Focused Care at Linden

Inspectors wroteBased on interview and record review the facility failed to allow the resident the right to obtain a copy of the records or any portions thereof, including in an electronic from or format when such records were maintained electronically, upon request and 2 working days advance notice to the facility for 1 of 1 resident (Resident #1) reviewed for the right to access copies of records. The facility failed to provide medical records for Resident #1 to the legal representative of Resident #1's family member within two working days of a request on [DATE] and [DATE]. This failure could place residents at risk by causing a negative health impact due to not having continuity of care.

Inspectors wroteBased on interview and record review, the facility failed to send a copy of the transfer or discharge notice to a representative of the Office of the State Long-Term Care Ombudsman for 2 of 2 residents (Resident #1 and Resident #2) reviewed for discharge notices. The facility did not ensure Ombudsman A was provided with a copy of the 30-day discharge notices for Resident #1 and Resident #2. This failure places residents at risk of not having access to an advocate who could have informed them of their options and rights and being inappropriately discharged from the facility.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that residents received adequate supervision and assistance devices to prevent accidents for 1 (Resident #20) of 6 residents reviewed for accidents and supervision. The facility failed to ensure adequate supervision and implementation of safety interventions for a resident assessed to be at risk for elopement. This resulted in Resident #20 exiting the building on 03/19/2026 without staff knowledge or supervision, placing the resident at risk for harm. The noncompliance was identified as PNC. The Immediate Jeopardy (IJ) began on 03/19/2026 and ended on 03/20/2026. The facility had corrected the noncompliance before the survey began. This failure could result in residents leaving the facility without supervision, placing them at risk for injury, harm, or death.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 2 of 17 residents (Resident #3 and Resident #21) reviewed for pharmacy services.1. The facility failed to administer (7) doses of Multivitamin with minerals, (9) doses of Pepcid (famotidine-medication to reduce stomach acid), and (10) doses of Stress B Complex (dietary supplement designed to support energy and immune system function during times of stress) for Resident #3.2. The facility failed to administer (12) doses of Multivitamin with minerals, (14) does of famotidine, and (10) doses of GlycoLax (medication for constipation) for Resident #21 from 3/01/2026 to 4/13/2026. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards for 2 of 6 residents (Resident #27 and Resident #8) and 1 of 2 medication carts (100/300 hall medication cart) reviewed for drugs and biologicals.1. The facility failed to ensure RN E locked the 100/300 hall medication cart when she went into Resident #27's room on 4/14/2026.2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food safety requirements. The facility failed to ensure there was minimal carbon buildup on 3 skillets. The facility failed to ensure the stove was clean from debris and black carbon buildup on the stove top. The facility failed to ensure there was no grease buildup on the fryer. The facility failed to ensure the toaster was clear of debris on 4/14/2026. These failures could place residents at risk of foodborne illness and food contamination.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for 1 of 17 residents (Resident #21) reviewed for resident rights.1. The facility failed to ensure RN E closed the window blinds, opening to the parking lot in front of the building, while performing medication administration and tube feeding through Resident #21's PEG tube (tube inserted through the abdominal wall directly into the stomach to deliver nutrition, fluids, and medications when oral intake was insufficient) on 4/14/2026.2. [...]

Inspectors wroteBased on interviews and record review, the facility failed to notify the resident's representative when there were changes in the resident's physical, mental, or psychosocial status for 1 of 3 residents (Resident #50) reviewed for notification of changes. The facility failed to notify Resident #50's RP after resident- to- resident incident resulting in a scratch to right forearm on 3/30/2026. This failure could place residents at risk of not having their preferred responsible party represent them in care decisions. Findings Included: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure an encoded, accurate, and complete MDS discharge assessment was electronically completed and transmitted to the CMS System within 14 days after completion for 1 of 1 resident (Resident #10) reviewed for discharge MDS assessments. The facility did not ensure Resident #10's discharge MDS assessment was transmitted within 14 days of completion. This failure could place residents at risk of not having records completed and submitted in a timely manner as required.

Inspectors wroteBased on interviews and records reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 (Resident #8) of 15 residents reviewed for care plans. The facility failed to ensure Resident #8 had a comprehensive care plan for pain. This failure could place residents at risk of not having their individualized needs met and a decline in their quality of care and life.

Inspectors wroteBased on observation, interview, and record review the facility failed to post the daily nurse staffing information with the current date, resident census, and numbers of staff actual hours worked at the beginning of each shift in a place readily accessible to residents and visitors for 2 of 3 days, in that: The facility failed to update and post the daily nurse staffing information on 04/14/2026 and 04/15/2026. This failure could affect residents, their families, and facility visitors by placing them at risk of not having access to information regarding staffing data and facility census.

Inspectors wroteBased on observation, interviews and record review the facility failed to provide or obtain radiology and other diagnostic services to meet the needs of its residents for 1 of 4 (Resident #1) residents reviewed for radiology services. The facility failed to ensure Resident #1's STAT x-ray results were obtained and reported to the physician in a timely manner. Resident #1's x-ray results were not reviewed by the facility until 10/20/25, which was 4 days after the STAT x-ray was performed. This failure could result in a delay in treatment of broken bones, increased pain, and a decreased quality of life.

Inspectors wroteBased on interview, and record review, the facility failed to provide the necessary services to maintain personal hygiene for 1 of 10 residents reviewed for ADLs. (Resident #2)The facility failed to provide Resident #2 with his scheduled showers. This failure could place residents who required assistance from staff for ADLs at risk of not receiving care and services to meet their needs which could result in poor care, risk for skin breakdown, feelings of poor self-esteem, lack of dignity and health.

Inspectors wroteBased on interview and record review, the facility failed to ensure the right to be free from abuse was provided for 1 of 7 reviewed for abuse. (Resident #1) The facility failed to ensure Resident #1 was free from abuse when RCP A told Resident #1, You better get out of my face and get back in your room. on 07/05/25 as witnessed by LVN B and LVN C. This failure could place residents at risk for verbal abuse and emotional harm.

Inspectors wroteBased on interview and record review, the facility failed to implement written policies and procedures that prohibit and prevent abuse, neglect, exploitation, or mistreatment of residents for 1 of 7 residents reviewed for abuse and neglect. The facility failed to prevent Resident #1 from being abused when RCP A told Resident #1 You better get out of my face and get back in your room. on 07/05/25 as witnessed by LVN B and LVN C.The facility failed to immediately suspend RCP A. The facility staff failed to immediately interview Resident #1 concerning the allegations. These failures could place residents at risk for continued abuse and neglect due to inappropriate interventions and failure to report the allegations of abuse timely.

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 of 6 residents reviewed for accidents. (Residents #2) The facility failed to keep Resident #2 free of injury after her bed rolled, hitting a wall, while LVN C provided incontinent care. This failure could place residents at risk of injury from accident and hazards.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, or mistreatment are reported immediately or not later than 2 hours for 1 of 6 residents reviewed for abuse and neglect. (Resident #1) The facility staff (RCP A, LVN B, and the Social Worker) failed to report an allegation of abuse immediately to the Abuse Coordinator after Resident #1 alleged that RCP D threw a blanket on her face and told her to shut the hell up. This failure could place residents at risk for abuse and neglect.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure, at the time each resident was admitted , there were physician orders for the resident's immediate care for 1 of 7 residents reviewed for admission physician orders. (Resident #93) The facility failed to initiate wound care treatment after Resident #93 admitted on [DATE], with multiple areas of shearing. The facility failed to initiate Resident #93's wound care orders noted in the wound care doctor's progress notes on 02/08/25 until 02/10/25. An IJ was identified on 02/11/25. The IJ template was provided to the facility on [DATE] at 5:00 p.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure treatment and services was provided, consistent with professional standards of practice, to promote healing and prevent new ulcers from developing for 3 of 7 residents reviewed for quality of care. (Resident #93, Resident #11, and Resident #15) The facility failed to initiate wound care treatment after Resident #93 admitted on [DATE], with multiple areas of shearing. The facility failed to perform a weekly skin assessment on Resident #93 that was due on 02/08/25. The facility failed to initiate Resident #93's wound care orders noted in the wound care doctor's progress notes on 02/08/25 until 02/10/25. The facility failed to implement a specialty mattress (use in the treatment and prevention of pressure ulcers) for Resident #93, per their policy, due to multiple stage 3 pressure injuries on 02/01/25. [...]

Inspectors wroteBased on interviews and record review the facility failed to complete a performance review of each Resident Care Provider (RCP) at least once every 12 months, for 5 of 5 (RCP L, RCP O, RCP U, RCP V, and RCP W) reviewed for annual competency evaluations. The facility failed to complete annual RCP (facility titles CNA as RCP) competency evaluations for RCP L, RCP O, RCP U, RCP V, and RCP W based on the personnel file review results. This failure could affect residents and place them at risk of not receiving consistent, appropriate interventions necessary to meet the residents' needs.

Inspectors wroteBased on observation, interviews and records reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident to ensure the comprehensive care plan described the services and interventions to be used to attain and maintain the resident's practicable physical, mental, and psychosocial well-being for 3 of 13 residents reviewed for care plans (Resident #1, Resident #11, and Resident #15). The facility failed to ensure Resident #1's history of a fall, with a fracture prior to admission, triggered on the 12/08/24 MDS and actual fall on 01/15/25 were care planned. The facility failed to ensure Resident #1's unplanned weight loss experienced on 01/07/25, was care planned. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that respiratory care was provided consistent with professional standards of practice for 4 of 18 residents reviewed for respiratory care. (Resident #18, Resident #22, Resident #24, and Resident #38) 1. The facility failed to ensure Resident #18 had a filter (the air passes through a series of filters that remove impurities, ensuring that the oxygen delivered to the patient was of high quality) in the oxygen concentrator (takes air from the surroundings, extracts oxygen, and filters it into purified oxygen for resident to breathe). 2. The facility failed to ensure Resident #18's compartment that would have held the oxygen concentrator filter did not have gray fuzzy and hair-like particles covering the air intake area. 3. [...]

Inspectors wroteBased on interviews 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 2 of 13 residents (Resident #1 and Resident #15) reviewed for pharmacy services. The facility failed to ensure Resident #1's Atorvastatin (is medication used to lower cholesterol and triglycerides (fats) levels to help prevent heart disease, angina (chest pain), strokes, and heart attacks) was available for administration on 01/28/25. The facility failed to ensure Resident #1's Cannabidiol (is an active cannabinoid used as an adjunctive treatment for the management of seizures) was available for administration on 01/10/25, 01/13/25, 01/14/25, 01/15/25, and 01/16/25. [...]

Inspectors wroteBased on interviews, and record review the facility failed to ensure residents have the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives and to choose the option he or she prefers for 3 of 18 residents reviewed for the right to be informed. (Resident's #1, Resident #17, and Resident #18) 1. The facility failed to ensure Resident #1's psychoactive (substances that, when taken in or administered into one's system, affect mental processes) medication therapy consent was completed upon admission and prior to the administration for Sertraline (is an antidepressant). Resident #1's Sertraline was prescribed on 12/03/24. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 of 18 (Resident #18) residents reviewed for call lights. The facility failed to ensure Resident #18's call light button was within reach while Resident #18 was in her bed as evidenced by call light button was draped over the nightstand against the wall on her left side. This failure could place residents at risk for a delay in assistance and decreased quality of life, self-worth, and dignity.

Inspectors wroteBased on interview, and record review, the facility failed to ensure individuals with mental health disorders were provided an accurate Preadmission Screening and Resident Review (PASRR) Screenings for 1 of 5 residents (Resident #7) reviewed for PASRR. The facility failed to refer Resident #7 for a PASRR review following a new mental illness diagnosis of Bipolar Disorder (mental illness associated with episodes of mood swings ranging from extreme sadness to excitement) on 05/23/23. This failure could place residents at risk of not receiving needed assessments (PASRR Evaluation), individualized care, and specialized services to meet their needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) Level I assessment accurately reflected the resident's status for 1 of 6 residents (Resident #9) reviewed for PASRR Level I screenings. The facility failed to ensure the accuracy of the PASRR Level 1 screening for Resident #9. The PASRR Level 1 screening did not indicate a diagnosis of mental illness, although the diagnoses (Major Depressive Disorder, Schizoaffective Disorder, Bipolar Disorder) were present upon Resident #9's admission date on 12/30/22. This failure could place residents who had a mental illness at risk of not receiving a needed assessment (PASRR Evaluation), individualized care, or specialized services to meet their needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure the baseline care plan that included the instructions for resident care needed to provide effective and person-centered care was completed and provided to the resident and/or their representative for 1 of 6 residents reviewed for new admissions (Resident #93). The facility failed to provide Resident #93, a copy of the summary of the baseline care plan. Resident #93 was admitted on [DATE] and had not received a copy of the summary as of 02/10/25. This failure could place residents at risk of not receiving care and services to meet their needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, personal and oral hygiene for 1 of 13 residents (Resident #93) reviewed for ADL (activities of daily living) care. The facility failed to ensure Resident #93 was provided oral care on 02/10/25. The facility failed to ensure Resident #93 was provided bed baths on 02/10/25. Theses failures could place residents who required assistance from staff for ADLs at risk of not receiving care and services to meet their needs which could result in feelings of poor self-esteem, decrease socialization and skin breakdown.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure each resident received adequate supervision to prevent accidents for 2 of 16 residents (Resident #12, Resident #35) reviewed for adequate supervision. The facility failed to prevent Resident #35 from having rubbing alcohol in his room. The facility failed to ensure that electrical wires were encased in their protective covering and not exposed for Resident #12 These failures could place residents at risk for injury, harm, and impairment or death.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure a resident with urinary incontinence, based on the resident's comprehensive assessment, received appropriate treatment and services to prevent urinary tract infections (UTI) for 3 of 6 residents (Residents #10, Resident #15, and Resident #22) reviewed for urinary catheters. 1. The facility failed to ensure RCP O performed hand hygiene and changed gloves appropriately while providing incontinent/urinary catheter care to Resident #10. 2. The facility failed to ensure RCP O performed proper incontinent/urinary catheter care to Resident #10. 3. The facility failed to ensure Resident #15 had an indwelling (foley) catheter securement device on 2/10/25 and 2/11/25. 4. The facility failed to ensure Resident #22 had an indwelling (foley) catheter securement device on 2/10/25 and 2/11/25. 5. [...]

Inspectors wroteBased on interviews and record review, the facility failed to maintain 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 3 residents (Resident #1) reviewed for nutrition. The facility failed to obtain Resident #1's weekly weights times 4 on admission. The facility failed to obtain Resident #1's readmission weight after her hospital stay (12/26/24-12/31/24). Resident #1 was readmitted on [DATE]. The facility failed to follow Resident #1's January 2025 dietary recommendation for the health shakes to be changed to house shakes (nutritional supplement for weight concerns) and given for 90 days. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to attempt to use alternatives prior to installing a side or bed rail, obtain informed consent prior to installation, ensure correct installation, use and maintenance of bedrails for 1 of 10 residents (Resident #1) reviewed for bedrails. The facility failed to ensure informed consent for the use of Resident #1's bed rails were obtained prior to installation. The facility failed to obtain a bed rail assessment to assess the risk of entrapment for Resident #1's bed rails. These failures could place residents at risk of entrapment or injury.

Inspectors wroteBased on interviews and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary medications (is a medication used: in excessive doses (including duplicate therapy); or for excessive duration; or without adequate monitoring; or without adequate indication for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued) for 2 of 5 residents (Resident #1 and Resident #11) reviewed for unnecessary medications. The facility failed to ensure Resident #1, and Resident #11 had monitoring for being on an antiplatelet. The facility failed to ensure Resident #1 had side effect monitoring for her anticonvulsant use. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure each residents' drug regimen was free from unnecessary psychotropic drugs (without adequate behavior monitoring) for 2 of 5 residents (Resident #1, Resident #11) reviewed for unnecessary medications. The facility failed to ensure Resident #1 had behavior (monitor activities and mood) and side effect (are defined as unintended responses to approved pharmaceuticals (is any kind of drug used for medicinal purposes) given in appropriate dosages) monitoring for her prescribed Sertraline (antidepressant; is used to treat depression). The facility failed to ensure Resident #11 had behavior monitoring for her prescribed Buspirone (antianxiety; is used to treat anxiety disorders or in the short-term treatment of symptoms of anxiety) and Venlafaxine (antidepressant; [...]

Inspectors wroteBased on interviews, and record review, the facility failed to ensure that residents were free of significant medication errors for 2 of 13 residents (Residents #1 and Resident #93) reviewed for medication administration. The facility failed to ensure Resident #1's Protonix (is used to treat certain conditions in which there is too much acid in the stomach) was scheduled before meals for optimal desired results. The facility failed to ensure Resident #93's prescribed Midodrine (is used to treat low blood pressure (hypotension)) was not administered when her blood pressure was outside of the ordered parameters 2/6/25, 2/7/25, 2/8/25, 2/9/25, 2/10/25, and 2/11/25. The facility failed to ensure Resident #93 was administered Midodrine with meals per the physician's order. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure each resident receives and the facility provides food that accommodates residents' food preferences for 1 of 18 residents (Resident #17) reviewed for food preferences and the accommodation of resident's meal choices. The facility failed to honor Resident #17's request for an alternate meal choice for lunch service on 2/12/25 without state surveyor intervention. This failure could result in a decrease in resident choices, diminished interest in meals, and weight loss.

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 18 residents (Residents #10) reviewed for infection control practices. 1. The facility failed to ensure RCP O performed hand hygiene and changed gloves appropriately while providing incontinent care/indwelling urinary catheter care to Resident #10. 2. The facility failed to ensure RCP O did not place a plastic bag onto Resident #10's low air loss mattress (that required no bed sheets) twice that fallen onto the floor twice while RCP O performed incontinent/urinary catheter care. These failures could place residents at risk for cross contamination and the spread of infection.

Inspectors wroteBased on interview and record review the facility failed to ensure residents with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 of 3 residents (Resident #1) reviewed for pressure injury. The facility failed to ensure RN E performed wound care to Resident #1's right heel DTI (deep tissue injury- pressure induced damage to underlying tissues to intact skin) per the physician's orders. The facility failed to ensure RN E applied kerlix (rolled gauze) and ace wrap (elastic wrap) appropriately to Resident #1's right foot/leg. These failures could place residents at risk for deterioration of wounds.

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure a resident with urinary incontinence, based on the resident's comprehensive assessment, received appropriate treatment and services to prevent urinary tract infections (UTI) for 1 of 5 residents (Residents #2) reviewed for urinary catheters. 1. The facility failed to ensure Resident #2 had an indwelling urinary catheter (tube inserted into the bladder to drain urine) securement/anchor device (used to secure an indwelling urinary catheter). 2. The facility failed to ensure CNA A performed hand hygiene and changed gloves appropriately while providing incontinent care/indwelling urinary catheter care to Resident #2. These failures could place residents at risk for indwelling urinary catheter dislodgement, urethral (empties urine from the bladder and out of the body) damage, pain, and urinary tract infections.

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 2 of 5 residents (Resident #1 and Resident #3) reviewed for infection control. 1. The facility failed to ensure RN E followed the Enhanced Barrier Precautions (EBP) (interventions to prevent spread of infection in high-risk residents) policy of wearing a gown and gloves until she completed Resident #1's pressure ulcer wound care to his right heel. 2. The facility failed to ensure CNA D followed the EBP policy of wearing a gown while performing urinary catheter (tube inserted into the bladder to drain urine) care for Resident #3 who had a urinary catheter. 3. [...]

Inspectors wroteBased on interview and record review the facility failed to immediately consult the physician when a resident had a significant change in physical and mental condition for 1 of 7 residents reviewed for physician notification (Resident #1.) LVN A noted Resident #1 had a change in condition on 02/09/24 around 2:00 p.m. but LVN A did not consult the physician until 8:00 p.m. Facility staff failed to consult the physician when Resident #1's oxygen level was 87 percent and had vomited a black substance. The resident was also lethargic/unresponsive at dinner and unable to eat with assistance. EMS was called and placed a face mask on Resident #1 at 15L of oxygen and transported the resident to the ER where she was diagnosed with sepsis secondary to pneumonia. The resident was intubated and placed in ICU. An Immediate Jeopardy (IJ) was identified on 03/12/24. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure treatment and care was provided to meet professional standards of practice for 1 of 7 residents reviewed for quality of care. (Resident #1) The facility failed to ensure Resident #1 was provided a timely assessment when she experienced a change of condition. LVN A noted Resident #1 had a change in condition on 02/09/24 around 2:00 p.m. but LVN A did not assess the resident at that time. At 8:00 p.m., Resident #1's oxygen level was 87 percent and she had vomited a black substance. The resident was also lethargic/unresponsive at dinner and unable to eat with assistance. EMS was called and placed a face mask on Resident #1 at 15L of oxygen and transported the resident to the ER where she was diagnosed with sepsis secondary to pneumonia. The resident was intubated and placed in ICU. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure residents were free of any significant medication errors for 2 of 7 residents reviewed for medications. (Resident #1 and Resident #2) The facility failed to ensure: *Resident #1 (deceased ) was given medications as prescribed. She was given Venlafaxine 75mg two times daily for a total of 6 times over a period of 5 days when the medication was supposed to be on hold. *Resident #1 was given Lisinopril and Metoprolol Succinate ER 12 times in [DATE] and 3 times in February 2024 when the medications were supposed to be held because her blood pressure was below the parameters. *Resident #1's orders were followed due to the possible interactions of Venlafaxine, with Tramadol, Ibuprofen and other medications Resident #1 was receiving. The NP said to monitor for low blood pressure and fever due to Serotonin syndrome. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment to those residents who eat their meals in one of one dinning rooms. The facility failed to identify and rectify foul smells in the dining room. This failure could place residents at risk of an unsafe or uncomfortable environment and a decrease in quality of life and self-worth.

Inspectors wroteBased on interview and record review, the facility failed to ensure, based on the comprehensive assessment of a resident, residents who had not used psychotropic drugs were not given these drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for 3 of 5 residents (Resident #19, Resident #25, and Resident #29) reviewed for unnecessary psychotropic medications (are medications that affect the mind, emotions, and behavior). The facility failed to ensure Resident #19 had behavior monitoring for her prescribed antianxiety (treats anxiety disorders), anticonvulsant (are prescription medications that help treat and prevent seizures), and antipsychotic (are the main class of drugs used to treat people with schizophrenia) medications. [...]

Inspectors wroteBased on observation, record review and interview the facility failed to store all drugs and biologicals in locked compartments for 1 of 15 residents (Resident #14) and 1 of 1 treatment carts reviewed for drug storage. The facility failed to securely store over the counter medication Neosporin for Resident #14. LVN D failed to securely lock the wound treatment cart. These failures could place residents at risk for adverse reactions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote care for residents in a manner and in an environment that maintained or enhanced each resident's dignity and respect in full recognition of his or her individuality for 1 of 15 residents reviewed for dignity. (Resident #19) The facility failed to provide Resident #19 with a type of clothing protector (designed to protect clothing from mealtime mishaps) to ensure she did not have food on gown after eating. The facility failed to ensure Resident #19 was cleaned up promptly after meals. These failures placed residents at risk for diminished quality of life, loss of dignity and self-worth.

Inspectors wroteBased on interviews and record review the facility failed to ensure the residents has the right to be informed of the risks and participate in, his or her treatment which included the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or options he or she preferred, for 2 of 15 residents (Resident #19 and Resident #242) reviewed for resident rights. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 of 15 residents (Resident #19) reviewed for reasonable accommodations. The facility failed to ensure Resident #19's call light was placed on her dominant side and hand without a contracture (is a fixed tightening of muscle, tendons, ligaments, or skin). This failure could place residents at risk for unmet needs.

Inspectors wroteBased on observation, record review, and interview the facility did not immediately notify the physician and resident representative of a significant change in in the resident's mental or psychosocial status for 1 of 15 residents (Resident #5) reviewed for resident rights. The facility failed to inform the attending Physician and the residents representative for Resident #5 when she barricaded herself in her room on 10/22/2023. This failure could place residents at risk for not receiving appropriate care and interventions.

Inspectors wroteBased on interview and record review, the facility failed to ensure assessments accurately reflected the status for 1 of 15 resident reviewed for assessments. (Resident #25) The facility failed to code Resident #25's fall on his MDS. This failure could place residents at risk of not having individual needs met.

Inspectors wroteBased on 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 1 of 5 resident's (Resident #34) reviewed for PASRR. The facility failed to submit NFSS forms timely for Resident #34. This failure could place residents identified at a level II for PASRR evaluation at risk for their specialized services not being provided in a timely manner.

Inspectors wroteBased on interview and record review, the facility failed to ensure individuals with mental disorders were evaluated and received care and services in the most integrated setting appropriate to their needs for 1 of 5 residents, (Resident #16) reviewed for PASRR Level 1 screenings. The facility failed to complete a PASRR Level 1 screening for Resident #16 following a discharge from a mental health hospital with a new diagnosis of mental illness. This failure could place residents at risk of not being evaluated for PASRR services and receiving needed services.

Inspectors wroteBased on interview and record review, the facility failed to develop a baseline care plan within 48 hours of a resident's admission for one (Resident #192) of six residents reviewed for care plan completion. The facility failed to complete Resident #192's baseline care plan within the required 48-hour timeframe of admission. This failure could place residents who were admitted within the last 30 days at risk for not receiving necessary care and services or having important care needs identified.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet each resident's medical, nursing, mental and psychosocial needs for 2 of 15 residents reviewed for care plans. (Resident# 19, Resident #29) The facility failed to implement Resident #19's care plan intervention to off-load (is described as lifting or pushing an area of high pressure away from the cause of the pressure) her heels when in bed. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident's person-centered comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 1 of 15 residents (Residents #34), reviewed for care plans. The facility failed to revise and update Resident #34's comprehensive care plan for an anticoagulant medication (a medication that helps prevent blood clots). This failure could affect residents of the facility by not addressing their physical, mental, and psychosocial needs for each to attain or maintain their highest practicable physical, mental, and psychosocial outcome.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary services to maintain personal hygiene for 1 of 15 resident reviewed for ADLs. (Resident #19) The facility failed remove Resident #19's unwanted facial hair. The facility failed to provide Resident #19 her schedule bath/showers. These failures could place residents who required assistance from staff for ADLs at risk of not receiving care and services to meet their needs which could result in poor care, risk for skin breakdown, feelings of poor self-esteem, lack of dignity and health.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 1 of 4 residents (Resident #19) reviewed for range of motion and mobility The facility failed to ensure Resident #19 had on a hand device. This failure had the potential to affect resident with limited ROM by placing them at risk for a decline in their functional abilities.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents received appropriate treatment and services to prevent urinary tract infections (UTI) for 1 of 2 residents (Resident #23) who were reviewed for indwelling urinary catheter care. The facility failed to ensure CNA F followed appropriate procedures and infection control during foley catheter care for Resident #23. This failure could place residents at risk for urinary tract infections.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that respiratory care was provided consistent with professional standards of practice for 2 of 15 residents reviewed for respiratory care. (Resident #13 and Resident #19) 1. The facility failed to ensure Resident #13's yankauer suction catheter (hard-plastic tip with handle used to suction secretions from the mouth) was properly stored. 2. The facility failed to ensure Resident #19 had a filter (the air passes through a series of filters that remove impurities, ensuring that the oxygen delivered to the patient is of high quality) in the oxygen concentrator (take air from your surroundings, extract oxygen and filter it into purified oxygen for you to breathe). 3. The facility failed to ensure Resident #19's compartment that held the oxygen concentrator filter did not have white, fuzzy material. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 2 residents reviewed for transmission-based precautions. (Resident #6 and Resident #9) The facility failed to isolate Resident #6 and Resident #9 after urine cultures (test checks urine for germs (microorganisms) that cause infections) revealed ESBL (enzymes break down and destroy some commonly used antibiotics) in their urine. This failure could place residents at risk for being exposed to health complications and infectious diseases.