Fountain View Subacute and Nursing Center

Inspectors wroteBased on interviews and record review, the facility failed to provide timely incontinence care for one of three sampled residents (Resident 3) when Certified Nursing Assistant (CNA) 1 did not clean or change the resident after being notified the resident was wet. This deficient practice had the potential to increase the risk of infection, including urinary tract infections (UTIs, a bacterial infection that affects any part of your urinary system, including the bladder, urethra, or kidneys), and negatively affect Resident 3's care. During a review of Resident 3's admission record dated 7/23/2026, the admission record indicated Resident 3 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included but not limited to lymphedema (a condition where part of the body-often an arm or a leg-gets swollen because fluid builds up under the skin. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the development and implementation of person centered care plan for three of three sampled residents (Residents 1, 2, and 3) when:For Resident 1, the facility failed to create a person centered care plan that reflected the resident's assessed needs. For Residents 1, 2, and 3 the facility failed to implement care plan interventions by not administering medications as ordered, as required under professional standards and care plan directives. For Resident 3, the facility failed to implement the prescribed treatment as outlined in the resident's care plan. These deficient practices had result in unmet medical needs, increased risk of avoidable decline, and compromised quality of care for all affected Resident.1. [...]

Inspectors wroteBased on interviews and record review, facility failed to ensure three of three sampled residents (Resident 1, Resident 2 and Resident 3) were adequately monitored for changes in condition and adverse effects of medications, when:Resident 1 was not monitored for vital signs, pain level, seizure activity, hours of sleep and adverse effects of multiple medications,Resident 2 was not monitored for vital signs, pain level, seizure activity, opioid overdoes symptoms and adverse effects of multiple medications. Resident 3 was not monitored for vital signs, pain level, blood sugar level, oxygen level, opioid overdose, and anticoagulant (a medicine that helps prevent blood from clotting too easily) side effect. These deficient practices had potential to result in significant harm due to missed signs of deterioration or adverse medication consequences. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that medications were administered as ordered for three of three sampled residents (Residents 1, Resident 2 and Resident 3), whenfor Resident 1, the facility failed to administer multiple doses of prescribed seizure (a condition when the brain suddenly sends out a burst of fast, mixed up electrical signals. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure safe medication management by not identifying and reporting multiple significant medication irregularities for one of three sampled residents (Resident 1) as required by accepted standards of practice, when:nurses failed to report medication dosages given outside of recommended guidelinesnurses failed to report repeated drug to drug interaction alerts,These deficient practices increase the risk of ineffective therapy, medication toxicity, uncontrolled symptoms, and preventable adverse drug events for Resident 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that accuracy of medical record documentation for one of three sampled residents (Resident 1) when Resident 1 was admitted to the hospital on [DATE] and not physically present at the facility on 6/18/2026, the Nurse Practitioner (NP) 1 documented in her 30 days follow up notes dated 6/18/2026 that resident was seen and evaluated at the facility. This deficient practice had potential to result in mislead clinical staff, and affect Resident 1 care planning, and compromise the integrity of Resident 1's medical record. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the standardized recipes for lunch menu were followed on 6/8/2026 when:-Eleven residents (unidentified) on pureed diet (foods that do not require chewing and are easily swallowed. All food should be smooth and pureed to the consistency of pudding) received pureed carrots instead of pureed mixed vegetables (corn, carrots, peas, and green beans) per the menu. This failure had the potential to result in meal dissatisfaction and decreased nutritional intake for the residents (unidentified) on the pureed diet.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and preparation practices in the kitchen when:1. One large box of breaded chicken was thawing inside the Walk-in refrigerator with no thaw date.2. the ice machine was not maintained in a sanitary manner, the inner plastic board inside the ice storage bin had pink color stains and residue.3. One cook (Cook1) wearing layered gloves did not wash hands and replace gloves when moving between different tasks.4. Temperature of the potato salad held for cold holding during lunch service on 6/8/2026 was at 55.5 degrees Fahrenheit (F). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the documentation was accurate and complete for three of seven sampled residents (Resident 7, Resident 85, and Resident 74) by failing to ensure:1. Licensed nurses (in general) documented the presence of new skin alterations (change to the skin's color, texture, or growth pattern) accurately on Resident 7's Medication Administration Record (MAR).2. Licensed nurses (in general) documented the Change in Condition Evaluation (a sudden clinically important deviation from a resident's baseline in physical, behavioral, or functional domains) form completely for Resident 85. 3. completed documentation in the MAR for Resident 74 as required. 4. Documenting a medication as administered when it was not given or delivered by the pharmacy for Resident 74. [...]

Inspectors wroteBased on interview and record review, the facility failed to obtain an informed consent (a process during which residents or caregivers are educated regarding the potential risks and benefits of medication therapy) from the resident or their responsible party (a person delegated to make medical decisions for the resident in the event they are unable to do so) prior to treatment with sertraline (a medication used to treat mental illness) for one of five sampled residents (Resident 62) reviewed for unnecessary medications. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide reasonable accommodations of needs by not having the call light within reach for one out of one sampled resident (Resident 12). This failure had the potential for Resident 12 to not be able to receive assistance in a timely manner.

Inspectors wroteBased on interview and record review, the facility failed to ensure to complete the Advance Directive (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) Acknowledgement Form (a written documentation of request or refused formulation of advanced directives) for one of eight sampled residents (Resident 73). This failure violated Resident 73's rights to be fully informed of the option to request or refuse medical care and treatment.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three randomly selected residents (Resident 32) and/or resident representative received mandatory information on Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN: a Skilled Nursing Facility [SNF] must issue this notice to a resident when it believes that Medicare (Federal health insurance) may not cover their care or stay. The SNF must provide the notice to the resident before providing the non-covered care) appeal process. This failure resulted in the facility denying Resident 32's right to accept or declined non-covered specific skilled services or ability to file an appeal placing Resident 32 at risk for unexpected financial burden/crisis.

Inspectors wroteBased on interview and record review, the facility failed to ensure adequate monitoring for the symptoms of anxiety (nervousness) and manifestations of verbalizing feeling anxious and/or nervous for one of five sampled residents (Resident 101) who had physician orders for Alprazolam (a medication used to treat anxiety) 0.25 milligrams (mg, a unit of weight and mass). This failure had the potential for Resident 101 to experience anxiety that was not treated, affecting the resident's quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide and accurate Minimum Data Set (MDS - a resident assessment tool) for one of five sampled residents (Resident 6) by failing to: -Document Resident 6's diagnosis of deep vein thrombosis (a serious condition that occurs when a blood clot forms in a deep vein usually in the leg or thigh). This failure had the potential to result in a delay in the necessary care and treatment for Resident 6.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an individualized care plan was in place for two of two sampled residents (Resident 12 and Resident 70): to monitor for side effects and effectiveness of mirtazapine (a tetracyclic antidepressant (TeCA) primarily prescribed to treat Major Depressive Disorder (MDD) for Resident 12.to monitor episodes of restlessness for Resident 70 every shift. These failures had the potential for Resident 12 and Resident 70's delaying of care and treatment to be unidentified.

Inspectors wroteBased on interview and record review, the facility failed to update and revise the care plan for one of eight sampled residents (Resident 73) for hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney) by failing to: -Ensure the licensed nurses (in general) updated Residents 73's Care Plan Report to include hemodialysis orders on 4/25/2026 and change of hemodialysis days. This failure had the potential to result in a delay in nursing care for Resident 73.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one of three sampled residents (Resident 2) received the necessary treatment and services to promote healing of a pressure ulcer/injury (localized damage to the skin and/or underlying tissue usually over a bony prominence) by failing to:-Ensure the licensed nurses (in general) promptly identified Resident 2's Stage 2 pressure ulcer/injury (partial-thickness loss of skin, presenting as a shallow open sore or wound) to the right heel.-Ensure Treatment Nurse 1 (TN 1) was competent (having the necessary skill, knowledge, or ability to do something well enough to meet a specific standard or requirement) in identifying pressure ulcers/injuries.-Notify the wound specialist (a medical professional-such as a specialized physician or a nurse practitioner-with advanced training in managing and treating complex, [...]

Inspectors wroteBased on observation interview and record review, the facility failed to ensure there was effective coordination and communication of hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) care for one of nine sampled residents (Resident 73) reviewed for dialysis by failing to ensure to:-Obtain and maintain Resident 73's current hemodialysis orders in Resident 73's medical record following readmission on [DATE] and after changes to Resident 73's dialysis treatment schedule on 5/12/2026.-Place an identifiable dialysis emergency kit (a sudden, unexpected, and dangerous situation that poses an immediate threat to life and health) readily available. These failures had the potential to delay recognition of changes to Resident 73's hemodialysis treatment orders and emergency interventions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three Treatment Nurses (TN 1) was competent in wound care services by failing to ensure:- TN 1 identified a Stage 2 pressure ulcer/injury (partial-thickness loss of skin, presenting as a shallow open sore or wound) on Resident 2's right heel. This failure had the potential for Resident 2's pressure ulcer/injury (localized damage to the skin and/or underlying tissue usually over a bony prominence) to worsen and develop an infection, and/or for the resident to develop new pressure ulcers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to label an open Trelegy Ellipta inhaler (a medication used to treat breathing problems) with a complete open date affecting Resident 19 in one of three inspected medication carts (SNF North Cart). This failure increased the risk for Resident 19 to receive medication that has become ineffective or toxic due to improper storage, potentially leading to health complications that could result in hospitalization or death.

Inspectors wroteBased on observations, interview, and record review, the facility failed to maintain infection control practices (the set of everyday habits and rules used to stop germs such as viruses and bacteria from spreading) necessary to prevent the spread of infections for two of two sampled residents (Resident 60 and Resident 67) by failing to:-Ensure Certified Nursing Assistants (CNA 1 and CNA 2) performed hand hygiene (the act of cleaning your hands to remove germs, dirt, and viruses) when feeding the residents (Resident 60 and Resident 67). These failures had the potential to increase the risk of infection among the residents (Resident 60 and Resident 67).

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure one of two residents' rooms (Resident 31's room) were free of insects. This failure had the potential to increase the risk of a bacterial and/or respiratory infection in the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) were free from abuse by failing to ensure alleged abuse reported by Resident 1 on 1/26/2026 was immediately reported, investigated, and addressed by facility staff. This failure resulted in delayed intervention by the facility, placing Resident 1 and other residents at risk for continued abuse. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnosis of heart failure (the heart muscle isn't pumping blood as well as it should, failing to meet the body's needs for oxygen and nutrients, leading to fluid buildup (swelling) and symptoms like shortness of breath and fatigue) and need for assistance with personal care. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) was safe through the implementation of its abuse prevention and reporting policies, resulting in failure to identify, report, and investigate alleged abuse on 1/26/2026. This failure resulted in the alleged perpetrator Certified Nursing Assistant 1 (CNA1) to continue to work at the facility and come in contact with Resident 1, placing Resident 1 and other residents at risk for continued abuse. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents' (Resident 1) allegations of abuse, were immediately reported to facility administration on 1/26/2026 in the required time frame of two hours and appropriate authorities in accordance with federal requirements. This failure resulted in placing Resident 1 and other residents at risk for continued abuse by allowing alleged perpetrator to continue coming in contact with residents. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure timely follow-up and communication with one of four sampled residents (Resident 2) regarding Resident 2's request to transfer to another facility. This failure resulted in Resident 2 experiencing frustration and dissatisfaction with communication and care and impeded Resident 2's request to transfer. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnosis of heart failure (the heart muscle isn't pumping blood as well as it should, failing to meet the body's needs for oxygen and nutrients, leading to fluid buildup (swelling) and symptoms like shortness of breath and fatigue), obesity (excessive body fat), and reduced mobility. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to:Ensure one of four sampled residents (Resident 1) attended scheduled physician appointments outside the facility on 11/6/2025, 10/21/2025, 12/3/2025, and 12/23/2025. Document nursing progress notes following outside medical visits to address new orders and follow up care. These deficient practices resulted in missed appointments, delay in treatment, unmet care needs, and did not support the resident's highest practicable physical well-being for Resident 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure timely follow-up and communication with one of four sampled residents (Resident 2) regarding Resident 2's request to transfer to another facility. This failure resulted in Resident 2 experiencing frustration and dissatisfaction with communication and care and impeded Resident 2's request to transfer and maintain his highest practicable physical, mental and psychosocial well-being. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnosis of heart failure (the heart muscle isn't pumping blood as well as it should, failing to meet the body's needs for oxygen and nutrients, leading to fluid buildup (swelling) and symptoms like shortness of breath and fatigue), obesity (excessive body fat), and reduced mobility. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a Comprehensive Care Plan (a personalized document that outlines a resident's needs, goals, and the specific services required to achieve them, ensuring consistent and holistic care) for one of three sampled residents (Resident 3), to address Resident 3's left eye blindness. This failure resulted in the absence of individualized interventions and assessments to manage Resident 3's reported pain of 7/10 and eye dryness in her left eye. During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE] with diagnosis that included left eye blindness, and low vision on right eye. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer an ordered 6 AM eye medication on 11/24/2025 to one of three sampled resident (Resident 3), and failed to document reason for the omitted dose, and endorse the omission with the oncoming licensed nursing staff. This failure resulted in lack of continuity of care and left eye discomfort for Resident 3, and the potential for unresolved symptoms and further medication errors. During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE] with diagnosis of left eye blindness, and low vision on right eye. During a review of Resident 3's Minimum Data Set (MDS- a resident assessment tool), dated 11/14/2025, the MDS indicated Resident 3 had cognitive skills for daily decision making. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the standardized recipes for lunch menu were followed on 5/5/2025 by failing to: 1. Ensure to follow the lunch menu and portion sizes as written for residents on a pureed diet. Six residents who were on a pureed diet (foods that have a soft, pudding-like consistency) received half a cup of enchilada instead of one cup per the spreadsheet (food portion and serving guide). 2. Ensure the 23 residents who were on CCHO diet (Controlled Carbohydrate Diet-diet for blood sugar control for residents with diabetes) received four ounces (oz., a unit of weight) of rice instead of two oz. according to the spreadsheet's instruction. 3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe and sanitary food storage and preparation practices when: -The facility stored unpasteurized shell eggs (raw eggs) in the facility's reach in refrigerator (a vertical storage unit commonly found in commercial kitchens). The Residents received fried eggs with unpasteurized shell eggs. Salmonella (bacteria) may be present in raw shell eggs that were not pasteurized. One tray with seven single serving containers of brown color pureed food was stored with no label. This failure had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to food borne illness in 64 out of 74 residents who received food from the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure to provide privacy to one of three sampled residents (Resident 50) by failing to pull the privacy curtain during the administration of medication through Resident 50's gastrostomy tube (g-tube, a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). This failure had the potential for the staff not to uphold Resident 50's dignity.

Inspectors wroteBased on interview and record review, the facility failed to develop a care plan for one of three sampled residents (Resident 73) who had a ventilator (life support technique where a machine assists or replaces a person's natural breathing)/tracheotomy (a surgical procedure to create an opening in the trachea [windpipe] to facilitate breathing). This failure had the potential for Resident 73 not to receive effective tracheostomy care.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure to review and revise the care plan quarterly for one of one sampled resident (Resident 46) who used hand mitten (a type of glove that encloses all the fingers together). This failure had the potential for Resident 46 not to receive nursing interventions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the appropriate Low Air Loss Mattress (LALM - a pressure-relieving mattress used to prevent and treat pressure injuries) settings for one of four sampled residents (Resident 59). This failure had the potential to place Resident 59 at risk for discomfort and the development of pressure ulcers/injuries (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device).

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection control practices for two of five sampled residents (Resident 3 and Resident 33) by failing to: -Ensure Certified Nursing Assistant 1 (CNA1) performed hand hygiene and changed the protective personal equipment (PPE, protective clothing, gloves, face shields, goggles, facemasks and/or respirators or other equipment designed to protect the wearer from the spread of infection or illness) before and after CNA1 provided personal hygiene care to Resident 3 and Resident 33 on 5/7/2025 at 2:17 pm. This failure had the potential to spread infections to Resident 3 and Resident 33.

Inspectors wroteBased on observation, interview, and record review the facility failed to meet the required 80 square feet per resident in multiple residents' bedrooms for 12 of 36 resident room (rooms 2, 4, 6, 8, 14, 18, 20, 22, 24, 28, 30, and 37). This failure had the potential to result in inadequate useable living space for the residents and inadequate working space for the health care givers.

Inspectors wroteBased on interview and record review the facility failed to ensure care plan interventions were followed for one of five sampled residents (Residents 3). This failure had the potential to negatively impact the delivery of care and services to Resident 3.

Inspectors wroteBased on interview and record review, the facility failed ensure medical record for two of four sampled residents (Resident 1 and 3) was accurate and compete for: 1. Resident 1 ' s ventilator (a machine or device used medically to support or replace the breathing of a person) administration record, 2. Resident 3 ' s vital sign summary and late entry nurse progress note. This failure resulted in an inaccurate and incomplete medical record for Resident 1 and 3. Cross reference with F626 for Resident 3.

Inspectors wroteBased on interview and record review, the facility failed to ensure they are compliance with professional standards of care by failing to ensure its policy and procedure are implemented and followed according to their agreement regarding staff ' s meal-break policy. This finding infringed upon the employee's agreement and acknowledgment.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the actual hours worked by licensed and unlicensed nursing staffing directly responsible for resident care per shift were posted for two of two sampled days (10/15/2024 and 10/16/2024). This deficient practice resulted in the actual staffing information not being readily accessible and available to residents and visitors and had the potential to cause inadequate staffing.

Inspectors wroteThis is a repeat deficiency from the Recertification Survey conducted on 4/18/2024. Based on observation, interview, and record review, the facility failed to implement interventions to prevent and control scabies (a highly contagious skin condition caused by the itch mite that infests and irritates your skin), per the facility policy and procedure (P&P) tiled, Scabies Identification, Treatment and Environmental Cleaning, for four of four sampled residents (Residents 1, 2, 3 and 4), by failing to: -Identify and detect symptoms of scabies and provide treatment for Resident 1 when the resident had a skin rash on 6/7 and 6/8/2024. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Infection Preventionist Nurse (IP) completed the required specialized training related to infection control on an annual basis. This deficient practice resulted in contact precautions not being maintained for Resident 1, who was diagnosed with scabies (a highly contagious skin condition caused by the itch mite that infests and irritates your skin) and had the potential to spread infection and disease throughout the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure the certification requirements were up to date, for one of three certified nurse assistants (CNA 2). This deficient practice had the potential for a knowledge, training, and certification deficit among the CNA, leading to inadequate resident care.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive care plan for four of 18 sampled residents (Resident 31, Resident 70, Resident 188, and Resident 25) as evidenced by: 1. Failing to ensure that Resident 31's care plan included measurable goals for monitoring cerebrovascular accidents ([CVA] - an interruption in the flow of blood to cells in the brain] by thinning the blood) and aspirin (medication used to prevent CVA) use. 2. Failing to develop and implement a care plan to monitor the adverse effects (undesired harmful effect) of a psychotropic medication (a drug that can affect how the brain works) for Resident 70. 3. Failing to develop and initiate a care plan for transmission-based precautions (TBP, specific steps healthcare providers take to prevent the spread of infections from one person to another) for Resident 188. 4. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a complete Restorative Nursing Assistant (RNA - assists patients with long-term treatment and recovery after an accident, surgery, or illness) treatment per physician's orders for three of four sampled residents (Residents 2, 53, and 71) and accurately document treatment provided/refused by failing to: a. Provide range of motion (ROM - extent of movement of a joint) exercises to the left and right lower extremities (legs) as ordered for Resident 2. b. Provide ROM exercises to the left lower extremity and to the left and right upper extremities (arms) as ordered for Resident 53. c. [...]

Inspectors wroteBased on interview, and record review the facility failed to: 1. Account for two doses of Controlled Substances ([CS]- medications which have a potential for abuse and may also lead to physical or psychological dependence) for Residents 24 and 63 in one of three inspected medication carts (Medication Cart South.) 2. Account for two doses of CS's for Residents 39 and 56 in one of three inspected medication carts (Medication Cart North.) 3. Include the verifying signatures of either the Director of Nursing (DON) or a Registered Nurse (RN) along with Licensed Vocational Nurse (LVN) on the Controlled or Antibiotic Drug Record accountability logs for two sampled month records (3/2024, 4/2024). As a result, control and accountability of CS awaiting final disposition (process of returning and/or destroying unused medications) did not follow the facility policy and procedures. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate of less than five percent (%) during medication administration affecting two of five sampled residents (Resident 43 and 83) out of 26 total opportunities (medications ordered for administration during observations). This contributed to an overall medication error rate of 7.69%. The medication errors were as follows: 1. Resident 43 received vitamin D3 (form of vitamin D called cholecalciferol that helps the body absorb the vitamins calcium and phosphorus) 5000 iu instead of vitamin D2 (a form of vitamin D called ergocalciferol) 50000 iu as per physician's order. 2. Resident 83 received folic acid (a medication used to treat or prevent folic deficiency) 400 micrograms ([mcg]-a unit of measure of mass) instead of folic acid 1 mg tablet as per physician's order. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure medications were safely stored as per facility policy and procedures titled Storage of Medications, dated November 2020, by failing to ensure medications were not left on a bedside table unattended, for one of five residents (Resident 83) observed during medication administration. These deficient practices had the potential to result in unsafe medication administration, improper administration, overdose, interactions with prescribed medications, and serious injury or harm. These deficient practices also had the potential to affect medication efficacy (the power to produce the desired effect) and reduce the therapeutic (intended to treat diseases or disorders) effects of medications administered.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that infection control procedures were maintained for two of 18 sampled residents (Resident 41 and Resident 188) as evidenced by: 1. Not disinfecting (cleaning with a solution that destroys organisms) resident care items and equipment, for Resident 41. 2. Failing to ensure the correct transmission-based precautions (TBP, specific steps healthcare providers take to prevent the spread of infections from one person to another) sign was posted for Resident 188 who required contact isolation (a type of transmission-based precautions used to reduce transmission of germs for residents with a suspected or known infection) due to a history of carbapenem-resistant Enterobacterales (CRE, a group of bacteria difficult to treat with antibiotics) and immunocompromisation (having a weakened immune system). [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to have the call light (a device used by the residents to notify the facility's staff for assistance) within reach for one of four sampled residents (Resident 7). This failure had the potential not to address needs and delay of services for Resident 7 .

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 67) had an Advance Directive (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor or to facility staff) on file as part of the resident's medical record as stated in the facilities policy and procedures (P&P) titled Advanced Directive dated 3/23/2022. This failure had the potential for Resident 67 to be denied the right to request or refuse medical care and treatment.

Inspectors wroteBased on interview and record review, the facility failed to accurately complete the minimum data set (MDS- standardized data collection tool used to assess cognitive and functional status, and care needs) assessment Section I (active diagnoses) on 03/08/2024 for one of two residents sampled for unnecessary medications (Resident 31) by omitting (not including) a diagnosis of cerebrovascular accidents ([CVA] - an interruption in the flow of blood to cells in the brain) in the clinical record. This deficient practice had the potential to negatively affect Resident 31's plan of care and delivery of necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure staff properly assessed and document one out of six sampled residents (Resident 5's) medical diagnosis listed on admission Record, (a medical record that includes past and present medical history and findings), and on Preadmission Screening and Resident Review (PASARR- a federally required screening to help identify individuals with possible serious mental illnesses requiring a specialized follow up evaluation). The deficient practice resulted in Resident 5 not receiving a PASARR II (assessment that determines if resident's mental condition could be met in the nursing facility or if the individual requires specialized services) and subsequent follow up.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide skin and pressure ulcer (injuries to the skin and underlying tissue, primarily caused by prolonged pressure on the skin) preventative care consistent with professional standards of practice and per physician's orders for one of 18 sampled residents (Resident 72). By Failing to: 1. Provide weekly skin assessments, monitoring, and care needed to prevent Resident 72 who was at risk for skin breakdown from developing a left heel pressure injury while residing in the facility. 2. Complete an initial wound assessment upon discovery of a left heel pressure injury on 2/19/2024. 3. Obtain physician's orders to treat and provide treatment to Resident 72's left heel pressure ulcer from 2/21/2024 to 2/29/204. 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary respiratory care services for two of five sampled Residents (Resident 238 and Resident 5) by failing to administer oxygen therapy (administration of oxygen at concentrations greater than that in the air with the intent of treating or preventing the symptoms of low oxygen), per physician's order. This deficient practice had the potential to result in Resident 238 and Resident 5 experiencing hypoxia (insufficient amount of oxygen reaching the body's tissues) and respiratory distress (difficulty breathing).

Inspectors wroteBased on observation, interview and record review, the facility failed to post the federally required daily actual hours worked by the staff in an area accessible to the public for two out of 17 days for the month of April 2024. As a result, the actual hours worked by the staff was not readily accessible to residents, family, or visitors.

Inspectors wroteBased on interview and record review, the facility failed to include appropriate monitoring to ensure that residents drug regimen was free from unnecessary medications (any medication in excessive dose, excessive duration, without adequate monitoring) for one of two sampled residents (Resident 31). As a result, Resident 31's aspirin (medication used to prevent cerebrovascular accidents [CVA] - an interruption in the flow of blood to cells in the brain] by thinning the blood) did not include monitoring for sign and symptoms of bleeding for 36 days. This deficient practice had the potential to cause Residents 31 to receive suboptimal (less than the highest standard or quality) care, experience serious adverse consequences (unwanted, uncomfortable, or dangerous effects that a drug may have) possibly resulting in bleeding, hospitalization, or death.

Inspectors wroteBased on interview, and record review, the facility failed to ensure necessary care was provided consistently for a resident who was receiving hospice service (A program that gives special care to people who are near the end of life and have stopped treatment to cure or control their disease and offers physical, emotional, social, and spiritual support for residents and their families) for one of 18 sample residents (Resident 27), by failing to: 1. Provide Resident 27 hospice licensed nurse and hospice aide visits twice a week per the Integrated (working together) hospice and facility plan of care. 2. Ensure that the hospice agency provided a calendar of visits for the month of April 2024. These deficient practices had the potential to lead to the Resident 27 experiencing unnecessary pain and discomfort, and not receiving the needed and necessary services timely.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain a working call light (a device used by residents to signal their needs for prompt assistance from staff) for one of one sampled resident (Resident 69). This deficient practice had the potential for Resident 69 to fall resulting in possible injury or death to the resident.

Inspectors wroteBased on observation, interview, and record review the facility failed to meet the required 80 square feet per resident in a multiple residents' bedroom for 12 out of 36 resident rooms (rooms 2, 4, 6, 8, 14, 18, 20, 22, 24, 28, 30, and 37). This deficient practice had the potential to result in inadequate useable living space for the residents and inadequate working space for the health care givers.

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents who have tracheostomy (opening created at the front of the neck so a tube can be inserted into the trachea (windpipe) to help with breathing) and ventilator (machine that helps with breathing or that breathes for you) received respiratory care and services in accordance with the residents' care plan and professional standards of practice for one of three sampled residents (Resident 1). For Resident 1, the facility failed to: 1. Provide two persons assistance when Resident 1 was repositioned on 12/15/23 at 9 p.m. 2. Ensure the ventilator circuit tubing (tubing that connects the ventilator to the patient) were properly secured before turning Resident 1 on 12/15/23 at 9 p.m. [...]

Inspectors wroteBased on interview and record review the facility failed to provide sufficient staffing to meet the care needs of two of three sampled residents (Resident 1 and Resident 2). The facility cut back the working hours for the certified nursing assistants (CNA) in the sub-acute unit (level of care needed by a patient who does not require hospital acute care but who requires more intensive licensed skilled nursing care than is provided to the majority of patients in a skilled nursing facility) during the afternoon and the night shift from seven hours to six hours on 12/9/23. This deficient practice resulted in Resident 1 stated he was not being turned regularly, his call light not being answered timely and Resident 2 ' s family member (FM 1) stated Resident 2 was not being changed two times a shift.

Inspectors wroteBased on interview and record review the facility failed to ensure the documentation was complete and accurate for two of three sampled residents (Resident 1 and Resident 2). The facility failed to ensure the bowel movement for Resident 1 and Resident 2 were accurately recorded for the month of December. This deficient practice resulted in failing to accurately determine the bowel movements for Resident 1 and Resident 2.

Inspectors wroteBased on interview and record review, the facility failed to implement their policy regarding investigating and reporting of residents ' injuries and to submit a conclusion report of investigation within five days or in accordance with state or federal law for one of four sampled resident, Resident 1. This resulted in a delay of an onsite inspection by the Department of Public Health to ensure the residents' injuries were investigated which can also lead to a delay in prevention of further injury and potential abuse for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to implement their policy regarding investigating and reporting of accidents to the state agency (Department of Public Health) when one of four sampled resident (Resident 1) was found on the floor with a cut on left upper cheek and was bleeding profusely (to a great degree; in large amounts) and then transferred to General Acute Care Hospital (GACH 1) on 1/15/2023. This resulted in a delay of an onsite inspection by the Department of Public Health to ensure the residents' injuries were investigated which can also lead to a delay in prevention of further injury and potential abuse for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to provide the care and services necessary to prevent urinary tract infections (UTI: infection in the urinary system) to one out of four sampled residents (Resident 2), by failing to ensure staffs provide all the preventative measures in order to prevent a UTI for Resident 2. This deficient practice resulted in Resident 2 developing a UTI while in the facility on 11/26/2023.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide necessary respiratory care consistent with professional standards of practice by failing to: 1. Ensure breathing treatment medications were administered timely and as per physician(s) order for five of 14 sampled residents (Resident 3, 4, 6, 8 and 9). 2. Ensure timely documentation of respiratory assessment and monitoring for four of 19 sampled residents (Resident 10, 11, 13 and 14 ' s) respiratory condition. These deficient practices can negatively impact the delivery of respiratory services provided to Resident 3, 4, 5, 6, 8, 9, 10, 11, 13 and 14.

Inspectors wroteBased on interview and record review, the licensee failed to ensure that the facility was administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident in the facility by failing to: 1. Ensure facility reported a disease outbreak on COVID-19 (Coronavirus- a deadly respiratory disease transmitted from person to person) to the state or federal agencies per facility policy. 2. Ensure facility assessment (FA) was updated with respiratory therapist staffing ratio in the subacute unit. These deficient practices had the potential to result in an increased risk of not meeting needs of all residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to update the Facility Assessment (FA) annually to reflect the current census and its staffing plan to meet the resident care needs by ensuring that respiratory therapist staffing ratio was included in subacute (provided on an inpatient basis for those individuals needing services that are more intensive than those typically received in a skilled nursing facilities but less intensive that an acute care) staffing plan. This deficient practice had the potential to result in the facility failure to identify specific factors that would require a change to the assessment and had the potential to affect the resident care and decline in quality of care.

Inspectors wroteBased on interview and record review, the facility failed to provide sufficient staffing in order to accommodate resident needs for three of six sampled residents (Residents 1, 3, and 5). For Resident 1, five medications were administered over three hours late. For Resident 3, the Humalog (insulin) Kwik pen (disposable pre-filled medication for lowering blood sugar) was not administered per Physician's Order and the resident was frustrated. For Resident 5, the Restorative Nursing treatment was not performed three times per week, as ordered by the physician. These deficient practices resulted in residents not receiving timely and efficient care and needed services. Cross Reference:

Inspectors wroteBased on interview and record review, the facility failed to obtain informed consent (a process by which residents or their responsible parties have the choice to accept or decline certain medication therapy or treatments once they are educated about the risks and benefits) prior to administering psychotropic medications (medications that affect brain activities associated with mental processes and behavior) for one of six sampled residents (Resident 5). Resident 5 received psychotropic medication for 13 days without consent. This deficient practice denied Resident 5 the right to be informed regarding the risks and benefits of psychotropic medication therapy possibly resulting in diminished overall physical, mental, and psychosocial well-being. Cross Reference:

Inspectors wroteThe licensee failed to ensure the facility was administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. As a result, for all residents in the facility there was an increased risk that their needs were not met while residing in an unsafe environment. Cross Reference:

Inspectors wroteThis is a Repeat Deficiency from a previous investigation dated 9/14/2023. Based on observation, interview, and record review, the facility failed to follow its policy and procedure titled, Answering the Call Light, for two of six sampled residents (Residents 2 and 4). Resident 2 and Resident 4 did not have the call light within reach. This deficient practice had the potential to result in a delay in care and services and the resident's inability to ask for assistance.

Inspectors wroteBased on observation and interview, the facility failed to ensure residents were provided a homelike environment for one of six sampled residents (Resident 6). Resident 6's mattress was unclean and in poor condition. This deficient practice had the potential to spread infection and negatively impact the resident's quality of life, as Resident 6 was frustrated because the mattress smelled like urine.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the posted staffing information was accurate and current. As a result, the total number of staff directly responsible for resident care for that day was not made available to residents and visitors.

Inspectors wroteBased on interview and record review, the facility failed to update the facility-wide assessment annually to reflect the current census and their staffing plan to meet the resident care needs. This deficient practice may result in the facility failing to identify specific factors that would require a change to the assessment and had the potential to affect the resident care and decline in quality of care. Cross Reference:

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the policy and procedure titled, Answering the Call Light, for one of four sampled residents (Resident 1). Resident 1, who was at risk for pressure ulcer, was totally dependent on staff for bed mobility, and was always incontinent of stool, waited over 30 minutes to be changed after being soiled. This deficient practice caused an increased risk in Resident 1's dignity and the potential to develop worsening skin conditions.

Inspectors wroteBased on interview and record review, the facility failed to develop and initiate a care plan for moisture associated dermatitis (MASD - inflammation of the skin caused by prolonged exposure to various sources of moisture, including urine or stool, perspiration, wound exudate, mucus, saliva, and their contents) for one of four sampled residents (Resident 1). This deficient practice had the potential to cause Resident 1 further skin breakdown and harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an additional Respiratory Therapist (RT) at night in accordance with their facility assessment and Respiratory Therapist Schedule for one of four sampled residents (Resident 2). For Resident 2, who had chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body), there was one RT at night which caused an increased risk of not being suctioned timely or dressing remained soiled. This deficient practice had the potential to result in a delay in care and respiratory services for Resident 2 and other residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose of expired nursing supplies, as evidenced by: -77 expired latex foley catheters (flexible tube that passes through the urethra and into the bladder to drain urine) observed in the medication room by the south nurse ' s station. -20 expired leg bags (a bag that holds urine that drains from the foley catheter) observed in the medication room by the south nurse ' s station -35 expired hypodermic 25-gauge safety needles (needles used to provide injections under the skin) found in the medication room by the north nurse ' s station. This deficient practice had the potential to lead to infection, adverse reaction (an unexpected or unintended effect), and harm to residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection control practices as evidenced by: -Licensed Vocational Nurse (LVN) 1 and Respiratory Therapist (RT) 1 were observed wearing their N95 respirator mask (a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) below their chin exposing their nose and mouth. -Housekeeper (HK) 1 was not N95 respirator mask fit tested (test protocol conducted to verify that a respirator is both comfortable and provides the wearer with expected protection). -HK 1 and Certified Nursing Assistant (CNA) 2 were observed not wearing full personal protective equipment (PPE) in droplet isolation (precautions that require care providers to use PPE that includes a mask, gown, gloves, and protective eyewear) rooms. [...]