of not providing the appropriate, consistent, and individualized care to the residents

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to provide the individualized and ongoing activity program to meet the needs and interests of one of 21 final sampled resident reviewed for activities (Resident 49). * The facility failed to provide Vietnamese cultural music and TV program in the room for Resident 49 as per activities assessment. This failure had the potential for the resident to experience feelings of social isolation and frustration.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 21 final sampled residents (Resident 49) remained free of accident hazards and four smokers were provided adequate supervision as evidenced by: * The facility failed to ensure the safety and supervision were provided during smoking times for four residents who were smoking. * The facility failed to ensure Resident 49's right floor mat was placed near the resident's bed. In addition, the facility failed to monitor resident's BP while lying, sitting and standing as per the care plan to address the fall that occurred on 5/21/25. Furthermore, Resident 49 was assessed to have changes from clear to rambling speech as per the neurocheck for the fall on 5/27/25; however, the facility failed to notify the physician for the changes in the resident's neurological status. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary GT care and services for two of three final sampled residents (Residents 16 and 42) reviewed for GT feeding. * The facility failed to ensure the GT feeding formulas were not stored at bedside and the GT formula labels were accurate and matched the physician's orders for Residents 16 and 42. These failures posed the risk of misleading information on the residents' GT feeding rate and could lead to overfeeding or underfeeding, and storing a feeding formula at bedside posed a risk of contamination and spoilage, and increased risk of unauthorized access of the feeding formula.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the adequate and appropriate pain management for two of three final sampled residents (Resident 20 and 67) reviewed for pain management. * The facility failed to ensure the pain medication was administered as per the physician's orders for Resident 20. * The facility failed to ensure the non-pharmacological pain interventions were implemented and documented before the administration of the PRN pain medication for Resident 67. These failures had the potential for residents not to receive the appropriate treatment for pain.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the competency of the licensed nurses on obtaining and evaluating the orthostatic hypotension as evidence by: * The facility failed to provide in-services and conduct the competency evaluations for the orthostatic hypotension monitoring as verified by the DON. * The facility failed to ensure the competency of the licensed nurses (LVNs 1 and 3, and LPTs 1 and 2) in obtaining and evaluating for orthostatic hypotension. These failures had the potential to put the residents at risk for the care not provided in a safe and competent manner.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the pharmaceutical services to ensure the accurate administration of the medications as evidenced by: * The facility's medication error rate was 3.85%. One of two licensed nurses (RN 1) who was observed during the medication administration was found to have an error. RN 1 failed to administer the complete dose of one of Resident 53's medications when significant residual of the medication was observed in the medication cup after RN 1 administered the docusate sodium (stool softener) to Resident 53. This failure had the potential to negatively impact the residents' health outcomes. * The facility failed to ensure the accurate reconciliation and documentation of the controlled medications for one nonsampled resident (Resident 748). [...]

Inspectors wroteBased on observation, interview, facility P&P review, and facility document review, the facility failed to provide the necessary pharmacy services to ensure proper storage, labeling, and disposal of medications. * The facility failed to ensure the orally administered medications were kept separate from externally used medications, e.g., suppositories, eye drops. This failure posed the risk for the occurrence of error in the medication administration. * The facility failed to ensure the refrigerator containing insulins, vaccines, and other medications requiring refrigeration was monitored daily to ensure the temperature was within the required range. This failure had the potential for the medication to lose the stability and effectiveness of the medication. [...]

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen. * The facility failed to ensure proper labeling and dating of food in the walk-refrigerator. * The facility failed to ensure the plate lowerator was clean. * The facility failed to ensure the walk-in freezer was free from ice build-up. * The facility failed to ensure proper backflow prevention under the dishwasher. These failures had the potential to cause foodborne illnesses in a medically vulnerable resident population who consumed food prepared from the kitchen.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to follow the facility's P&P regarding the use and storage of food brought to the residents by the family or visitors. In addition, the facility failed to ensure the staff were aware of the facility's P&P on safe food handling of outside food. These failures had the potential to cause foodborne illnesses to the medically vulnerable resident population who consume food brought from outside sources.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to implement the infection control practices designed to provide a safe and sanitary environment; and prevent the transmission of diseases and infections for two of 21 final sampled residents (Residents 31 and 45) and six nonsampled residents (Residents 17, 27, 28, 33, 40, and 84). * The facility failed to ensure CNA 1 performed hand hygiene between assisting Residents 31 and 84 with meals. In addition, the facility failed to ensure CNA 1 performed hand hygiene between assisting Residents 31 and 17 with meals. * The facility failed to ensure CNA 2 performed hand hygiene between assisting Residents 27 and 28 with meals. * The facility failed to ensure CNA 3 performed hand hygiene between assisting Residents 33 and 45 with meals. [...]

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the menu and recipes were followed when: * The facility failed to ensure the residents on regular diets were served with roasted red potatoes instead of mashed potatoes. The food substitution was not communicated in advance to the residents receiving regular diet. This failure posed the risk for negatively impacting the residents' satisfaction and dietary compliance.

Inspectors wroteBased on interview and medical record review, the facility failed to provide the necessary services as ordered by the physician for one of eight sampled residents (Resident 6). * The facility failed to ensure the psychiatric evaluation and treatment were provided to Resident 6 as ordered. This failure had the potential for the resident not to receive the necessary care and services.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the post fall assessments were completed for two of two residents (Residents 4 and 5) reviewed for falls. * Resident 4's post fall neuro check assessment was not done. * Resident 5's post fall neuro check assessment was incomplete. These failures had the potential to delay the identification and response to post fall neurological changes.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen as evidenced by: * The facility failed to ensure the heavy-duty blender used for the puree preparation was air dried prior to use. * The facility failed to ensure the sanitary condition of the hood over the stove was maintained. * The facility failed to ensure the ice machine utilized for the residents and staff was maintained in a sanitary condition. * The facility failed to ensure the cutting boards were kept in a sanitary condition and with cleanable surface. * The facility failed to ensure the kitchen utensils had a smooth cleanable surface and were in good conditions. * The facility failed to ensure the kitchen utensils were clean and free of food particle or residue. [...]

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to maintain the infection control program designed to help prevent the development and transmission of diseases and infections. * The facility failed to implement their infection control surveillance program for the months of January through March 2024. The facility failed to conduct an accurate infection surveillance as per the McGeer's Criteria (a set of criteria used in long term care facilities to identify if residents' symptoms meet the criteria of a true infection). This failure posed the risk for not identifying infections and controlling the transmission of communicable disease to other residents throughout the facility. * The facility failed to ensure the infection control practices were maintained in the facility's laundry room area. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to offer PCV 15/PCV 20 (PCV 15 protects against two additional serotypes and PCV 20 protects against seven additional serotypes involved in cases of invasive pneumococcal disease (IPD) and pneumonia) immunizations for 11 of 19 final sampled residents (Residents 10, 16, 27, 29, 32, 37, 39, 40, 51, 52, and 54) and 47 nonsampled residents (Residents 1, 2, 3, 4, 6, 7, 8, 9, 13, 19, 21, 24, 25, 30, 33, 34, 36, 38, 41, 42, 43, 44, 45, 49, 50, 53, 56, 57, 58, 59, 60, 61, 62, 64, 65, 66, 67, 68, 70, 71, 73, 79, 83, 89, 448, and 449) reviewed for pneumococcal vaccination (a vaccine given to protect the resident from pneumococcal disease) in accordance with the CDC's recommendations. [...]

Inspectors wroteBased on interview and medical record review, the facility failed to ensure one of 19 final sampled residents (Resident 20) received a timely Level II Mental Health Evaluation for suspected mental illness. * Resident 20's initial Level 1 PASRR screening conducted on 3/20/23, was positive for mental illness and required a Level II mental health evaluation. However, Resident 20 was not available for her Level II mental health evaluation, as Resident 20 was on isolation as a health/safety precaution. When Resident 20 was no longer isolated, the facility failed to submit another Level 1 PASRR screening (as indicated on Resident 20's Unable to Complete Level II Evaluation report dated 4/10/23). [...]

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary care and services to ensure three of 19 final sampled residents (Residents 37, 16, and 51) attained and maintained their highest practicable well-being. * The facility failed to coordinate the care of Resident 37 with the contracted hospice. The hospice calendar and the sign-in/out forms did not show complete skilled nursing and CHHA visits were provided as per the physician's orders. In addition, the nursing clinical notes, and hospice aide notes were not updated. These failures had the potential for the residents to not receive appropriate hospice care and services. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of one final sampled residents reviewed for the use of side rails (Resident 20) remained free from accident hazards due to the use of elevated side rails. * The facility failed to attempt alternatives prior to the use of elevate side rails for Resident 20. This failure had the potential to place the resident at risk for entrapment and serious injury.

Inspectors wroteBased on interview and facility document review, the facility failed to have an RN on duty for at least eight consecutive hours a day. This failure has the potential for the residents' clinical needs not being met either directly by the RN or indirectly by the licensed nurses for whom the RN was responsible for overseeing resident care.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to provide the necessary pharmacy services to meet the need of the residents. * The facility failed to ensure the quantities documented for the discontinued controlled medications matched the quantities of the medication bubble pack and/or bottle. In addition, the facility failed to document one discontinued controlled medication on the Discontinued Controlled Drug Log sheet. * The facility failed to ensure the two discontinued controlled medications were documented on the Discontinued Controlled Drug Log sheet for the TRC. These failures had the potential for drug diversion (illegal distribution or abuse of prescription drugs).

Inspectors wroteBased on interview and medical record review, the facility failed to ensure one of five final sampled residents reviewed for unnecessary medications (Resident 18) were properly monitored for the medications. * Resident 18 was administered Norvasc (amlodipine besylate, a medication used to treat high blood pressure) when Resident 18's pulse was below the parameter prescribed by the physician. This failure had the potential to negatively impact the resident's well-being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure three of six final sampled residents reviewed for the use of psychotropic medications (Residents 3, 18, and 54) were free from the unnecessary psychotropic medications. * The facility failed to ensure Residents 3 and 54 were properly monitored for orthostatic blood pressures (measure the blood pressure while laying down or sitting and again upon standing up) as ordered by the physician for the use of the Seroquel (antipsychotic medications). [...]

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the medications were safely and securely stored. * The facility failed to ensure Resident 32's insulin pen was properly labeled. * The facility failed to ensure the safe storage of the insulin pen for Resident 32. * The facility failed to ensure the staff reported to the licensed nurse when Resident 53's medicated patch came off. * The facility failed to ensure Medication room [ROOM NUMBER] did not have expired containers of Sani-Hands sanitizing wipes. * The facility failed to ensure the SNF Medication Cart 2 was secured and locked. These failures had the potential to result in unsafe medication administration, and posed the risk of unauthorized access to the medications and undermining the efficacy of the sanitizing wipes.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the laboratory test for one of the 19 final sampled residents (Resident 18) was completed as ordered by the physician. * The facility failed to ensure TSH blood test was completed for Resident 18 as ordered by the physician. This failure posed the risk for undetected blood test abnormality which could significantly impact the resident's well-being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the medical record was accurately maintained for two of 19 final sampled residents (Residents 20 and 40). * Resident 40 was transferred to the acute care hospital. Resident 40's medical record failed to show documentation for Resident 40's change of condition which required a transfer to the acute care hospital. * Resident 20's POLST failed to show documentation as to whether Resident 20 had formulated an advance directive. These failures had the potential for the residents' care needs not being met as the medical record was incomplete.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure a designated IDT member was appointed to coordinate care between the facility and hospice agency for one of one final sampled resident reviewed for hospice services (Resident 37). This failure had the potential to put the resident on hospice services at risk of uncoordinated medical care between the facility and the hospice agency.

Inspectors wroteBased on observation and interview, the facility failed to ensure the garbage was properly stored in three of three garbage dumpsters. This failure of the facility to ensure the garbage was contained and covered had the potential to attract pest/rodents that carried disease.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure one of one final sampled resident reviewed for respiratory care (Resident 37) was provided with the appropriate respiratory care when: * The facility failed to ensure Resident 31's oxygen tubing was not touching the floor. In addition, the facility failed to formulate a plan of care for the use of oxygen therapy. This failure had the potential to affect the respiratory health and well-being of the resident in the facility.

Inspectors wroteBased on observation and interview, the facility failed to ensure one of one of one medication storage room refrigerator (freezer compartment) was free of ice buildup. This failure posed the risk of the refrigerator not being kept in safe, operating condition.

Inspectors wroteBased on interview, medical record review, and facility document review, the facility failed to ensure one of two residents (Resident 1) was treated with respect and dignity. * A male staff member entered the shower room when a female resident (Resident 1) was present in the shower room. Resident 1 stated she felt a bit uncomfortable. This had the potential to negatively impact the Resident 1's well-being.