Four Seasons Healthcare & Wellness Center, LP

Inspectors wroteBased on interview and record review, the facility failed to document the administration of a PRN (as needed) dose of Tylenol (pain medication) in the resident's medical record after the medication was administered for one of three sampled residents (Resident 1). This failure had the potential to result in inaccurate clinical records, duplicate medication administration, ineffective assessment of Resident 1's pain management, and impaired continuity of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Resident 1 had a functioning call light for one of three sampled residents (Resident 1). This failure had the potential to delay Resident 1's ability to call staff for assistance, increasing the risk of unmet care needs and compromising the resident's safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide reasonable accommodation of resident needs and preferences by failing to ensure the pad call light (a specialty alerting device that have ultra-sensitive touch surface for patients with limited mobility for nurses or other nursing personnel to assist a patient when in need) was within reach for one (1) of five (5) sampled residents (Resident 5) during an observation on 6/30/3036 at 10 a.m. This deficient practice had the potential to result in a delay in care and services, unmet needs, and possible injury to Resident 5 when the resident was unable to call for assistance.

Inspectors wroteBased on interview and record review, the facility failed to notify and provide a written notification to the resident and/or resident's representative(s) at least 30 days prior to a planned discharge for one (1) of three (3) sampled residents (Resident 1). This failure had the potential for incomplete information to be conveyed to Resident 1 and could have violated Resident 1's right to appeal the discharge (a formal, legally protected process that allows a resident to challenge a facility's decision to discharge or transfer them).

Inspectors wroteBased on interview and record review, the facility did not accurately code the Minimum Data Set (MDS - a resident assessment tool) by failing to ensure the MDS assessment for one (1) of five (5) sampled residents (Resident 1) was reflected accurately when Resident 1's quarterly assessment under discharge planning indicated there was no active discharge planning. This deficient practice had the potential to create confusion regarding Resident 1's discharge plan and delay the timely coordination of necessary care and services needed to support a safe and appropriate transition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection prevention and control practices for one (1) of three (3) sampled residents (Resident 1) by failing to ensure Resident 1's urinal (a handheld container designed for collecting urine) was labeled with the resident's name and room number as required by facility policy and procedure (P&P). This failure had the potential to result in cross contamination, the transfer of harmful bacteria from one person, object, or place to another, which may lead to the development of urinary tract infections (UTI - an infection of the urinary tract.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 3) was free of any significant medication error when on 5/18/2026 Resident 3 did not get her prescribed medication as ordered. This deficient practice had the potential to negatively affect Resident 3.

Inspectors wroteBased on interview and record review, the facility failed to ensure the medical records for one of four sampled residents (Resident 1) were maintained in accordance with accepted professional standards and practice, complete, and accurately documented by failing to ensure accurate documentation of the Long Term Care Evaluation (weekly documentation of residents' progress) form. This deficient practice had the potential for inaccurate medical interventions for Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of three sampled residents (Resident 1, Resident 2, and Resident 3): 1. Did not have medications that were left unattended at the residents' bedsides. 2. Had physician orders for the medications that were observed with no pharmacy labels at the residents' bedsides. 3. Had self-administration assessments for the medications that were observed at the residents' bedsides. These deficient practices had the potential to result in medication errors and harm to Resident 1, Resident 2, and Resident 3.

Inspectors wroteBased on interview and record review, the facility failed to ensure the care plan (a personalized, written plan that outlines a resident's health needs, goals, and the interventions required) of one of three sampled residents (Resident 1) was implemented to attain or maintain Resident 1's highest practicable physical, mental, and psychosocial well-being, when Registered Nurse (RN 2) failed to follow-up on the completion of diagnostic imaging tests (tests where technology is used to create pictures of inside a patient's body to identify the cause of symptoms or confirm the presence of disease) ordered by Resident 1's doctor and as indicated in Resident 1's care plan. This deficient practice resulted in delayed treatment for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure the medical record of one of three sampled residents (Resident 1) was complete and accurately documented, when Registered Nurse (RN 2) failed to document that RN 2 endorsed (the act of handing over responsibility and crucial information about a patient from one staff member to another) to case manager (CM) and to the next nursing shift that Resident 1's magnetic resonance imaging tests (MRI - a test where a patient lies down inside a tube-shaped scanner that produces detailed images of the body) and computed tomography test (CT - a test where a patient lies down on a table that slides into a doughnut shaped scanner that takes pictures of the body), scheduled on 11/6/2025, were cancelled because the testing center could not accommodate Resident 1's size and, as a result, the facility needed to locate another testing [...]

Inspectors wroteBased on interview and record review, the facility failed to follow professional standards of nursing practice for one of three sampled residents (Resident 1) by failing to ensure that licensed nurses appropriately monitored the resident's medical status following a documented change of condition (COC) on 1/18/2026. The record revealed there was no evidence that Resident 1's COC status was monitored for five consecutive shifts. This deficient practice had the potential to result in the failure to identify continued or worsening clinical deterioration, thereby placing Resident 1 at risk for adverse health outcomes and compromised safety.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that one of three sampled residents (Resident 2) was free from the use of physical restraints when the resident's bed was positioned against the wall in a manner that restricted the resident's voluntary movement. This deficient practice had the potential to limit Resident 2's freedom of movement, interfere with the resident's right to be free from physical restraints, and compromise the resident's right to be treated with dignity and respect.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 2) received care consistent with professional standards of practice to prevent pressure ulcers (PU, a localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure, or pressure in combination with shear) by failing to ensure Resident 2's low air-loss mattress (LALM - a mattress composed of inflatable air cushions used to relieve pressure on body parts) was set to appropriate settings per Physician Orders. This deficient practice placed Resident 2 at risk for the development of pressure ulcers. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an effective prevention and control program related to Enhanced Barrier Precautions (EBP-an infection control intervention designed to reduce transmission or multi[drug -resistant organisms through targeted gown and glove use during high-contact resident care activities) for one of three sampled residents ( Resident 2). This deficient practice placed Resident 2 at risks for potential exposure to transmission of infectious organisms.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the resident's right to be free from physical abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) for one of four sampled residents (Resident 1) when on 12/22/2025 (time unknown) in the Station A hallway (near the smoking patio entrance and Station A dining room), Resident 2 used a wooden back scratcher (a handheld tool used to reach and relieve back itches) to hit the top of Resident 1's head. This deficient practice resulted in Resident 1 being subjected to physical abuse by Resident 2 while under the care of the facility. On 12/23/2025, Resident 1 sustained an acute (sudden or short-term) pain one out of 10 to Resident 1's top of scalp.

Inspectors wroteBased on interview and record review, the facility failed to ensure the medical records of one of three sampled residents (Resident 1) were maintained in accordance with accepted professional standards and practice, complete, and accurately documented by failing to ensure licensed nurses documented Resident 1's change of condition (COC) in Resident 1's medical records. This deficient practice resulted in incomplete and inaccurate information on Resident 1's medical records and had the potential for delayed medical interventions.

Inspectors wroteBased on interview and record review the facility failed to exercise reasonable care for the protection of the resident's property from loss or theft for one of three sampled residents (Resident 1) when the facility failed to document Resident 1's lost or stolen coin purse containing her social security and identification card were documented in the facility's Theft and Loss log. This failure had the potential to prevent tracking of additional lost items and hinder the facility's ability to identify patterns or trends related to theft and loss of resident property.

Inspectors wroteBased on interview and record review, the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one of three sampled residents (Residents 1) by failing to ensure the licensed nursing staff would not sign Resident 1's Medication Administration Record for antibiotic (a type of medication used to treat or prevent bacterial infections by killing bacteria or stopping their growth) therapy on three different dates (9/20/2025, 9/23/2025, and 9/25/2025) when the medication had not been delivered to the facility. This deficient practice resulted in the medical record inaccurately representing care Resident 1 did not receive and had the potential to place the resident at risk for worsening infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a clean and sanitary environment for one of three sampled residents (Resident 1) when on 12/2/2025 Resident 1's bathroom wall was noted with a rusty brown dry water streak. This deficient practice had the potential to negatively impact Resident 1's well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep the call light (an alerting device for nurses or other nursing personnel to assist a resident when in need) within reach of the resident for one of five sampled residents (Resident 1) reviewed under accommodation of needs. This deficient practice had the potential for Resident 1 to be unable to summon health care workers for help as needed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident's environment was free of accident hazards for one of five sampled residents (Resident 2) reviewed for accidents by failing to ensure Resident 2's fall/floor mats (a cushioned floor pad designed to help prevent injury should a person fall) did not have any furniture or medical equipment on top of them. The deficient practice increased the risk of accidents such as falls with injuries on residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure that one of three sampled residents (Resident 1) and or conservator (appointed by a judge to act or make decisions for the person who needs help) was informed of Resident 1's change in condition on 10/22/2025. This failure had violated conservator's right to be informed.

Inspectors wroteBased on interview and record review the facility failed to maintain an accurate and complete medical record for one of three sampled residents (Resident 2) by failing to ensure accurate time of notification was documented in Resident 2's medical record. This failure had the potential to cause confusion in care and the medical records containing inaccurate documentation.

Inspectors wroteBased on interview and record review, the facility failed to provide laboratory (lab) services for one of four sampled residents (Resident 1) on 10/4/2023. On 10/4/2023, Resident 1 was discharged without the ordered labs being completed. This deficient practice had the potential for a delay in Resident 1's care.

Inspectors wroteBased on observation, interview, and record review the facility failed to set up the total amount for the gastrostomy tube (g-tube - is a feeding tube that delivers nutrition, fluids, and medicine directly to the stomach through a surgically created opening in the abdomen) machine for one of three sample resident (Resident 1). This facility deficient practice could lead to fluid overload, unintended weight gain, increase the risk of regurgitation and discomfort for Resident 1.

Inspectors wroteBased on interview and record review the facility failed to ensure that medication was administered according to the physician order for one of three sample resident (Resident 2). This deficient practice had the potential for Resident 2 to not receive the full benefit of the medication.

Inspectors wroteBased on interview and record review, the facility failed to have a documented process on tracking medical records requests for one of four sampled residents (Resident 1). Resident 1's legal representative sent a request to release Resident 1's medical records on 5/8/2025. This deficient practice violated the resident's rights to secure personal medical records.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an eye drop (liquid solutions you put on the surface of your eyes) was not left at bedside table and resident was assessed for self-administration of medication for one of three sampled residents (Resident 1). This deficient practice placed Resident 1 at risk for a negative outcome and the potential for another resident to take and misuse the medication (eye drop).

Inspectors wroteBased on interview and record review, the facility failed to ensure the medical records of three of three sampled residents (Resident 1, Resident 2, and Resident 3) were maintained in accordance with accepted professional standards and practice, complete, and accurately documented by failing to: 1. Ensure Certified Nursing Assistants (CNAs) documented Residents 1, 2, and 3 ' s percentage (% - per one hundred) of food eaten on the correct time. 2. Ensure CNA 1 accurately documented Resident 1 ' s bowel movement (defecation). 3. Ensure Registered Nurse (RN) 1 completed and signed Resident 1 ' s Change in Condition Evaluation (CIC). These deficient practices resulted in inaccurate information on Residents 1, 2, and 3 ' s medical records and had the potential for delayed and inaccurate medical interventions.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was provided supervision to prevent elopement (the act of leaving a facility unsupervised and without prior authorization) for one of three sampled residents (Resident 1). On 6/7/2025, at 12:27 p.m., Resident 1, who was assessed as a high risk for elopement, walked out of the facility unassisted and without permission. Resident 1 exited the facility building through the main facility entrance door with the Receptionist (REC) 1 at the reception desk who stated he (REC 1) did not see Resident 1 go out of the facility main door. REC 1 stated the reception area had a list of residents on elopement risk and one of his responsibilities was to ensure the residents do not go out of the main facility door unassisted and without permission. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep the call light (an alerting device for nurses or other nursing personnel to assist a patient when in need) within reach of the resident for four of four sampled residents (Residents 489, 390, 139, and 133) reviewed under the environment care area. This deficient practice had the potential for residents not being able to summon health care workers for help as needed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the confidential personal information of 15 of 15 sampled residents were protected by failing to: 1. Ensure the diet type report for Resident 144, Resident 83, Resident 162, Resident 70, Resident 3, Resident 29, Resident 107, Resident 147, Resident 106, Resident 85, Resident 63, Resident 182, Resident 157 was not in the handwashing trash in the kitchen. 2. Ensure documents containing protected health information ([PHI]- any health information that can be used to identify a specific individual which must remain confidential to prevent harmful consequences) was shredded prior to disposing in the waste container for Resident 38 and Resident 129. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow its Grievance and Complaint Policy and Procedure (P&P) by failing to: 1. Follow the Grievance and Complaint Policy and Procedure (P&P) when Resident 13 complained to Licensed Vocational Nurse (LVN) 4 that Certified Nursing Assistant (CNA) 3 refused to warm up Resident 130's meal for one of two sampled residents (Resident 130) reviewed during the Sufficient and Competent Staffing task. 2. Follow the Grievance and Complaint P&P when the Grievance Official failed to follow-up and inform Resident 157 of the findings of the investigation for one of seven sampled residents (Resident 157) reviewed during the Dining Observation task. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignity including the right to be free from physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the resident's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) for six (6) of 6 sampled residents (Residents 16, 159, 73, 489, 97, and 72) reviewed for physical restraints care area by failing to: 1. Complete Resident 16's restraint assessment quarterly. 2. Ensure Resident 159 had a physician's order and care plan for the placement of bed against the wall. 3. Accurately complete Resident 73's restraint assessments for the use of restraint bed against the wall. 4. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (is a tool that ensures residents receive personalized, comprehensive, and goal-oriented care in a nursing home setting) for: 1. Two of four sampled residents (Residents 489 and 42) reviewed for mood/behavior by failing to develop and implement a care plan on the use of antidepressants (Trazadone and Alprazolam, prescription medicines to treat depression). 2. One of two sampled residents (Resident 10) reviewed for antibiotic use by failing to develop and implement a care plan on the use of Cefepime HCl. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide care in accordance with professional standards to three of three sampled residents (Residents 52, 390, and 159) reviewed for insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) insulin administration sites. The deficient practice had the potential for adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin such as excessive bruising, lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services to two of 10 sampled residents (Residents 116 and 173) with limited range of motion (ROM - full movement potential of a joint [where two bones meet]) by failing to: 1. Ensure Resident 116 did not have a delay in start of Restorative Nursing Aide (RNA - nursing aide program that help residents to maintain their function and joint mobility) services for passive range of motion (PROM - movement at a given joint with full assistance from another person) for both upper extremities (BUE - shoulder, elbow, wrist, hand) and both lower extremities (BLE - hip, knee, ankle, foot) five times a week. 2. Ensure Resident 173 did not have a delay in the start of RNA services for PROM for the left lower extremity and right residual limb five times a week. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment was free of accident hazards for seven (7) of nine (9) sampled residents (Residents 390, 99, 8, 489, 97, 54, and 488) reviewed for accidents by: 1. Failing to ensure Resident 390's bed was not placed in a high position. 2. Failing to ensure Resident 8's bed pad alarm (a pressure-sensitive pad placed under the mattress or seat cushion that trigger an alarm or warning light when they detect a change in pressure) was functioning properly. These deficient practices placed the residents at risk for increased chances of incurring injury such as falls with fracture (a break or crack in a bone) and even death. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents with a urinary catheter (FC - also known as an indwelling catheter or Foley catheter, a hollow tube inserted into the bladder to drain or collect urine) received appropriate care and services to prevent urinary tract infections (UTI - an infection in the bladder/urinary tract) for three (3) of four (4) sampled resident (Residents 390, 99, and 8) reviewed for urinary catheter or UTI by: 1. Failing to ensure Residents 390's and 99's urinary catheter tubing did not have a kink or loop while hanging on the side of the bed. 2. Failing to ensure Resident 8's urinary catheter was anchored with a leg strap and change the leg bag with a regular urinary drainage bag while in bed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respiratory care provided to residents was consistent with professional standards of practice for two of two sampled residents (Resident 152 and 42) reviewed for respiratory care by failing to: 1. Ensure oxygen was administered per physician's order, documented when administered or refused, and the physician was notified when Resident 152 refused the administration of continuous supplemental oxygen and remained on room air (RA). 2. Ensure the oxygen via nasal cannula (NC, a device that gives additional oxygen [supplemental oxygen or oxygen therapy] through the nose) was attached to the Resident 42's nostrils. These deficient practices had a potential for the residents to develop complications such as shortness of breath and desaturation (low levels of oxygen in the blood).

Inspectors wroteBased on interview and record review the facility failed to account for two (2) doses of Controlled Substances (also known as Narcotics, Controlled Drug and Controlled Medications [CS, N, CD, CM]- medications which have a potential for abuse and may also lead to physical or psychological dependence) for Residents 139 and 153 in one (1) of three (3) inspected medication carts (Medication Cart Station 2 Cart A.). As a result, control and accountability of medications and CS's did not follow state and federal regulations and facility policy and procedures. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from the use of unnecessary psychotropic (any medication capable of affecting the mind, emotions, and behavior) medications in accordance with the facility policy and procedure (P&P) for one of two sampled residents (Residents 130) reviewed during the Sufficient and Competent Nurse Staffing task and three of five sampled residents (Resident 488, 390, and 42) reviewed during the Unnecessary Psychotropic Medication task, by failing to: 1. Obtain informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) for Resident 130's lorazepam (a psychotropic medication used to treat feelings of anxiousness). 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five (5) percent (%). Two (2) medication errors out of 30 total opportunities contributed to an overall medication error rate of 6.67% affecting two (2) of five (5) residents observed for medication administration (Resident 30 and 181.) The medication errors were as follows: 1. Resident 30 did not receive ceftriaxone (an antibiotic [medication used to treat infections caused by bacteria]) as ordered by Resident 30's physician. 2. Resident 181 received docusate (a medication used for bowel [intestine] management) at a different time than ordered by Resident 181's physician. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free of any significant medication errors (means the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order, manufacturer's specifications, and accepted professional standards) by failing to: 1. rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous ([SQ] - beneath the skin) insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) administration sites for three (3) of three (3) sampled residents (Residents 52, 159, 390) reviewed for insulin. 2. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Label one (1) artificial tears (a medication used for eye dryness) eye drop bottle for Resident 68, in accordance with facility policies, in one (1) of three (3) inspected medication carts (Medication Cart Station 3). 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure kitchen staff were routinely trained and evaluated for competency skills when two (2) of 2 staff (Cook 1 and [NAME] 2) were not able to verbalize the correct cool-down process (a method to safely reduce the temperature of cooked food and prevent bacterial growth) of food. This failure resulted in improper cooling of roast turkey and roast beef which had the potential to result in harmful bacterial growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) in 164 of 176 medically compromised residents who received food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the menu and did not meet nutritional needs of residents when [NAME] 1 did not follow the recipe for gravy on 4/22/2024 for lunch. This failure had the potential to result in salty food item resulting to excessive nutrient intake of sodium (a nutrient naturally found in salt), ineffective therapeutic diet provisions, increased blood pressure, water retention, and poor food intake to 50 of 176 residents on consistent carbohydrate diet (CCHO, a diet with the same amount or servings of carbohydrates in each meal for blood sugar control) and CCHO, renal diet (a diet low in salt, potassium, phosphorus and limited in protein) residents including Resident 157 getting food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare food by methods that conserved temperature, flavor and appearance when: a. The temperature of the roast turkey was at 125 degrees Fahrenheit (°F, a scale of temperature), apple sauce at 51°F, vanilla mousse at 46°F and grape juice was at 46°F. b. Roast Turkey for renal (a diet low in salt, potassium, phosphorus and limited in protein) consistent carbohydrate (CCHO, a diet with the same amount or servings of carbohydrates in each meal for blood sugar control) diets was salty. c. Puree mashed potatoes and puree roast turkey did not hold its shape on the plate. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare foods in a form designed to meet individual needs when puree (foods that are smooth with pudding like consistency) roast turkey and puree mashed potato did not hold their shapes and were flat on the plates. These failures had the potential to result in difficulty in swallowing, chewing, decreased in food intake and nutrient intake to 12 of 176 residents on puree diet, resulting to unintended (not planned) weight loss and chocking (when food gets stuck in your airway, blocking the flow of air to the lungs).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: 1. Kitchen equipment and utensils were not maintained in their proper condition (smooth and easy to clean). a. The shelves in the reach-in refrigerator by the supervisor's office had chips and cracks b. The shelves in the reach-in refrigerator by the exit door had amber discoloration, cracks, chips and rust. c. Fifty (50) of 50 residents cracked trays. 2. A broken thermometer was found in the vegetable freezer. 3. A tub of cottage cheese was at 51.8 degrees Fahrenheit (°F, a scale of temperature), mocha mix was at 48°F inside the milk reach-in refrigerator. 4. Improper cooling was observed for the following food items: a. 4/13/2025 roast turkey was cooled for a total of eight (8) hours. b. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care in a manner that maintained a resident's dignity for one (1) of 1 sampled resident (Resident 16) reviewed for dignity by failing to ensure Certified Nursing Assistant (CNA) 7 was sitting at eye level when assisting the resident while eating. This deficient practice had the potential to negatively affect the residents' psychosocial wellbeing.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from the use of unnecessary psychotropic (any medication capable of affecting the mind, emotions, and behavior) medications in accordance with the facility policy and procedure for one of two sampled residents (Resident 130) reviewed during the Sufficient and Competent Nurse Staffing task, by failing to obtain informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) for lorazepam (a psychotropic medication use to treat feelings of anxiousness). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that the discharge information is documented in the resident's medical record and is communicated to the resident for one of three sampled residents (Resident 188) reviewed under Discharge care area by: 1. Failing to ensure the inventory belonging's list for Resident 188 was signed when it was released to the resident. 2. Failing to document on the resident's medication list the complete information to include the quantity of medications supplied and the last administration times (the time the resident was given the medications) to Resident 188. These deficient practices had the potential to result in discontinuity of the resident's care and an unsafe transition of care.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a baseline care plan for each resident for one of six sampled residents (Resident 489) reviewed for physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the resident's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) on the use of side rails (bars attached to the sides of a bed) and bed alarms (a pad with sensors that will alarm when a resident stands up unassisted to help prevent falls by alerting staff). The deficient practice had the potential for delay in the provision of essential healthcare services affecting the resident's well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assure that each resident receives care and services for the provision of parenteral fluids (formulated liquids that are injected into a vein to prevent or treat dehydration [a condition caused by the loss of too much fluid from the body]) consistent with professional standards of practice to one out of two sampled residents (Resident 10) reviewed for antibiotic (medicines that stop bacteria from growing) use by failing to ensure Resident 10's: 1. Midline catheter (a long, thin, flexible tube that is inserted into a large vein in the upper arm) dressing was changed every 48 hours per physician's order. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure licensed nurses had the specific competencies (measurable pattern of training, skills, experience, and knowledge in order to perform occupational tasks successfully) and skill sets necessary to care for residents' needs for one of five sampled staff reviewed for sufficient and competent nurse staffing by failing to ensure Registered Nurse (RN) 1 had a skills competency on administering intravenous (IV, within a vein) antibiotics (medicines that fight bacterial infections) through a midline/peripheral catheter (thin, soft tube that is placed into a vein, usually in the arm). The deficient practice had the potential to induce bloodstream infections such as sepsis (a serious condition in which the body responds improperly to an infection) to residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident's drug regimen are free from unnecessary drugs for one of two sampled residents (Resident 10) reviewed for antibiotic use by failing to ensure the antibiotic (Cefepime HCl) had monitoring for adverse effect (unwanted undesirable effects that are possibly related to a drug). This deficient practice placed the residents at risk for unnecessary medication and undetected adverse/side effects.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one (1) of 1 sampled resident (Resident 182) received and consumed foods in the appropriate nutritive content as prescribed by a physician when staff did not update the diet for Resident 182. Resident 182, who was on renal (a diet low in salt, potassium, phosphorus and limited in protein) diabetic diet ([consistent carbohydrate diet] CCHO, a diet with the same amount or servings of carbohydrates in each meal for blood sugar control) regular portion, received diabetic, renal large portion diet instead. This deficient failure had the potential to cause unplanned weight gain and ineffective therapeutic diet (a meal plan that controls the intake of certain food and nutrients) for Resident 182.

Inspectors wroteBased on interview and record review, the facility failed to: A. Document a change of condition (COC, is a sudden, clinically important deviation from a resident's baseline in physical, cognitive, behavioral, or functional domains) for two of two sampled residents (Residents 40 and 98) reviewed for hospitalizations for: 1. Resident 40, who went to General Acute Care Hospital (GACH) 1 for gastrostomy tube (GT, a tube inserted through the belly that brings nutrition directly to the stomach) placement on 12/16/2024. 2. Resident 98, who went to GACH 2 for seizure (a sudden, temporary disruption of the brain's normal electrical activity, often causing changes in awareness, movement, or behavior) on 2/24/2025. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections by failing to ensure Resident 389 was placed on enhanced barrier precautions (EBP - targeted steps taken by healthcare staff in nursing homes to prevent the spread of multidrug resistant organisms [MDROs - resistant germs] during high-contact care activities) who had a urinary catheter (FC - also known as an indwelling catheter, a hollow tube inserted into the bladder to drain or collect urine). This deficient practice had the potential to spread infections and illnesses among residents.

Inspectors wroteBased on interview and record review, the facility failed to implement the facility's Antibiotic Stewardship Program (ASP - a set of commitments and actions designed to improve the use of antibiotics [a medication used to treat bacterial infections]) for one of five sampled residents (Resident 99) reviewed during the Infection Control task by failing to monitor and include Resident 99's use of methenamine hippurate (a type of antibiotic) in the ASP infection surveillance data. This deficient practice had the potential to place the resident at risk for microbial resistance and reduced resident outcomes.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled resident ' s (Resident 1) comprehensive, person-centered care plan interventions were created and accurately documented. This deficient practice had the potential for confusion amongst Resident 1 ' s care team and delayed provision of necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure the medical records of one of three sampled residents (Resident 1) were maintained in accordance with accepted professional standards and practice, complete, and accurately documented by failing to: 1. Ensure Licensed Nurses documented Resident 1 ' s accurate bowel (a long tube in the body which digested food passes from the stomach to the anus)and bladder (a hallow organ that stores urine in the body) status. 2. Ensure Licensed Nurses documented the level of care provided to Resident 1 after the resident ' s change of condition (COC). These deficient practices resulted in inaccurate information on Resident 1 ' s medical records and had the potential for delayed and inaccurate medical interventions.

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) for one of three sampled residents (Resident 1) by: 1. Failing to ensure Licensed Vocational Nurse 2 (LVN 2) and LVN 3 administer a medication following a physician ' s order. 2. Failing to ensure LVN 1 obtain a physician order for Resident 1 to self-administer a medication (when a person can take their own medicines). 3. Failing to ensure LVN 1 followed facility ' s policy for medication administration. These deficient practices had the potential to result in medication error.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's right for communication and access to persons and services inside and outside the facility for one of three sampled residents (Resident 1) was accommodated. Resident 1 did not receive an outside incoming call. This failure had the potential to negatively impact the psychosocial well-being of the resident.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) who was assessed as not safe to self-administer a medication and did not have a physician order to self-administer was given one tablet of Percocet (controlled medication [a drug or substance that is regulated by the government due to its potential for addiction] used to treat pain) 7.5-325 milligram (mg - metric unit of measurement, used for medication dosage and/or amount), to take outside the facility when Resident 1 went out to church. This failure had the potential to result in unsafe medication administration for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was provided with his requested medical records. This failure resulted to Resident 1's delay in receiving requested medical records.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive care plan for one of three sampled residents (Resident 1) by failing to ensure a care plan was develop on Resident 1 ' s refusal of Lidoderm external patch ( medicated adhesive material applied to skin to treat pain) and Lasix (also known as water pill, a medication used to prevents your body from absorbing too much salt, causing it to be passed in your urine). This deficient practice had the potential for delayed provision of necessary care and services to Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to maintain accurate and complete medical record for one of three sampled residents (Resident 1) by: 1. Failing to document complete blood pressure as ordered by the physician to monitor for orthostatic hypotension (a condition in which blood pressure drops significantly when a person stands up from a sitting or lying position) 2. Failing to document attempts to call the physician to obtain a refill of a medication. These deficient practices had the potential to cause confusion in Resident 1's care and medical records containing inaccurate documentation.

Inspectors wroteBased on interview and record review, the facility failed to ensure four of five sampled residents (Resident 1, Resident 4, Resident 5, and Resident 6) received care consistent with professional standards of practice to prevent pressure ulcers (PU, a localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure, or pressure in combination with shear) by failing to: 1. Ensure Residents 1, 4, and 6 were turned and repositioned as indicated on the residents' care plan. 2. Ensure Resident 5's care plan intervention included the resident to be turned and repositioned. Resident 5 had a PU on the sacral region (area at the base of the spine, near the hips). These deficient practices had the potential for Residents 1, 4, 5, and 6's PUs to worsen and had the potential for the development of more PUs.

Inspectors wroteBased on interview and record review, the facility failed to ensure medical records were complete and accurately documented for one of three sampled residents (Resident 1) by failing to: 1. Ensure Licensed Vocational Nurse 1 (LVN 1) documented timely Resident 1's change of condition (COC) in the resident's medical records. 2. Ensure LVN 1 documented the level of care provided to Resident 1 after the resident's change of condition. 3. Ensure Registered Nurse 1 (RN 1) documented timely Resident 1's COC in the resident's medical records. 4. Ensure RN 1 documented the time Resident 1's attending physician and resident representative were notified of the resident's COC. 5. Ensure LVN 5 documented the care provided to a resident on the correct resident's medical record. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow professional standards of practice for one of three sampled residents (Resident 1) by failing to: 1. Ensure Licensed Vocational Nurse 1 (LVN 1) monitored Resident 1's blood sugar after the resident's change of condition (COC). 2. Ensure Resident 1's vital signs (measurements of the body's most basic functions that includes blood pressure [the force of your blood pushing against the walls of your arteries], heartrate, respiratory rate [the number of breaths a person takes per minute], oxygen saturation [amount of oxygen level of the blood], and temperature) were checked when Resident 1 had a COC on 1/9//2025. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow professional standards of practice for one of five facility staff when Certified Nursing Assistant 5 (CNA 5) slept while on duty. This deficient practice had the potential for services and care to not be provided to the residents that had the potential to cause harm to the residents such as falls and elopement.

Inspectors wroteBased on interview and record review, the facility failed to protect one of five sampled residents (Resident 1) right to be free from sexual abuse (any sexual activity that occurs without consent [permission]), when on 11/23/2024 at approximately 8 p.m., Certified Nursing Assistant 1 (CNA 1) inserted his (CNA 1) fingers inside Resident 1's vagina (female genitalia [reproductive organ of a female involved in producing children]). CNA 1 then grabbed Resident 1's right hand and coerced (to persuade [cause] someone forcefully to do something that they are unwilling to do) Resident 1 to touch CNA 1's penis (male genitalia [reproductive organ of a male]). [...]

Inspectors wroteBased on interview and record review, the facility failed to protect the resident ' s right to be free from abuse for one of seven sampled residents (Resident 1), when on 11/4/2024, Certified Nursing Assistant 1 (CNA 1) witnessed Resident 2 slap Resident 1 across the face. CNA 1 also confirmed Resident 2 was cursing towards Resident 1 using profanities (type of language that includes dirty words and ideas). This deficient practice resulted in Resident 1 being subjected to verbal (a type of abuse that uses language) and physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) resulting in an abrasion (skin scrape) on the upper left side of cheek bone while under the care of the facility. Findings a.1. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement comprehensive, person-centered care plan (contains relevant information about a resident's health conditions, goals of treatment, specific actions that must be performed, and a plan for evaluation) with measurable objectives and interventions for one of six sampled residents (Resident 2) by failing to indicate specific interventions for Resident 2's risk for falls. This deficient practice placed Resident 2 at risk for not receiving the necessary services and assistance that can result in serious injuries.

Inspectors wroteBased on interview and record review, the facility failed to ensure medical records were complete and accurately documented for two of six sampled residents (Resident 1 and Resident 2) by failing to: a. Ensure Social Service Assistant 1 (SSA 1) documented timely Resident 1's condition in the resident's clinical records after an alleged sexual abuse. b. Ensure SSA 2 documented the level of care provided to Resident 2 based on the resident's level of care assessment. These deficient practices resulted in inaccurate information on Resident 1 and Resident 2's clinical records and had the potential for delayed and inaccurate medical interventions.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Fall Risk Evaluation (used to find out if you have a low, moderate, or high risk of falling) was accurately documented to reflect the fall risk of one of three sampled residents (Resident 1). This deficient practice had the potential to negatively affect Resident 1's plan of care and delivery of necessary care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly prevent coronavirus disease 2019 (COVID-19, a viral infection that is highly contagious and easily transmits from person to person, causing respiratory problems and may cause death) by failing to: a. Ensure Registered Nurse 1 (RN 1) and RN 2 wore the N95 mask (respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) properly. RN 1 and RN 2 ' s N95 mask did not cover their nose and mouth while at nurse station 1. b. Ensure the transportation company personnel wore personal protective equipment (PPE - equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) before entering the facility and prior to assisting Resident 4 with transport. [...]

Inspectors wroteBased on interview and record review, the facility failed to discuss or assist Resident 1 in formulating an Advance Directive (are legal documents that provide instructions for medical care) for one of three sampled residents (Resident 1). This deficient practice had a potential in not honoring Resident 1's preferences for medical treatment.

Inspectors wroteBased on interview and record review the facility failed to provide professional standard of care for one of four (Resident 2) residents when Resident 2 was given enteral nutrition (any method of feeding that uses the gastrointestinal [GI] tract to deliver nutrition and calories) through Residents 2 ' s gastrostomy (a surgical procedure used to insert a tube, often referred to as a G-tube [GT], through the abdomen and into the stomach) using a urinary catheter (a flexible tube used to empty the bladder and collect urine in a drainage bag) from 5/10/2024 until 6/9/2024. This deficient practice place Resident 2 at risk for complications including repeated rupture (bursting) of catheter balloon tubing, lumen (space inside the catheter) blockage, and catheter migration (when a catheter moves from its intended position to another part of the body).

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control measures for one of three sampled residents (Resident 3) by failing to ensure Certified Nursing Assistant 1 (CNA 1) wore protective gown when changing Residents 3's linen who was on enhanced barrier precaution (expand the use of personal protective equipment and refers to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of multidrug resistant organisms [MDRO- are germs that are difficult to treat because they are resistant to many antibiotics]). This deficient practice had the potential for cross contamination (unintentional transfer of bacteria/germs or other contaminant from one surface to another) of infection among residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to evaluate and modify the diet texture to meet the nutritional needs for one of one sampled resident (Resident 103). This deficient practice resulted in a 26.35 percent ([%] a part of every 100) or 39 pounds ([lbs.] unit of measurement) unplanned weight loss, within a six-month period for Resident 103.

Inspectors wroteBased on interview and record review, the facility failed to offer the resident or the resident's representative assistance with formulating an Advance Directive (AD - a legal document telling the doctor one's wishes about their healthcare in the event they cannot make the decision for themselves) on admission to two out of two sampled residents (Residents 324 and 57) investigated during review of advance directive care area. This deficient practice violated the resident or their representative the right to be fully informed of the option to formulate an AD and had the potential to delay emergency treatment or the potential to force emergency, life-sustaining procedures against the resident's personal preferences.

Inspectors wroteBased on interview and record review the facility failed to: 1. Notify a resident's representative of a change in condition of one of one sampled resident (Resident 149) investigated during a review of a complaint when Resident 149's wound on the right heel was reclassified from deep tissue pressure injury (DTPI, purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear) to diabetic ulcer (a slow-healing wound that commonly appears on the feet) on 2/16/2024. This deficient practice violated the resident's rights and/or the representative's right to be fully informed of Resident 149's change of condition. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure licensed nurses provide care in accordance with professional standards to three of four sampled residents (Residents 149, 36, and 78) investigated during review of insulin (a hormone that lowers the level of blood sugar in the blood) by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) insulin (a drug used to control the amount of sugar in the blood) injection sites. The deficient practices had the potential for adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin such as lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (a rare disease that occurs when a protein called amyloid builds up in organs).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents with pressure ulcers (or pressure injury, localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) receive the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing to three of three sampled residents investigated during review of pressure ulcers (Resident 74, 15, and 223), when the facility failed to set Resident 74, 15, and 223's low air loss mattresses (LALM - a pressure reducing device) to the resident's weight per manufacturer's guidelines. These deficient practices had the potential for development and worsening of pressure ulcers/injuries to residents.

Inspectors wrote2. A review of Resident 37's Face Sheet (admission Record) indicated the facility admitted the resident on 8/29/2020 with the following diagnoses, but not limited to acute kidney disease (define), hypertension (a condition in which the force of the blood against the artery wall is too high), diabetes,( a disease that results in too much sugar in the blood) myocardial infarction ( a blockage of blood flow to the heart muscle) peripheral vascular disease ( a circulation condition in which narrowed blood vessels reduce blood flow to the limb ) A review of Resident 37's Minimum Data Set (MDS - an assessment and screening tool) dated 5/2/2024, it indicated the resident was originally admitted to the facility on [DATE] and was able to understand others make herself understood, and not appropriate to self-medicate. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a residents who experienced urinary retention (inability to completely empty the urinary bladder by urinating) was assessed and provided appropriate treatment and services to maintain as much normal bladder function as possible and to prevent catheter (flexible hollow tube inserted into the urethra [tube that transports urine from the bladder to the exterior of the body] to drain the bladder of urine) associated urinary tract infections (CAUTI or UTI, condition that occurs when bacteria enters the urinary tract by way of a catheter resulting in an infection) for one of one residents (Resident 39) investigated during the Urinary Catheter care area by failing to: 1. [...]

Inspectors wroteb. A review of Resident 94's admission Record indicated the facility admitted the resident on 8/7/2020, with diagnoses including schizophrenia (a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions) and bipolar disorder (a mental health condition that causes extreme mood swings that include emotional highs [mania or hypomania] or lows [depression]). A review of Resident 94's H&P, 7/1/2023, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 94's MDS, dated [DATE], indicated the resident usually had the ability to make self-understood and understand others. The MDS indicated the resident was on a high-risk drug class antipsychotic medication (a type of drug used to treat symptoms of psychosis). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five percent (%). Four medication errors out of 28 total opportunities contributed to an overall medication error rate of 14.29% affecting two of four residents observed for medication administration (Resident 37 and 41.) The medication errors were as follows: 1. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure residents are free of any significant medication by failing to: 1. Rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) insulin (a hormone that lowers the level of blood sugar in the blood) insulin injection sites to three out of four sampled residents (Residents 149, 36, and 78) investigated during review of insulin use. The deficient practices had the potential for adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin such as lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (a rare disease that occurs when a protein called amyloid builds up in organs). Cross Reference F658 2. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Label one insulin (medication used to regulate blood sugar levels) glargine (long-acting insulin) prefilled pen (an injection device containing insulin) for Resident 57 at room temperature, in accordance with manufacturer's requirements in one of three inspected medication carts (Medication Cart Station 2A.) 2. Store or label one insulin Humulin R (short-acting insulin) vial for Resident 78, in accordance with manufacturer's requirements in one of three inspected medication carts (Medication Cart Station 3.) These practices increased the risk that Residents 57 and 78 could have received medication that had become ineffective or toxic due to improper storage or labeling, possibly leading to health complications resulting in hospitalization or death.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow the menu and did not meet nutritional needs of 19 of 124 residents on puree diet (diet that contains food with smooth like pudding consistency) and five (5) of 124 residents on regular texture by: a. Not following standardized recipes for puree bread and puree scrambled eggs. b. Not following portion sizes for gravy based on facility spreadsheet. This deficient practice had the potential to cause difficulty in eating, chewing, and swallowing to the residents and decrease food intake resulting to unintended (not done on purpose) weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare food by methods that conserved flavor, appearance, and temperatures when: a. Twenty (20) of 138 residents' food on Styrofoam plates and bowls for breakfast trayline. b. Sixty-five (65) of 138 resident's tray were not garnished for breakfast. c. Fifty-nine (59) of 59 eggs were bland in taste for regular diet (diet with no restriction) residents. d. Registered Dietitian 1 (RD 1) was not aware of the menu substitution for breakfast. e. One of two sampled residents investigated under the Food care area (Resident 69) was served cold and bland scrambled eggs. These deficient practices had the potential to cause unplanned weight loss, a consequence of poor food intake facility residents who getting food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: 1. Proper food handling a. English muffins were on top of the preparation table near the toaster. b. Residents' food from home was expired and not labeled with name. 2. Hygiene a. Staff were wearing jewelries while cooking hamburgers and food preparation. b. Staff failed to handwash when changing from one task to another. 3. Cross-contamination a. Three (3) dented cans were found in the dry storage area. b. Water gallons were stored on the floor. c. Eighty three (83) of 130 trays used for lunch service were chipped and cracked. d. Expired Quaternary (Quat, a group of chemicals used to disinfect surfaces and equipment) Ammonium compound sanitizer test strips. e. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose garbage and refuse properly by not completely covering two (2) of four (4) black dumpster (a large trash container designed to be emptied into a truck) for unknown amount of time. This deficient practice had a potential to attract flies, insects, cats, and other animals to the dumpster area placing 124 of 138 facility residents getting food from the kitchen cross-contamination (a transfer of harmful bacteria from one place to another).

Inspectors wroteBased on interview and record review the facility failed to maintain accurate clinical records in accordance with accepted professional standards and practices by failing to: 1. Ensure Treatment Nurse 1 (TN 1), Vocational Nurse 1 (LVN 1), and Licensed Vocational Nurse 5 (LVN 5) did not willfully falsify entries in the Treatment Administration Record (TAR, a flow sheet where nursing documents treatments provided to a resident daily) by documenting the resident was intermittently catheterized by licensed nurses for one of one residents (Resident 39) investigated under the Catheter (flexible hollow tube inserted into the urethra [tube that transports urine from the bladder to the exterior of the body] to drain the bladder of urine) care area. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection control practices for seven out of seven sampled residents (Residents 333, 101 56, 94, 330, and 40) during a random observation by: 1. Failing to ensure the resident's urinal bottles (a container for receiving urine) were labeled with Resident 333's name. 2. Failing to ensure Certified Nursing Assistant 11 (CNA 11) washed Resident 333's urine bottles after emptying. 3. Failing to ensure Resident 101's nasal cannula tubing (a lightweight tube which on one end splits into two prongs which are placed in the nostrils to provide supplemental oxygen to the body) was not touching the floor. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement its policy and procedures for antimicrobial stewardship (AMS- a coordinated program that promotes the appropriate use of antimicrobials [including antibiotics, drugs used to treat infections caused by bacteria and other microorganisms], improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms) for one of six sampled residents (Resident 2) when clindamycin (an antibiotic) was ordered on 1/29/2024 as indefinite and the facility failed to monitor the antibiotic use for 77 days. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide reasonable accommodation of resident needs and preferences by failing to ensure the call light (an alerting device for nurses or other nursing personnel to assist a patient when in need) was within reach for one of two sampled residents (Resident 8) investigated under the Environment task. This deficient practice had the potential to result in the delay of care and services and possible injury to Residents when they are unable to summon health care workers.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of one sampled resident (Resident 54)'s clothes were not lost when sent to the laundry room. This failure resulted in Resident 54 being distressed.

Inspectors wroteBased on interview and record review, the facility failed to resolve a grievance for one of one sampled resident (Resident 54) regarding their lost clothing. The failure resulted in Resident 54 being upset.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents were treated with respect and dignity including the right to be free from physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the resident's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) to two of two sampled residents (Residents 94 and 18) investigated during review of physical restraints care area by failing to: 1. Ensure Resident 94's bed was not placed against the wall without assessing the need for use and assessing for risk of entrapment prior to use. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement its abuse prevention policy to one of three sampled residents reviewed during an investigation of a facility reported incident (FRI) involving an allegation of staff to resident abuse, by failing to immediately report, but not later than 2 hours after the allegation was made, to the State Survey Agency (SSA), the Ombudsman (assist residents in long-term care facilities with issues related to day-to-day care, health, safety, and personal preferences), and local law enforcement agency. This deficient practice had the potential to result in an unidentified abuse in the facility and had the potential for the residents to experience further abuse.

Inspectors wroteBased on interview and record review the facility failed to thoroughly investigate an allegation of staff to resident abuse and failed to report the results of the investigation to the administrator and the State Survey Agency (SSA), within five working days of the incident. This deficient practice had the potential to result in an unidentified abuse in the facility and had the potential for the residents to experience further abuse.

Inspectors wroteBased on interview and record review the facility failed to ensure safe and orderly discharge to one out of three sampled residents (Resident 170) investigated during closed record review by failing to provide documentation that the resident was provided complete information (including phone numbers) of the home health agency prior to discharge. This deficient practice placed the resident at risk for not receiving the necessary care and services related to the resident's discharge goals and needs.

Inspectors wroteBased on interview and record review the facility failed: 1. To develop and implement a care plan addressing placement of bed against the wall for two of two sampled residents (Resident 94 and 18) investigated during review of physical restraints (the use of manual hold to restrict freedom of movement of all or part of a resident's body, or to restrict normal access to the resident's body). This deficient practice had the potential for residents to not receive the proper and necessary care related to use of restraints. 2. To develop and implement a care plan for one of one sampled resident (Resident 86) for refusing activities and range of motion (ROM-movement of the joints) treatments. This failure had the potential to place Resident 86 at risk for physical and psychosocial decline.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the resident's comprehensive care plan was reviewed and revised by the interdisciplinary team to one out of four sampled residents (Resident 74) investigated during review of pressure injury/ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) care area when the resident refused to have the low air loss mattress (LALM, a mattress designed to prevent and treat pressure wounds) be set according to resident's weight. The deficient practice had a potential for worsening of the pressure injury (the breakdown of skin integrity due to pressure) of the resident.

Inspectors wroteBased on interview and record review the facility failed to ensure residents receive treatment and services to maintain vision to one out of one sampled resident (Resident 104) investigated during review of communication/sensory care area by failing to assist the resident in scheduling an ophthalmology (eye care specialist) appointment. The deficient practice had the potential to result in worsening of the resident's vision and could negatively affect the resident's overall well-being.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide appropriate treatment and services to prevent complications of enteral feeding (EF - a form of nutrition that is delivered into the digestive system as a liquid) to one of three random observations (Resident 80) by labeling the feeding formula bottle with an incorrect gastrostomy (GT, tube inserted through the wall of the abdomen directly into the stomach) feeding rate. This deficient practice had the potential to result in weight loss or gain and altered nutritional status that can lead to complications.

Inspectors wroteBased on observation, interview and record review, the facility failed to administer parenteral fluids (the intravenous administration of medication) consistent with professional standards of practice for two (2) out of 2 sampled resident (Residents 324 and 57) during random observation of residents with intravenous (IV) catheter (a thin, flexible tube that is inserted into a vein to draw blood and give treatments including IV fluids, drugs, or blood transfusions) by: 1. Failing to label the IV dressing with the date when the peripheral intravenous line (PIV - a soft, flexible tube placed inside a vein, usually in the hand or arm to give a person medicine or fluids) dressing was last changed for Resident 324. 2. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure kitchen staff were routinely trained and evaluated for competency skills as followed: a. Staff failed to verbalize proper air-drying procedures when washing dishes. b. Staff failed to verbalize and follow the manufacturer's guidelines of J512 test paper (a type of test strip) when checking the Quaternary Ammonium Compounds (Quats, a group of chemicals used to disinfect surfaces and equipment) sanitizer concentration. These failures had a potential to result to cross-contamination (a transfer of bacteria from one object to another), unsanitized food preparation areas and bacterial growth to food that could lead to food borne illness (an illness caused by contaminated food and beverages) in 124 of 138 medically compromised residents who received food and ice from the kitchen.

Inspectors wroteBased on observation, interview, and record review the facility failed meet resident's (Resident 152) food preferences when there were missing items on the resident's tray. This deficient practice had the potential to cause frustrations and decrease food intake resulting to unintended (not done on purpose) weight loss.

Inspectors wroteBased on interview and record review, the facility failed to ensure the arbitration (a private process where disputing parties agree that one or several other individuals can make a decision about the dispute after receiving evidence and hearing arguments) agreement (a written contract in which two or more parties agree to settle a dispute out of court) was explained to residents in a form and manner that he or she understands, including a language the resident understands, and the resident acknowledged that he or she understands the agreement to two of three sampled residents reviewed under the Arbitration care area (Resident 156 and 230) when: a. Resident 156, whose primary language was Spanish, signed the facility's English language arbitration agreement without understanding what she was signing. b. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents' bedrooms meet the requirement of 80 square feet (a unit of measure for distance) per resident in multiple resident bedrooms for x of y rooms (Rooms 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 15, 18, 19, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, and 37). This deficient practice had the potential to result in inadequate space to provide safe nursing care, privacy for the residents, and limit the residents' ability to maneuver personal care devices.

Inspectors wroteBased on interview and record review, the facility failed to inform the responsible party for one of six sampled residents (Resident 1). After encountering a change in health condition with injury, Resident 1's responsible party (RP) was not contacted or provided an update to Resident 1's change in health condition. This deficient practice denies Resident 1's RP the information required to make informed decisions for Resident 1's health related care and needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure that one of three sampled residents (Resident 1) who was unable to carry out activities of daily living (ADL-such as personal hygiene, bathing, bed mobility, dressing and transfers) received the necessary services to maintain good grooming and personal hygiene. This deficient practice had the potential to negatively affect Resident 1's self-esteem and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary respiratory care and services for one of four sampled residents (Resident 3) by failing to ensure oxygen tubing was dated on when it was changed. This deficient practice had the potential for Resident 3 to develop respiratory diseases.

Inspectors wroteBased on interview and record review, the facility failed to maintain a complete and accurate medical records in accordance with accepted professional standards for one of four sampled residents (Resident 1). This deficient practice had resulted to inaccurate information entered in Resident 1's medical record.

Inspectors wroteBased on observation, interview, and record review, the facility failed to observed infection control measures for one of four sampled residents (Resident 3) by failing to ensure oxygen tubing was not touching the floor. This deficient practice resulted in the contamination (the process of making something dirty) of the resident's care equipment and placed Resident 3 at risk for infection.

Inspectors wroteBased on interview and record review, the facility failed to respect the rights and dignity for one of six sampled residents (Resident 1) by failing to provide Activities of Daily Living (ADL) grooming needs. This deficient practice prevents Resident 1 from reaching the highest potential for mental, emotional, and/or psychosocial well-being. Findings A review of Resident 1's admission Record noted an original admission date of 10/23/2023 with the following diagnoses of hypertensive heart disease (chronic or prolonged high blood pressure) with heart failure (decreased ability of the heart to pump blood for the body's needs), muscle weakness, and dementia (having impairments with thought process and decision making). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a comprehensive person-centered care plan for one of three sampled residents (Resident 6) to address residents ' refusal for nail care. On 11/17/2023, Resident 6 had long and dirty fingernails. This deficient practice had the potential to negatively affect Resident 6's self-esteem and placed her at risk for infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 6) who was unable to carry out activities of daily living (ADL ' s such as bathing, dressing and personal hygiene) received the necessary services to maintain good grooming. On 11/17/2023, Resident 6 had long and dirty fingernails. This deficient practice had the potential to negatively affect Resident 6 ' s self-esteem and placed her at risk for infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of seven sampled residents (Resident 1), who did not have the capacity to understand and make decisions, who had wandering (going about from place to place, walking without purpose) behavior, and was assessed at risk for fall and elopement (a form of unsupervised wandering that leads to the resident leaving the facility without notice or permission and doing so may present an imminent threat to the resident ' s health or safety) was free from neglect (the failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress) by: 1. Not ensuring staff provided Resident 1 with supervision and monitoring (a process of observing and tracking activities and progress) to assure that care was provided that met the needs of Resident 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of seven sampled residents (Resident 1), who did not have the capacity to understand and make decisions, who had a wandering (going about from place to place, walking without purpose) behavior, and was assessed at risk for fall and elopement (a form of unsupervised wandering that leads to the resident leaving the facility without notice or permission and doing so may present an imminent threat to the resident ' s health or safety) received supervision to prevent elopement by: 1. Not ensuring staff provided Resident 1 with supervision and monitoring (a process of observing and tracking activities and progress) to assure that care was provided that met the needs of Resident 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to esure it has policies and procedures on the use of a wander guard (a monitoring bracelet that alarms once the bracelet crosses sensors on an exit door) and resident supervision affecting all residents. The facility also failed to implement its policy on the use of security and surveillance cameras (video cameras that record images in or outside a building or in a public place) to be monitored since per policy, the video surveillance cameras were monitored for the safety and benefit of its residents and video footages were stored. As a result, on 10/4/2023, Resident 1 eloped and was last seen at 6 a.m. inside the facility building in the hallway near Nursing Station 3 by the Director of Staff Development (DSD), who was walking in the hallway going to Nursing Station 4. [...]

Inspectors wroteBased on interview and record review, the facility failed to employ a qualified social worker on a full-time basis for a facility that has more than 120 beds. This deficient practice had a potential for the residents not being assisted and receiving medically related social services to attain the highest practicable well-being.

Inspectors wroteBased on interview and record review, the facility failed to assess and monitor resident's urinary discomfort and burning sensation for potential symptoms of a urinary tract infection (UTI, infection that affects part of the urinary tract-kidneys, ureters, urinary bladder, and the urethra) for one of three sample residents (Resident 93) investigated under the Urinary Catheter or UTI care area. This deficient practice had the potential to negatively affect the resident's physical comfort and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately account for 10 doses of controlled substances (medications with a high potential for abuse) affecting nine residents (Residents 11, 50, 52, 65, 69, 93, 98, 130, and 141) in one of four inspected medication carts (Medication Cart 4A). This deficient practice increased the risk that Residents 11, 50, 52, 65, 69, 93, 98, 130, and 141 could have received too much or too little medication due to lack of documentation possibly resulting in serious health complications requiring hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper food handling practices by: 1. Failing to ensure that two boxes of apple juice were not stored on the floor in dry storage room. 2. Failing to ensure that three prepared milk trays in Fridge #2 (refrigerator #2) were dated. 3. Failing to ensure Resident 2's food brought in by family and stored in staff refrigerator was labeled with storage date. These deficient practices had the potential to result in foodborne illness (an infection or irritation of the gastrointestinal tract [including the stomach and intestines] caused by food or beverages that contain harmful bacteria/germs, chemicals, or other organisms) for 127 out of 127 residents who receive and consume food from the facility kitchen and the resident designated refrigerator.

Inspectors wroteb. A review of Resident 20's Face Sheet indicated the resident was readmitted on [DATE] with diagnoses including Parkinson's disease (a progressive nervous system disorder that affects movement) and resistance to other specified beta lactam antibiotics (management and treatment of bacterial infections). During a concurrent observation and interview, on 08/12/2021 at 9:29 a.m., observed Certified Nurse Assistant 3 (CNA 3) put on gown and gloves before entering Resident 20's room. CNA 3 provided bed bath to Resident 20. CNA 3 washed the resident's upper body with wash cloth soaked with soap and water and rinsed off with wash cloth and pat dry with towel. Using the same gloves, CNA 3 washed resident's perineal area and proceeded to resident's lower extremities and back area. Using the same gloves, CNA 3 placed new sheets and repositioned resident lying on his left side. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the call light was within reach for one out of one resident (Resident 91) investigated under the care area of accommodation of needs. This deficient practice had the potential for the resident's needs not being met as resident was unable to call for this assistance.

Inspectors wroteBased on interview and record, the facility failed to ensure the resident's advance directives (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) were readily accessible in the physical chart for one of four sampled residents (Resident 105). This deficient practice had the potential to delay emergency treatment or the potential to force emergency, life-sustaining procedures against the resident's personal preferences.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement an individualized plan of care for activities for one of one resident (Resident 129) investigated under the care area of care planning. This deficient practice resulted to failure in the delivery of necessary care and services for Resident 129.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that two of two sampled residents (Resident 16 and 129) investigated under the care area of activities were engaged in preferred activities as evidenced by: a. Resident 129 was not assessed for activities nor was offered activities. b. Failing to conduct an activities assessment for Resident 16. These deficient practices had the potential to affect the resident's sense of self-worth and psychosocial well-being through feelings of usefulness, self-respect, and self-satisfaction.

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat a resident's contractures (muscles or tendons that have remained too tight for too long, thus becoming shorter) by not applying hand rolls as ordered for one of one sampled residents (Resident 61). This deficient practice had the potential to further affect the resident's limited range of motion and further worsening of the contracures.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that a resident requiring a Foley catheter (indwelling catheter - a flexible tube that passes through the urethra [tube that leads from the bladder and transports and discharges urine outside the body] to drain urine) was connected and draining urine for one of one resident (Resident 73) investigated under the care area of urinary catheter. This deficient practice led to unnecessary resident abdominal pain and discomfort.

Inspectors wroteBased on observation, interview, and record review, the facility failed to fully assess and effectively manage pain for one of one sampled resident (Resident 105), by failing to: 1. Perform a pain assessment after Resident 105 reported pain to Licensed Vocational Nurse 7 (LVN 7). 2. Assess Resident 105's pain intensity before and after pain medication administration on 8/6/2021. These deficient practices had the potential to result in ineffective pain control and Resident 105 experiencing unnecessary pain.

Inspectors wroteBased on interview and record review, the facility failed to act upon in a timely manner on the Consultant Pharmacist's Medication Regimen Review recommendations including the documented rationale (underlying reason) for the ongoing need for routine use of Voltaren (diclofenac, used to relieve pain and swelling) and continuous use of Restoril (hypnotic used to treat insomnia [trouble sleeping]) for one of five sampled residents (Resident 65) investigated under the Unnecessary Medications, Psychotropic Medications, and Medication Regimen Review care area. This deficient practice had the potential to result in unnecessary medications placing the resident at risk for potential adverse consequences (unwanted, uncomfortable, or dangerous effects that a drug may have).

Inspectors wroteBased on interview and record review, the facility failed to ensure signs and symptoms of bleeding were monitored for the use of Eliquis (a medication used to prevent blood clots) for one of five sampled residents (Resident 7.) The deficient practice of failing to monitor for signs and symptoms of bleeding during Eliquis therapy increased the risk that Resident 7 could have experienced adverse effects (unwanted and dangerous side effects of medication) such as bleeding and bruising leading to health complications requiring hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five percent (%). Two medication errors out of 26 total opportunities contributed to an overall medication error rate of 7.69 % affecting one of four residents observed for medication administration (Resident 131.) The deficient practice of failing to administer medications in accordance with the attending physician's orders increased the risk that Resident 131 may have experienced health complications related to incorrect medication administration which could have negatively impacted her health and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one bottle of bromfenac ophthalmic solution (a medication use to treat eye conditions) for Resident 9 was removed from the medication cart once expired for one of three inspected medication carts (Medication Cart 4B.) This deficient practice increased the risk that Resident 9 could have received medication that had become ineffective or toxic due to improper storage or labeling possibly leading to health complications resulting in hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS - a comprehensive resident assessment tool) was accurately completed to reflect: 1. A diagnosis of anxiety (a mental disorder characterized by persistent feelings of worry, nervousness, or unease strong enough to interfere with daily activities) in one of five sampled residents (Resident 7). 2. A diagnosis of Major Depressive Disorder (MDD - a mental disorder characterized by depressed mood and loss of interest in activities) in one of five sampled residents (Resident 9). 3. Routine use of antipsychotic (medications used to treat mental illness) medications in one of five sampled residents (Resident 9). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that 30 of 78 resident rooms (Rooms 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 15, 18, 19, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, and 37) met the square footage requirement of 80 square feet (sq. ft.) per resident in multiple resident rooms.