Five Points at Lake Highlands Nursing and Rehab

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain nutrition, grooming and personal and oral hygiene for 1 of 4 residents (Resident#1) reviewed for ADLs. The facility failed to ensure Resident #1 had her fingernails cleaned and trimmed on 05/26/26. This failure could place residents at risk for loss of dignity, risk for infections, and a decreased quality of life. A record review of Resident #1's annual MDS assessment, dated 02/21/26, reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 had diagnosis which included: [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to review and revise the person-centered comprehensive care plan for 1 (Resident #55) of 7 residents reviewed for comprehensive care plan revisions. The facility failed to revise Resident #55's comprehensive care plan to include a diagnosis of dementia. This failure could place residents at risk of not receiving appropriate interventions to meet their current health needs. Record review of Resident #55's face sheet, printed 03/31/26, reflected an [AGE] year-old female admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 7 residents (Resident #2, #12, #24, #91, #126, #144, and #156) of 10 residents reviewed for ADLs. The facility failed to ensure: Resident #24, Resident #91, Resident #144 had their fingernails trimmed on 03/29/2026. Resident #126 had her fingernails trimmed and cleaned and facial hair trimmed on 03/29/2026. Resident #156 had his fingernails cleaned and trimmed on 03/29/2026. Resident #2 had her fingernails trimmed and cleaned on 03/29/2026. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food prepared that conserved nutritive value, flavor, and appearance for 6 residents (Resident #s 11,29,72,87,129, and 133) of 6 residents on pureed diet. Cook A failed to follow the recipe for the pureed potato salad served for lunch service on 03/30/26. This failure could place residents at risk of weight loss, altered nutritional status, and diminished quality of life.

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to provide each resident with at least three meals daily, at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests, and plan of care for 1 of 5 halls ( A1) reviewed for designated meal service times. The facility failed to provide lunch according to the designated meal service schedules on multiple occasions. This deficient practice could place residents at risk of low blood sugar levels, increased stress levels, slowed metabolism rates, weakened immune systems, malnutrition, weakened hearts, and organ failures. Record review of the facility's undated posted meal service reflected breakfast mealtime was 7:30 a.m., lunch mealtime was 12:30 p.m., and dinner mealtime was 5:30 p.m. [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to store food in accordance with professional standards for food service safety for the facility's only kitchen in that:The facility failed to ensure food items in the kitchen were appropriately covered and food item discarded after the expiry date on 3/29/2026. These failures could affect residents who received their meals from the facility's kitchen, by placing them at risk for food-borne illness, if consumed and food contamination.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes the services that attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 32 residents (Resident #87) who were reviewed for care planning. The facility failed to create a comprehensive care plan to maintain the placement of Resident #87's Scopolamine Base Patch (used to manage excessive drooling) as ordered by his physician. This failure could affect residents by placing them at risk by not having their physician orders followed, choking on his saliva, and loss of dignity. Record review of the MDS assessment dated [DATE] revealed Resident #87 as a [AGE] year-old male initially admitted to the facility on [DATE]. Resident #87's diagnoses included: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that a resident who needed respiratory care, including tracheostomy care, was provided such care, consistent with professional standards of practice for one (Resident #89) of one resident reviewed for tracheostomy (a surgical opening in the neck providing a direct airway through the trachea) care. The facility failed to ensure RN D followed the procedure for tracheostomy care for Resident #89 on 03/30/26 by:Changing his gloves and performing hand hygiene before applying a clean trach drainage spongeUsing sterile technique when inserting the inner cannula into the resident's trach. These failures could place residents at risk for respiratory infections. Review of Resident #89's Comprehensive MDS assessment, dated 03/16/26, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate administering of all drugs and biologicals) to meet the needs of each resident for 1 of 22 (Resident #112) residents observed for pharmacy services. CMA R failed to ensure Resident #112's medications were administered by leaving a cup containing medications on her bedside table for the resident to take later without supervision. This failure could place residents who received medications from CMA A by placing them at risk for medication errors and receiving less than therapeutic benefits from medications. Review of Resident #112's MDS assessment, dated 02/29/26, revealed a [AGE] year-old female admitted to facility on 02/29/26 with diagnoses included: [...]

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 6 medication carts observed for medications labeling and. The Hall C2 medication cart contained an insulin bottle of Lispro injection 100 unit/ml with no open date. This failure could place residents at risk for not receiving the therapeutic benefit of the medication or adverse reaction to expired medication. During observation and interview on 03/30/26 at 1:47 PM, the medication cart for Hall C2 with LVN J, observation of top-drawer holding insulin, found an insulin bottle of Lispro insulin with no open date. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for 2 residents (Resident #140 and Resident #190) of 5 residents observed for infection control. The facility failed to ensure:CNA C changed gloves and completed hand hygiene during incontinent care for Resident #140 on 3/29/26. CNA Q performed hand hygiene while providing incontinence care to Resident #190 on 03/29/26. CNA P and CNA Q wore proper PPE while performing incontinent care for Resident#190 ,who was in enhanced barrier precautions for indwelling medical devices on 03/29/26. These failures could place residents at risk for infection and cross contamination of pathogens and illness. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the resident environment remained as free of accident hazards as possible and failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 2 residents (Resident #1) reviewed for accidents and hazards. The facility failed to ensure adequate supervision and put measures in place to prevent Resident #1 who was at risk for eloping from the facility. On 09/29/25, Resident #1 eloped out of the facility and was found in a nearby hospital about 12 hours later. Resident #1 retuned back to the facility and continued on one-to-one supervision. The noncompliance was identified as Past Non-compliance (PNC). The Immediate jeopardy (IJ) began on 09/29/25 and ended on 09/30/25. The facility had corrected the noncompliance before the survey began. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to immediately notify the resident representative and the resident's physician, when there was significant change in resident's physical, mental, or psychosocial status for one of eight (Resident #2) reviewed for resident rights. The facility failed to ensure LVN K notified the RP and the physician when Residents #2 was hit with the door. On 11/24/25 LVN K entered Resident #2's room hitting him with the door, she failed to complete an incident report, document assessments completed, and any required ongoing monitoring for delay in injury and failed to notify the resident's responsible representative of the resident's broken dentures. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents had the right to a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for 1 of 7 residents (Resident #3). The facility failed to ensure Resident #3's room was free from hazards. This deficient practice could place residents at risk of living in an unsafe environment which could lead to falls and injuries.

Inspectors wroteBased on interviews and record review the facility failed to ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 4 residents (Resident #5) reviewed for ADL care provided to dependent residents. The facility failed to ensure Resident #5 received any of her scheduled showers based on records reviewed for November and December 2025. This failure could place residents at risk of not receiving necessary services to maintain good personal hygiene, skin integrity, or decreased self- esteem. Findings Included: Record review of Resident #5's Face Sheet, dated 12/09/25, reflected she was an [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included Cerebral Infarction impacting left dominant side (stroke) and reduced mobility. [...]

Inspectors wroteBased on interview and record review the facility failed to obtain from hospice the hospice election form, hospice plan care, and physician certification and recertification of the terminal illness specific to the patient and failed to designate a member of the facility's interdisciplinary team who was responsible for working with hospice representatives to coordinate care to the resident for one of three (Resident #2) residents reviewed for hospice services. The facility failed to coordinate care between the facility and Hospice Agency J for Resident #2 at the time of her Respite stay from 11/22/25 through 11/26/25 which resulted in her not receiving her Hospice aide services from 11/24/25 through 11/26/25. These failures could place residents on hospice at risk of not having services coordinated between service providers.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the resident had the right to be treated with respect and dignity for 1 of 4 residents (Resident #4) reviewed for dignity. The facility failed to ensure Resident #4 had a privacy curtain. This deficient practice could place the resident at risk of not feeling as if they were being treated with dignity and respect while being fed.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide the necessary services for residents who were unable to carry out activities of daily living to maintain good grooming and personal hygiene for 1 resident (Resident #3) of 6 residents reviewed for ADLs. The facility failed to ensure Resident #3 had his fingernails cleaned and trimmed on 11/06/25. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections, and a decreased quality of life. Record review of Resident #3's admission MDS assessment dated [DATE] reflected Resident #3 was an [AGE] year-old male admitted to the facility on [DATE]. [...]

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 6 residents (Resident #1, Resident #2) observed for infection control. The facility failed to ensure CMA A disinfected the blood pressure cuff in between blood pressure checks for Residents #1 and Resident #2 during a medication pass on 11/06/25. These failures could place residents at-risk of cross contamination which could result in infections or illness. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to provide and document sufficient preparation and orientation of resident to ensure safe and orderly transfer or discharge from the facility and ensure the orientation was provided in a form and manner that the resident could understand for one (Resident #1) of five residents reviewed for discharge. The facility failed on 8/21/2025 to ensure Resident #1's post-discharge destination and continued care provider could meet Resident #1's needs in that Resident #1 did not go to the Resident Representative's (RP) home, Resident #1 was taken to another family members residence because Resident #1 RP couldn't care for her due to work schedule and on or about 25 or 26 August 2025 Resident #1's RP obtained an order of protective custody for Resident #1 and Resident #1 was arrested and taken to a psychiatric hospital. [...]

Inspectors wroteBased on observation, interviews and records review the facility failed to ensure each resident received adequate supervision and transferred in a safe manner to prevent an accident for one (Resident #1) of four residents reviewed for accidents and hazards, in that: The facility failed to provide Resident #1 with adequate supervision and assistance with transfers to prevent an accident. On 05/14/25, Resident #1 had an unexpected or unintentional incident, which resulted in an injury to her left knee when transferred by two CNAs from the bed to a dialysis chair. On 05/19/25, the facility sent Resident #1 to the hospital after an x-ray of the bilateral (both) knees, dated 05/16/25 , revealed a possible acute nondisplaced fracture (the bone did not move when the fracture occurred) . follow-up x-rays or CT scan is recommended. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide the necessary services to maintain good nutrition, grooming, and personal and oral hygiene to residents who are unable to carry out activities of daily living for one (Resident #1) of four residents reviewed for quality of life. The facility failed to assist Resident #2 with timely incontinence care . These failures could put residents at risk of poor personal hygiene, impaired skin integrity, and decreased feelings of self-worth and dignity.

Inspectors wroteBased on record review, observations and interviews, the facility failed to assure that medications were secure and inaccessible to unauthorized staff and residents, for one (medication cart #1) of two medication carts observed for medication storage. On 06/09/25 at 7:53 AM, MT Q failed to ensure medications were secured or attended to by authorized staff when MT Q did not lock the medication cart (#1) before she walked away. This failure placed residents at risk of a potential for more than minimal harm if a resident accessed and ingested medications or drug diversion.

Inspectors wroteBased on observation and interview, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents in 1 of 5 rooms observed. The metal vent cover was missing from the air conditioning opening in the ceiling. The built-in dresser was missing 4 dresser drawers and 2 dresser doors. This facility failure could place Residents at risk for an unsafe environment.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement a comprehensive person-centered care plan for each resident to meet a resident's medical, nursing, and mental and psychosocial needs in order attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for one (Resident #1) of five residents reviewed for care plans. The facility did not put a floor mat for Resident #1 as indicated in his care plan as an intervention in the resident's care plan who was a high fall risk while he was in his bed on 05/14/25. This failure can put residents at risk for falls to sustain injuries due to not following interventions for fall precautions in place.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for 1 of 6 residents (Resident #10) reviewed for ADL care. The facility failed to ensure Resident #10 was provided showers as scheduled. This failure could place residents at risk of not receiving services and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure personnel provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives for 1 of 4 (Emergency Response Cart 1) emergency crush carts reviewed for emergency preparedness. Facility failed to check inventory daily on an Emergency Response Cart 1 on C hallway from [DATE] to [DATE]. These failures could place residents at risk for delayed emergency response care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement their written policies and procedures that prohibit and prevent abuse, neglect and exploitation of residents and misappropriation of resident's property for one (Resident #1) of five residents reviewed for injuries of unknown origin. The facility staff failed to report an injury of unknown origin to the abuse and neglect coordinator when Resident #1 sustained a large bruise to her right and left eyes and laceration to her right eyebrow. This failure could place the residents at risk for further potential abuse due to unreported and uninvestigated allegations of abuse, neglect, and injuries of unknown origin.

Inspectors wroteBased on interviews and record review, the facility failed to provide pharmaceutical services (including the procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for one (Resident #1) of five residents reviewed for medications and pharmacy services. The facility failed to take Resident #1's blood pressure and administer her medication in accordance with the physician orders. Resident #1 was administered Propranolol (a beta blocker medication that relaxes blood vessels in the body is used to treat a variety of conditions including high blood pressure) three times a day from 12/01/24 through 01/18/25. The medication was only to be given if her blood pressure was over 110/60. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen safety. 1. The facility failed to ensure food in the facility's dry storage, refrigerator, and freezer areas were labeled and dated according to guidelines. 2. The facility failed to seal open items in plastic bags in the dry storage pantry, refrigerator, and freezer areas. 3. The facility failed to ensure that expired items in the dry storage pantry, refrigerator and freezer areas were removed. These deficient practices could affect residents who received meals and/or snacks from the main kitchen and place them at risk for cross contamination and other air-borne illnesses. Findings Included: [...]

Inspectors wroteBased on observation, 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 three (Resident #104, Resident #62, and Resident #89) of nine residents observed for infection control. 1. The facility failed to ensure CNA D performed hand hygiene while providing incontinence care to Resident #104. 2. The facility failed to implement enhanced barrier precautions for Resident #62 and Resident #89. These failures placed residents at risk for healthcare associated cross contamination and infections.

Inspectors wroteBased on observations, interviews, and interviews the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for one (Resident #98) of five residents reviewed for environment. The facility failed to ensure Resident #98's windowsill was repaired after it was broken leaving damaged wood and debris exposed to the room. This failure could place residents at risk for a diminished quality of life due to the lack of a homelike environment.

Inspectors wroteBased on interviews and record review the facility failed to ensure all Pre-admission Screening and Resident Review (PASARR) level 1 residents with mental illness were provided with a PASARR level 2 evaluation for 7 of 10 residents (Resident #104, Resident #82, Resident #5, Resident #14, Resident #21, Resident #64's, and Resident #76), reviewed for resident assessment. Resident #104, Resident #21, Resident #64, and Resident #76 PASARR's level 1 screening form did not reflect mental illness and the residents did not have a PASARR level II evaluation. Resident #82 was not referred to the Local Mental Health Authority (LMHA) for PASARR Level 2 screening. Resident #5 and Resident #14 did not have a PASARR level 1 or 2 evaluation completed. These failures could place residents at risk of not receiving necessary specialized services to meet their individual needs.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident to meet the resident's medical and nursing needs for one (Resident #57) of four reviewed care plans. The facility failed to develop a care plan to address Resident #57 smoking. This failure could place residents who smoke at harm due to not completing safe smoking assessment.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for one (Resident #104) of four residents reviewed for ADL care. 1. The facility failed to provide Resident #104 with thorough incontinence care on 12/08/24. This failure could place residents at risk for a skin breakdown and infection.

Inspectors wroteBased on observations, interviews, and record review, the facility failed ensure that a resident who was incontinent of bowel received appropriate treatment and services to restore as much normal bowel function as possibleto for 1 (Resident #104) of 4 residents reviewed for incontinence care. 1. CNA D failed to clean Resident #104's peri-area during incontinence care provided on 12/08/24. These deficient practices affect residents who depend on nursing care and could place residents at risk for infection and harm.

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles and include the appropriate accessory and cautionary instructions, and the expiration date when applicable on one of five carts the medication cart. Medication cart contained an insulin pen of Humalog open with no open date. This failure could place residents receiving medications at risk for drug diversion, drug overdose, and accidental or intentional administration to the wrong resident which could lead to exacerbation of their disease process and deterioration in general health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident received food prepared in a from designed to meet individual needs for one (Resident #6) of 3 residents reviewed for nutrition services. The facility failed to ensure the lunch meal served to Resident #6 on 12/08/24 had the appropriate consistency for the meat serving for the mechanical soft diet. The deficient practice could affect residents who received mechanical soft meals from the kitchen by contributing to choking, poor intake, and/or weight loss.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to have housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for one (Hall 300) of three halls and five residents (Residents #2, #5, #6, #7 and #8) of 13 residents reviewed for safe clean environment. 1. The facility failed to ensure the housekeeping and nursing departments cleaned the Sit to stand mechanical lift on the 300 hall. 2. The facility failed to ensure Resident #2's bed frame, G-tube machine, wall, and light fixture was thoroughly cleaned and repaired a large hole in the wall next to the headboard of her bed. 3. The facility failed to ensure the housekeeping and nursing departments cleaned Residents #5, #6, #7, # 8's wheelchairs. 4. The facility failed to ensure Resident #8's room was cleaned properly and free from dust and debris particles. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to respect the resident's right to personal privacy for four (Residents #1, #2, #3 and #4) of 13 residents reviewed for confidentiality of records. The facility failed to ensure LVN A did not leave Residents #1, #2, #3, #4's medication blister packs on top of an unattended Medication cart while she was in Resident #4's room with the door closed. This failure could place residents at risk of having their medical information exposed causing HIPAA violations with their personal information being known to other residents and visitors, resulting in embarrassment, frustration, and decreased psycho-social well-being.

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 1 (Resident #8) of 13 residents reviewed for infection control. The facility failed to ensure staff did not leave an unwrapped piston syringe (used to withdraw bodily fluids) to flush Resident #8's urinary catheter, was left on her dresser with her personal belonging around it. This failure could place residents at risk of getting sick with infections due to cross contamination which could result in a change in condition and decreased psycho-social well-being.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure the resident environment remains as free of accident hazards as is possible and that residents received adequate supervision to prevent accidents for one (Resident #1) of four resident reviewed for quality of care. The facility failed to ensure Resident #1 was adequately supervised to prevent her from leaving the facility unsupervised. There was a door near the secure unit that did not have an audible alarm. It was determined the noncompliance was identified as a Past Noncompliance Immediate Jeopardy (IJ). The IJ began on 06/01/2024 and ended on 06/02/2024. The facility corrected the noncompliance before the investigations began. This failure placed residents at risk for harm and/or serious injury.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to assist residents in obtaining routine and 24-hour emergency dental care for 4 out of 9 residents (Resident #3, Resident #4, Resident #7 and Resident #8) reviewed for dental services. The facility failed to provide timely dental services for Resident #3, Resident #4, Resident #7, and Resident #8 from December 2023 through May 17, 2024. This failure could place residents at risk of oral complications, dental pain, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a safe, clean, comfortable, and homelike environment, for 5 of 9 residents (Residents #1, #2, #7, #8, #9) reviewed for environment. The facility failed to ensure Residents #1, #2, #7, #8, and #9 had hot water for washing and bathing in their rooms. This failure affected residents by placing them at risk for a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide residents who were unable to carry out ADLs the necessary services to maintain good personal hygiene for 6 of 9 residents (Residents #1, #2, #5, #7, #8, #9) reviewed for showers. The facility failed to ensure Residents #1, #2, #5, #7, #8, and #9 received showers as scheduled. This failure affected residents by placing them at risk for discomfort, diminished self-esteem, and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to treat each resident with respect, dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 of 5 (Resident #1) observed for resident rights. The facility failed to ensure Resident #1 was treated with dignity and respect while being fed by a staff member. This failure can damage resident's self-esteem and self-worth causing negative psychosocial outcomes affecting their health.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that the Resident's environment remained as free of accident hazards as was possible; and each resident received adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 9 residents reviewed for accidents. The facility failed to ensure Resident #1 had an environment free of accident hazards by not keeping her bed at a safe angle while being fed thereby preventing a choking hazard. This failure affected residents by placing them at risk for choking and aspiration.

Inspectors wroteBased on observations, interviews and record review the facility failed to ensure each resident received adequate supervision to prevent accidents for 2 (Resident #11 and Resident #81) of 2 residents reviewed for accidents, hazards, and supervision. 1. The facility failed to ensure safe smoking for Resident #11 when he had a lighter and a pack of cigarette in his possession. 2. The facility failed to ensure safe smoking for Resident #81 when he had a lighter and a pack of cigarettes in his possession. This failure could place residents at risk for injury, burns and an unsafe smoking environment.

Inspectors wroteBased on observation, interview and record review, the facility failed to establish policies, in accordance with applicable Federal, State, and local laws and regulations, regarding smoking, smoking areas and smoking safety that also took into account nonsmoking residents for 2 of 2 residents (Resident #11, Resident #81) reviewed for safe smoking. The facility failed to develop a policy to address residents signing in and out on a Release of Responsibility for Leave of Absence form to smoke, which included Resident #11 and Resident #81. This failure could place residents at risk for injury, burns and an unsafe smoking environment.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents who were fed by enteral means received the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal pharyngeal ulcers for one of 3 residents (Resident #7) reviewed for enteral nutrition. LVN D failed to check for residual volume prior to medication administration. This failures could place residents at risk for metabolic abnormalities, medical complications, or a decline in health.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 11%, based on three out of 27 opportunities, which involved 2 of 5 residents (Resident #7 and Resident #75) reviewed for medication errors. 1. LVN D failed to administer medications as ordered to Resident #7 by administering Vitamin B-12 1000 mcg instead of Vitamin B-12 500 mg and administered Folic acid 800 mcg instead of 1mg. 2. LVN D failed to administer medication as ordered to Resident #75 by administering Levemir 18 units instead of Lantus 18 units. These failures could place residents at risk of not receiving the desired therapeutic effect of their medications and uncontrolled pain.

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 one of five residents (Resident #152) reviewed for infection control. 1. CNA A failed to complete hand hygiene while providing incontinent care to Resident #152. 2. The facility failed to ensure linens and trash were not on the floor in Resident #152's room and bathroom. These failures could place residents at risk for contamination and infection and foul smell in the rooms.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure that a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for one (Resident #1) of four residents reviewed for pressure ulcers. The facility failed to appropriately identify the Resident #1's pressure ulcers, obtain and provide appropriate treatment, monitor the wounds, and provide interventions to prevent further deterioration of the wounds. [...]