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Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident rooms were at a comfortable temperature for three (3) of 3 sampled residents (Resident 1, Resident 2 and Resident 3) by failing to ensure the facility's Heating, Ventilation and Air Conditioning (HVAC, a climate control system that keeps indoor areas at a comfortable temperature) was in good repair. This deficient practice had the potential to result in Residents 1, 2 and 3 feeling uncomfortably hot and negatively affect their quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one (1) of 3 sampled residents (Resident 1) who was dependent with staff for Activities of Daily Living (ADL, are activities related to personal care including bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating) were provided care and services to maintain good grooming, personal hygiene based on the facility's policy and procedure. This deficient practice had the potential for Resident 1 to develop infection and skin breakdown which could result in poor wound healing and the decline of the resident's well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a functional call light for two (2) of three (3) sampled residents (Residents 2 and 3) in accordance with the facility's policy and procedure (P&P) titled Call System (an emergency, nurse, or service-oriented communication setup that allows users to push a button to alert staff or caregivers), Resident. These failures had the potential to put Residents 2 and 3 at risk of experiencing delays in receiving assistance from facility staff, which could lead to an accident or injury.

Inspectors wroteBased on observation, interview, and record review, facility staff failed to revise the care plan (a dynamic, written document outlining a patient's health needs, goals, and customized interventions, formulated through assessment) for the use of mechanical lift (a device used to safely transfer individuals with limited mobility between beds, wheelchairs, and chairs, reducing physical strain on caregivers) for one of two (2) sampled residents (Resident 1) as indicated on the facility policy. This deficient practice had the potential for Resident 1 not to receive resident specific interventions to ensure safety.

Inspectors wroteBased on observation, interview, and record review, facility staff failed to develop and implement a care plan for proper safety precautions for one (1) of two (2) sampled Residents (Resident 1) by failing to identify interventions related to the resident's specific risks which included behavior of kicking his legs while in bed. This deficient practice resulted to Resident 1 sliding off from the bed on 3/24/2026 and potential for further falls which could cause injury and harm to the resident.

Inspectors wroteBased on interview and record review, the facility failed to change the enteral (nutrition taken through the mouth or through a tube that goes directly to the stomach or small intestine) feeding bag every shift/every 24 hours for one of four sampled residents (Resident 2) in accordance with the physician 's order and facility policy. This deficient practice had the potential for Resident 2 not to get adequate nutrients via enteral feeding which could lead to malnutrition (serious condition that occurs when a resident's diet does not contain the right amount of nutrients) and results in hospitalization and death.

Inspectors wroteBased on interview and record review, the facility failed to complete/and follow through with the Preadmission Screening and Resident Review (PASARR; a federal assessment requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care) for two (2) of three (3) sampled residents (Residents 3 and 4) under the PASARR care area by not: Completing a PASARR level 1 screening for Resident 3 upon admission on [DATE]. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper food handling pas practiced and was provided in accordance with the facility's policy and procedure (P&P) by failing to ensure an open bag with eight (8) chicken patties and a cheesecake in the kitchen's walk-in freezer was labeled with open date and best by (expiration) date. The deficient practice of failing to ensure unlabeled foods are disposed accordingly had the potential to result in growth of bacteria and transmission of foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea (the frequent passing of loose, watery stools), and fever and can lead to other serious medical complications and hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement facility's policy and procedures (P&P) for food brought by family/visitors for five of seven sampled residents (Residents 4, 9, 25, 37 and 32) by failing to ensure:1. A container of rice and noodles for Resident 4 was labeled with use by date.2. Food was removed and discarded from the resident's refrigerator for Resident 9 who was discharged from the facility on 9/26/2025.3. A container of pozole (a kind of soup) and bag of cabbage for Resident 25 was labeled with use by date.4. A box of pizza for Resident 37, dated 9/6/2025 was disposed. 5. Multiple containers of food containing rice fish, bitter melon and beef for Resident 32 was labeled with use by date.6. Food brought by Resident 32's visitor was not left in resident's room for more than 2 hours. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their infection control policies & procedures for five (5) of six (6) sampled residents (Residents 10, 18, 40, 61, and 77) by not ensuring:1-4. The availability of environmental Protection Agency (EPA; a United States federal agency that protects human health and safeguards the environment by creating and enforcing environment laws and regulations) registered sanitizing wipes or bleach wipes effective against Clostridium Difficile (C. diff; a highly contagious bacterial infection that causes an infection of the colon [the longest part of the long intestine]) for Residents 10, 18, 61 and 77 on contact isolation (a transmission based precautions to stop germs from spreading through direct touch with a patient or indirect touch with contaminated objects in their environment) for C. diff infection. 5. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to promote dignity and respect in accordance with the facility's policy and procedure for one (1) of two (2) sampled residents (Resident 49) under the Dignity Care Area, when Certified Nursing Assistant 3 (CNA 3) was observed standing above Resident 49's eye level while assisting the resident during mealtime. This failure had the potential to affect Resident 49's self-esteem and self-worth. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure three (3) of seven (7) sampled residents (Residents 6, 10 and 43) had their call light (a signaling device, typically a button, used by patients or residents in a healthcare setting to request assistance from staff) placed within reach under the Environment care area. This failure resulted in Residents 6, 10 and 43 not being able to call for help when they were attempting to reach for their call lights and placed them at risk for experiencing a delay in receiving assistance from facility staff which could have potentially led to a fall or accident.

Inspectors wroteBased on interview and record review, the facility failed to ensure a charge against one (1) of 24 sampled residents (Resident 79) personal funds was not imposed during the resident's stay at the facility from 4/3/2025 to 6/14/2025. This deficient practice had a potential to result in emotional distress brought about by a financial loss due to Resident 79 not receiving the required reimbursement from the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a clean, comfortable, and home-like environment for one (1) of 24 sampled residents (Resident 25) by failing to ensure that Resident 25's room has no pool of water beside the resident's bed and the resident's electric fan by the resident's room was not dusty. These deficient practices caused an unsanitary environment and had potential for Resident 25 to be placed at risk for infection and injuryFindings: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Low Air Loss mattress (LAL mattress, designed to prevent and treat pressure ulcer [localized damage to the skin and underlying soft tissue caused by prolonged pressure]) for one (1) of four (4) sampled residents (Resident 38) under pressure ulcer care area was set at the correct settings in accordance with the resident's weight. This deficient practice had the potential for Resident to develop new pressure injury.

Inspectors wroteBased on observation, interview and record review, the facility failed to identify the environment for potential hazard for one of two sample residents (Resident 12) under accidents care area by failing to ensure the floor was dry. This deficient practice had the potential for Resident 12 to sustain injury in an event of a fall due to the wet floor.

Inspectors wroteBased on interview and record review, the facility failed to provide dialysis (process of removing waste products and excess fluid from the body) care and services by failing to assess the resident's left upper arm dialysis access site (surgical or medical creations that allow for blood to be cleaned by a dialysis machine and returned to the body) on 11/11/2025, 11/12/2025, and 11/18/2025 for one of two sampled residents (Resident 25) under dialysis care area, in accordance with the facility policy and physician's order. This deficient practice had the potential for complications such as bleeding or infection on Resident 25's left upper arm arteriovenous (AV) fistula (shunt, a surgically created connection between an artery and a vein, most commonly in the arm, that provides access for hemodialysis when kidneys fail) dialysis access.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one (1) of three (3) sampled residents (Resident 17), under food care area, was provided with a meal tray that did not contain a food the resident was allergic to. This failure had the potential to result in Resident 17 experiencing an allergic reaction such as anaphylaxis (a severe, whole-body allergic reaction that happens quickly and is life-threatening).

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose garbage and refuse (disposable material, which includes both recyclable and non-recyclable material) from the kitchen properly when the designated green kitchen dumpster (a movable waste container designed to be brought and taken away by a special collection vehicle) was observed overfilled with a lid covering it halfway. This failure had the potential to result in the attraction and spread of vermin (animals that are believed to be harmful, or that carry diseases, e.g., rodent's parasitic worms or insects) that could potentially infiltrate the facility, affect the resident care areas and pose a threat to residents of the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the ice machine drainage has an air gap (a vertical, unobstructed space between the ice machine's drain and the building's drainage system that prevents contaminated drain water from flowing back into the machine's clean water supply. It is a safety feature, often a simple pipe fitting or a dedicated device, that acts as a barrier, with the most common requirement being a 1-2 inch gap to comply with health and plumbing codes) to ensure no contact with outside contaminated (unfit for use, or unsafe) source as indicated in facility's policy and procedures (P&P). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the facility's staffing information was posted and placed in a visible and prominent area on 9/27/2025, 9/28/2025, and 9/29/2025 in accordance with the facility's policies and procedures (P&P). This deficient practice had the potential for the residents and not to be informed of the actual number of nurses providing direct care to the residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 11 of 31 resident rooms (rooms 12, 14, 15, 16, 17, 21, 22, 23, 24, 25 & 26) met the square footage requirement of 80 square feet (sq. ft.) per resident in a multiple resident room. This failure had the potential to affect the residents' personal space, decrease freedom of mobility and could compromise the provision of care. During the initial observation on 9/29/2025 from 9:00 AM to 11:00 AM, rooms 12, 14, 15, 16, 17, 21, 22, 23, 24, 25 and 26 did not meet the minimum requirement of 80 sq. ft. per resident. The residents in these rooms were able to ambulate and/or move around in their wheelchairs freely. Nursing staff were observed to have enough space to provide safe quality care and there was enough space for beds, side tables, dressers and other medical equipment. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the food service area was maintained clean, sanitary, and in a functional manner while providing proper food handling in accordance with the facility's policy and procedure (P&P) by failing to ensure:1. Walk in freezer's temperature was checked on 8/4/2025 and 8/5/2025, Walk in refrigerator's (Refrigerator 1) temperature was checked on 8/4/2025 and 8/5/2025 and Standing refrigerator's (Refrigerator 2) temperature was checked on 8/2/2025, 8/3/2025, 8/4/2025 and 8/5/2025.2. Dishwasher machine's top surface was clean, without dust and crumbs. 3. [NAME] crispies were disposed after 6/30/2025 as labeled in the use by date sticker and flour with prepared date of 6/14/2025 was labeled with correct use by date.4. The dry food storage room's temperature was checked daily from 7/20/2025 to 8/5/2025. 5. [...]

Inspectors wroteBased on interview and record review the facility failed to readmit one (1) of two (2) sampled residents (Resident 1) back to the facility on 5/17/2025 after Resident 1 was discharged from General Acute Care Hospital (GACH) back to the facility in accordance with the facility's policy and procedure (P&P) titled Bed Holds and Returns. This deficient practice had the potential to violate the rights of Resident 1 and lengthen unnecessary stay in GACH.

Inspectors wroteBased on observation, interview, and record review the facility to provide treatment and services to attain the highest practicable mental and psychosocial well- being of one of two sampled residents (Resident 1) who was diagnosed with depression (a constant feeling of sadness and loss of interest, which stops you doing your normal activities) anxiety (a feeling of fear, dread, and uneasiness), and borderline personality disorder (a mental health condition that affects the way people feel about themselves and others, making it hard to function in everyday life) and who was identified as being danger to self and others (DTSO- the probability that a person will inflict serious physical injury upon the person or another person in the near future) on 4/28/2025 by failing to: 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a safe environment for one (1) of three (3) sample residents by failing to ensure Resident 1 did not possess one bottle of alcoholic beverage and eight (8) medication bottles from Pharmacy 2 (outside pharmacy) labeled with Resident 1's name while the resident is residing in the facility in accordance with the facility's policy titled Restricted Item /Contraband. As a result of noncompliance, on 5/12/2025 at 5:20 AM, Resident 1 was found unresponsive by Licensed Vocational Nurse (LVN 1) with two (2) opened prescription plastic containers of doxepin (medication to treat anxiety or depression - unknown dosage) and 1 bottle of ondansetron (medication used to prevent nausea and vomiting- unknown dosage). [...]

Inspectors wroteBased on interview and record review, the facility failed to implement its protocol for Antibiotic Stewardship to reduce inappropriate antibiotic (medication used to kill bacteria and to treat infections) use by not administering antibiotic drug if the antibiotic drug use criteria (McGeer criteria, a set of standardized definitions used to identify healthcare-associated infections in long-term care facilities for surveillance, tracking outbreaks, and making informed decisions about antibiotic use) was not met for two (2) of 2 sampled residents (Residents 1 and 2). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the facility employed a designated Infection Preventionist (IP) with specialized training. This failure had the potential to result in the prevention and control of infections among the residents and staff.

Inspectors wroteBased on interview and record review, the facility failed to report to State Survey Agency (SA, where state law provides for jurisdiction in long-term care facilities), ombudsman (OMB) (advocates for residents of nursing homes, board and care homes and assisted living facilities) and local law enforcement within the two (2) hour time frame and thoroughly investigate an allegation of physical abuse (intentional act causing injury or trauma to another person or animal by way of bodily contact) of one (1) of two (2) sampled residents (Resident 1) that happened on 2/17/2025 [NAME] accordance with the facility policy. [...]

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of sexual abuse (any act of sexual contact that a person suffers, submits to, participates in, or performs as a result of force or violence, threats, fear, or deception or without having legally consented to the act) for one (1) of two (2) sampled residents (Resident 1) within 2-hour timeframe to the State Survey Agency (SA, where state law provides for jurisdiction in long-term care facilities) and the state ombudsman (advocates for residents of nursing homes, board and care homes and assisted living facilities), in accordance with the facility's abuse policy. This deficient practice had the potential to compromise or impede the protection of Resident 1 from further abuse, which could result in emotional distress.

Inspectors wroteBased on interview, and record review, the facility failed to honor the food preferences for one (1) of two (2) sampled resident's (Resident 1) in accordance with the facility's policy and procedure (P&P) titled, Resident Food Preferences and as indicated on the physician's order. This deficient practice had the potential to cause Resident 1 to feel disrespected and to feel stomach discomfort.

Inspectors wroteBased on interview and record review, the facility failed to provide adequate assistance to prevent accidents for one (1) of two (2) residents (Resident 1). On 4/24/2024, Certified Nursing Assistant 2 (CNA 2) assisted Resident 1 back to bed from the resident's wheelchair without assistance of another facility staff. This failure resulted in Resident 1 having an assisted fall with CNA 2 and placed resident at risk of injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one (1) of two (2) sampled residents (Resident 2) received food that accommodated resident intolerances and preferences. This failure placed Resident 2 at risk for experiencing feelings of sadness and distress and had the potential to result in Resident 2 having decreased meal intake which would lead to weight loss and malnutrition (a state of nutritional deficiency or imbalance that occurs when the body does not receive or absorb sufficient nutrients [calories, protein, vitamins, minerals] to maintain health and function properly).

Inspectors wroteBased on interview and record review, the facility failed to ensure psychotropic medications (any drug that affects brain activities associated with mental processes and behavior) were not used unnecessarily for two of two sampled residents (Resident 1 and 2) by failing to: 1. [...]

Inspectors wroteBased on interview and record review the facility failed to prevent an accident by failing to monitor one of two sampled residents (Resident 1) for constant kicking of leg when severely anxious or agitated in accordance with the facility's policy and procedure (P&P), titled, Safety and Supervision of Residents, This deficient practice placed Resident 1 at risk for fracture on the foot and had the potential to result in reoccurring foot injuries.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure the facility's consultant pharmacist's recommendation for the use of lorazepam (Ativan-an anti-anxiety [characterized by feelings of worry, apprehension, or nervousness, often accompanied by physical symptoms like increased heart rate or sweating] medication) and quetiapine (Seroquel-a psychoactive medication used to treat schizophrenia [a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness and social interactions], bipolar disorder [a mental health condition characterized by extreme shifts in mood ranging from intense highs to periods of intense lows], and depression [low mood, fatigue, and hopelessness]) in the Drug Regimen Review (DRR- a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide appropriate pressure ulcer (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) management for two of three sampled residents (Resident 2 and 3), by failing to ensure the Low Air Loss mattresses (LAL- a type of mattress used for residents who are at risk of developing pressure sores or already have pressure sores) were at the correct weight settings for the residents. This failure resulted in inadequate therapy from the LAL mattresses, with the potential to worsen Resident 2 and 3's current pressure ulcers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to report an injury of unknown origin for one of one resident (Resident 1), who was observed with unexplained swelling (a raised/ enlarged, curved shape on the surface of your body which appears as a result of an injury or an illness) on the resident's right hand on 1/26/2025. This failure compromised Resident 1's safety and well-being by delaying appropriate medical evaluation and intervention.

Inspectors wroteBased on observation, interview, and record review, the facility failed to revise and update the Care Plan (CP- a tool that helps nurses and other care team members organize aspects of patient care according to a timeline, and allows them to think critically and holistically in a way that supports the patient's physical, psychological, social, and spiritual care) for one of one sampled resident (Resident 1), who had a fall incident on 2/11/2025. This failure resulted in a lack of new fall prevention interventions, placing Resident 1 at risk for another fall incident and/ or injury.

Inspectors wroteBased on interview and record review, the facility failed to provide the necessary care and services in accordance with professional standards of practice (guidelines that outline the expectations and requirements for professionals) to attain or maintain the highest practicable physical well-being (highest possible level of functioning and well- being) for one of two sampled residents (Resident 1) by failing to: 1. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to follow the menu and did not meet nutritional needs for 63 of 67 sampled residents on regular (diet with no restriction) and therapeutic diets (diet that controls certain food and nutrients) when [NAME] 1 did not follow the recipe for sauce and Cajun country rice. This failure had the potential to result in decrease food and nutrient intake resulting in unintended (not done on purpose) weight loss and increase blood pressure.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare food by methods that conserved flavor and appearance for breakfast when: Cook 1 did not follow the recipes for a. for tarragon sauce resulting to salty food product. b. Cajun rice affecting the flavors. These failures had a potential to result in 63 of 67 (including Resident 1 and Resident 2) unplanned weight loss.

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. Refrigerator racks had chips. 2. Three (3) plain Greek yogurts, two (2) low fat yogurts, 2 cottage cheeses, and 3 low fat cottage cheese passed their expiration date in the walk-in refrigerator. 3. Four (4) dented (a hollow made by a blow or by pressure) cans were stored along with non-dented cans. 4. [NAME] 1 did not wash his hands after wiping the food preparation sink and then immediately returned to work and touched the scoops for lunch trayline ' s (an area where foods were assembled on the trays), use. [...]

Inspectors wroteBased on interviews and record review, the facility failed to provide adequate supervision to prevent accidents for two (2) out of the four (4) sampled residents (Resident 1 and 4) by: 1. Failing to monitor Resident 1 at least every two (2) hours and as needed in accordance with the resident's care plan for Resident noted of picking up things quickly and hides it. On 1/3/2025, Resident 1 was observed with a ring (not the resident's ring) on the resident's left hand's middle finger. This deficient practice has resulted in Resident 1 's left hand middle finger to get swollen and appeared to have pus (a thick, usually yellowish-white, fluid matter that is formed as part of an inflammatory response typically associated with an infection) due to the ring that does not fit the resident and staff was not able to remove. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call pad/ call light (a device used by residents to call staff) was within reach for four of 17 sampled residents (Residents 6, 20, 171, and 34) in accordance with the facility policy. This failure had the potential for Residents 6, 20, 171, and 34 not to be able to call for help or assistance which could result to delay in the delivery of care and services, especially during an emergency, which could lead to illness and harm to the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to post precautionary and safety sign indicating use of oxygen (therapy a treatment that provides extra oxygen for people to breathe in) for two (2) of three (3) sampled residents (Residents 120 and 121) as indicated in the facility's oxygen administration policy. This deficient practice could potentially place Residents 120 and 121 at risk for injury and serious harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper food handling practices in accordance with its policy and procedure by failing to ensure: 1. Food containers were completely sealed and intact. 2. A can opener was clean and free of gunk (unpleasantly sticky or messy substance) and rust (a reddish-brown substance that forms on the surface of iron and steel as a result of reacting with air and water) 3. Resident 16's breakfast tray was replaced with a clean tray and plate prior to being delivered back to the resident. 4. The kitchen trashcan was not overflowing and was not touching the rack of clean plate cover. 5. The dietary aid (DA1) did not use a dirty potholder while preparing food on 10/30/2024. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to observe infection control measures as indicated on the facility policy and procedure (P&P) when the facility failed to: 1. Ensure Certified Nursing Assistant 2 (CNA 2), Licensed Vocational Nurse 1 (LVN 1) and LVN 3 donned (put on) personal protective equipment (PPE, equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) prior to entering Resident 26's room, which was an enhanced barrier precautions room (EBP; gown and glove use during high-contact resident care activities for residents who are at increased risk of multidrug-resistant organism [MDRO; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care in a manner that maintained or enhanced a resident's dignity and respect for one (1) of one sampled resident (Resident 20). The facility staff was observed standing over the resident while assisting the resident during a meal. This deficient practice had the potential to affect Resident 20's self-esteem and self-worth.

Inspectors wroteBased on interview and record review the facility failed to ensure the Advance Health Care Directive (a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them) was readily retrievable by any facility staff for one (1) of two (2) sampled residents (Resident 53). This failure had the potential to result in nursing staff not knowing if Residents 53 had specific resident wishes to follow in case of an emergency.

Inspectors wroteBased on observation and interview, the facility failed to protect the resident's right to be free from verbal abuse (a range of words or behaviors use to manipulate, intimidate, and maintain power and control over someone) by staff for one (1) of 17 sampled residents (Resident 123) when Licensed Vocational Nurse 4 (LVN 4) used inappropriate language with Resident 123. This failure resulted in Resident 123 experiencing feelings of disappointment in the facility staff caring for her and had the potential to result in mental and emotional distress.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one (1) of two (2) sampled residents (Resident 12) was provided assistance while eating as indicated in the care plan and facility's policy and procedure. This deficient practice had the potential for decline and not to maximize Resident 12's functional ability to perform Activities of Daily Living (ADL, basic tasks that people need to do to live independently) which can affect the resident's physical and mental wellbeing. This failure also had the potential not to meet Resident 12's nutritional needs which could lead to further malnutrition (a condition that occurs when a person's body doesn't get the right amount of nutrients it needs to function properly) and hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policy and procedure (P&P) regarding respiratory infection control for one (1) of four (4) residents (Resident 220) by not ensuring Resident 220's nebulizer (an electrically powered machine that turns liquid medication into a mist so that it could be breathed directly into the lungs through a face mask) tubing was stored in a plastic bag with a label indicating the date the tubing was changed and name of the resident. This failure had the potential to put Resident 220 at risk for infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care and services to one of two sampled residents (Resident 172) who is on hemodialysis (dialysis, a process of filtering the blood of a person whose kidneys are not working normally) by failing to ensure: 1. A dialysis emergency kit (dialysis e-kit, kit that contains emergency supplies that will be needed in case dialysis site got dislodged and/ or is bleeding) accessible at Resident 172 bedside. 2. A warning signage visible to warn facility staff not to use Resident 172's left arm for blood pressure (BP, pressure of blood on the wall your arteries as your heart pumps blood around your body) check, laboratory test/ blood draw, and no finger stick (pricking the skin of a finger to obtain blood usually done during blood sugar check). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest (a general term for organisms which may cause illnesses) control program in accordance with the facility's policy and procedure (P&P) by failing to ensure the facility was free from ants. This deficient practice had the potential for residents to get sick if the residents consume food that were contaminated by ants.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Daily Staffing Report (Nurse Staffing Information) posted on 10/29/2024, 10/30/2024, and 11/1/2024 was accurate in accordance with the facility's policy and procedure by failing to reflect the correct total number and actual hours of unlicensed nursing staff directly responsible for resident care. This deficient practice had the potential to inaccurately reflect the actual nurses providing direct care to the residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician visited residents at least once every thirty days for the first ninety days after admission, and at least once every sixty days thereafter for two (2) of 2 sampled residents (Residents 1 & 4). This deficient practice had the potential to negatively affect the residents' quality of care and delay of treatment.

Inspectors wroteBased on interview and record review, the facility failed to provide treatments and services to minimize decline in mobility and joint range of motion (ROM, full movement potential of a joint) for one of three sampled residents (Resident 1) who had limited range of motion and functional mobility when the facility failed to ensure Resident 1's Restorative nursing aide (RNA) program (nursing aide program to help residents maintain their function and joint mobility) treatments were not delayed after the discontinuation of physical therapy services (PT, a rehabilitation profession that restores, maintains, and promotes optimal physical function). This failure had the potential to cause further decline in Resident 1's range of motion, functional mobility, and ability to participate in activities of daily living.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement appropriate infection control when facility failed to ensure they have process in place and followed by facility staff on how to properly disinfect cloth gait belts (safety device worn around the waist that can be used help safely transfer a person from one surface to another) after each resident use. This deficient practice had the potential to transmit infections among residents and staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to initiate an individualized resident-centered care plan (a care plan that prioritizes the unique health needs and desired outcomes of the resident)for one (1) of two (2) sampled residents (Residents 1) to address the resident's need to have abduction pillow (stabilizes the legs and helps maintain proper leg positioning while recovering after surgery) in between his bilateral legs to prevent hip dislocation (medical emergency that occurs when the head of the thighbone separates from the hip socket) after a surgery. Resident 1 was observed not wearing the abduction pillow in between his bilateral legs on 9/23/2024. This deficient practice has the potential to result to Resident 1's delay in recovery and/ or having complication after a surgery.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physician orders for the use of an abduction pillow (stabilizes the legs and helps maintain proper leg positioning while recovering after surgery) for one of two residents (Resident 1). Resident 1 underwent a right hip hemiarthroplasty on 9/1/2024 (a surgical procedure that replaces the femoral head of the hip with a prosthetic component) due to a left hip fracture (a partial or complete break in the upper part of the thigh bone [femur] where it meets the pelvic bone) This deficient practice had the potential to result in right hip dislocation (an injury in which the hipbone is moved out of place) to Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to document monitoring for one of 2 sampled residents (Resident 1), for 72 hours after an alleged abuse. This deficient practice had the potential to place Resident 1 at risk for unmonitored mental, emotional changes that could negatively impact Resident 1 ' s well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light (one of the major communication technologies that link nursing home staff to the needs of residents) was accessible and addressed in a timely manner for four of six residents (Resident 2, Resident 3, Resident 4, and Resident 5). This deficient practice had the potential to result in a delay in care and services for Resident 2,3,4 and 5.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one (1) of five (5) sampled residents (Residents 1) was provided privacy during perineal care (the practice of washing the genital and rectal areas of the body). This deficient practice had the potential to result in Resident 1 ' s feelings of decreased self-esteem and self-worth.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement Coronavirus disease 2019 (COVID-19 - a highly contagious infectious disease caused by severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2]) infection control according to the facility ' s policy and procedure. 1. The facility failed to ensure a COVID-19 designated room had appropriate signage indicating droplet isolation (measures to prevent transmission when infection can be spread to others by speaking, sneezing, or coughing) 2. Facility staff did not wear all required personal protective equipment (PPE - worn to prevent or minimize exposure to hazards) while assisting Resident 2 who was COVID-19 positive. 3. There were no face shields (aims to protect the wearer's entire face) readily available in Resident 2 ' s isolation cart (store and transport your facility's personal protective equipment). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow the diet order for one of two sampled residents (Resident 2) in accordance with their policy. This deficient practice had the potential for Resident 2 not to receive his nutritional requirements which can lead to medical complications.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow proper food handling practices for one of two sampled residents (Resident 1) in accordance with its policy and procedure by: 1. Failed to ensure Resident 1's corn bread muffin was free from non-edible item such as wire (unknown what type of wire) on 5/16/2024. 2. Failed to ensure Resident 1's cup, bowls, and forks were free from residue. These deficient practices had the potential to result in residents developing foodborne illness and injury which can lead to other serious medical complications and hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents' (Resident 1) indwelling urinary catheter (tube that drains urine from the bladder into a drainage bag) was changed monthly as indicated in the physician's order. This deficient practice resulted in Resident 1 experiencing extreme pain when the indwelling catheter was changed on 3/15/24, five and half months after an order to change monthly was placed.

Inspectors wroteBased on interview and record review the facility failed to notify the medical doctor (MD) per physician ' s order after a change in condition for one of two sampled residents (Resident 1): 1 Licensed nurses did not notify the MD regarding Resident 1 ' s blood sugar (sugar located in the blood) below 120. 2. Licensed nurses did not notify the MD regarding Resident 1 not requiring medication administration of Humalog insulin (a medication that regulates the amount of sugar in the blood) for blood sugar below 120. This failure resulted in Resident 1 ' s MD not being notified of Resident 1 ' s blood sugar below 120 and not requiring insulin, which had the potential to negatively affect Resident 1 ' s treatment.

Inspectors wroteBased on interview and record review, the facility failed to withhold Humalog insulin (a medication that regulates the amount of sugar in the blood) doses as indicated on the physician ' s order for blood sugar levels (amount of sugar in the blood) less than 120 for one of two sampled residents (Resident 1). This failure had the potential for Resident 1 to become hypoglycemic (abnormally low levels of sugar in the blood) possibly leading to loss of consciousness (state of being awake, aware of and responding to one's surroundings) and death.

Inspectors wroteBased on interview and record review, the facility failed to follow through with the Preadmission Screening and Resident Review (PASRR, a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) recommendation to obtain a PASRR level II evaluation (a comprehensive evaluation by the appropriate state-designated authority and determines whether the individual has mental illness, intellectual disability, or a related condition, determines the appropriate setting for the individual and recommends what, if any, specialized services and/or rehabilitative services the individual needs) for two of three sampled residents (Residents 1 and 22). [...]

Inspectors wrote3. A review of Resident 57's admission Record indicated the facility admitted the resident on 8/18/2023 with diagnoses that included fracture (break in the bone) of left femur (uppermost part of thighbone) and atherosclerosis of aorta (fat and calcium has built up in the inside wall of a large blood vessel). A review of the Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 8/22/2023, indicate Resident 57 had moderate cognitive impairment (ability to think and reason). A review of the undated History and Physical Examination indicated Resident 57 did not have the capacity to understand and make decisions. A record review of Physician Order Sheet for October 2023, indicated Resident 57 was ordered oxygen (O2) at 2 liters per minute via nasal cannula as needed for hypoxemia (low oxygen that need supplemental oxygen administered). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement treatment for the prevention of pressure ulcer (painful wound caused as a result of pressure or friction) for three (3) of three sampled Residents (Resident 25, 27 and 22) in accordance with the facility's policy and procedure by failing to ensure: 1. and 2. The low air loss mattress (LAL, mattress used for residents who are at risk for developing sores or already have pressure ulcer designed to circulate a constant flow of air for the management of pressure sores) was on the correct settings for Residents 25 and 27. 3. Heel protectors were applied to Resident 22's bilateral heels as indicated on the Physician orders. These deficient practices have the potential to place the residents at risk for skin integrity complications and pressure injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide oxygen therapy (treatment that provides supplemental, or extra oxygen) and necessary respiratory care services for four (4) of 4 sampled residents (Resident 5, 7, 30, and 48) in accordance with the facility's policy and procedure when: 1. Resident 5's oxygen tubing (a tubing that connects to the oxygen source used to deliver oxygen) connected to the oxygen humidifier (a device designed to increase the moisture in the air) was kinked from the top of the oxygen concentrator (a medical device that gives extra oxygen by taking and filtering air from the surroundings) and the end of nasal cannula tubing was disconnected from the oxygen humidifier. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe provision of pharmaceutical services by failing to store received medications in the medication room as indicated on the facility policy. This deficient practice had the potential for adverse reaction if these improper stored medications were administered to the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Properly label foods and remove expired food items in the resident refrigerator, kitchen refrigerator, kitchen freezer and dry goods storage 2. Record refrigerator temperatures for the resident's communal refrigerator These failures had the potential to expose the residents to a food borne illness.

Inspectors wroteBased on observation and interview the facility failed to ensure the lids to the trash dumpster were fully closed and trash was disposed of properly. This failure had the potential to lead to an infestation (the presence of an unusually large number of insects or animals) that could enter the facility and spread diseases to the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure standard infection prevention control practices (a set of practices that prevent or stop the spread of infections and or diseases in the healthcare setting) were followed in accordance with the facility's policy and procedure when: 1. Resident 5's oxygen humidifier (a device designed to increase the moisture in the air) was found sitting on the floor. 2. The facility staff failed to wear gloves while handling soiled re-usable gowns. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two (2) of 22 sampled residents (Resident 3 and 30) were informed of the risks and benefits of psychoactive medication (a drug that changes brain function and results in alterations in perception, mood, consciousness, or behavior). 1. Resident 30 was not provided a psychoactive medication consent form for the use of Lorazepam (a medication used to treat anxiety). 2. Resident 3 was not provided a psychoactive medication consent form for the use of Lorazepam, divalproex (a medication used to treat bipolar disorder), and Quetiapine (a medication used to treat bipolar disorder). These deficient practices resulted in Resident 30 and Resident 3 not being informed of their care and making an uninformed decision regarding the use of psychoactive medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician was notified of a significant weight loss (loss of more than five [5] percent of usual body weight over six [6] to 12 months) for one of 22 sampled residents (Resident 366). This failure had the potential to result in the decline of the resident's health due to delays in interventions to prevent further weight loss.

Inspectors wroteBased on an observation, interview, and record review the facility failed to provide a safe, clean, and homelike environment for two (2) of 22 sampled residents (Resident 35 and Resident 167). This deficient practice had the potential to affect the resident's mental and psychosocial well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide adequate supervision while ambulating to prevent accidents for one of three sampled residents (Resident 24) based on the resident's care plans. This deficient practice has resulted to Resident 24 had an assisted fall (suddenly go down onto the ground or towards the ground unintentionally or accidentally) incident on 10/23/2023 which may lead to serious injury to the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 22 Residents (Resident 366) maintained ideal body weight by failing to inform the doctor of resident's change of condition resulting in significant weight loss (loss of more than 5 percent of usual body weight over 6 to 12 months). This failure has the potential to result in serious injury, harm, impairment, or death to the resident.

Inspectors wroteBased on interview and record review, the facility failed to ensure the attending physician reviewed and signed the POLST (Physician Orders for Life-Sustaining Treatment - medical order form that informs medical staff what to do during a medical emergency and Resident is unable to speak for themselves) for one of one resident (Resident 366). This failure has the potential to result in psychological and physical harm if the resident's wishes during a medical emergency were not met.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pharmaceutical services to meet the needs of residents as indicated on the facility policy by failing to: a. Ensure the Change of Shift Narcotics (drug that produces analgesia [pain relief], narcosis [state of stupor or sleep], and addiction [physical dependence on the drug]) Reconciliation Records contained two Licensed Nurses' signatures for one (1) of two (2) carts. This deficient practice had the potential for harm to the resident due to an inaccurate record of narcotic medication use, and the loss of accountability, which could affect the controls against drug loss, diversion (abuse of prescription drugs), or theft. b. [...]

Inspectors wroteBased on interview, and record review, the facility failed to appropriately monitor adverse side effects for one of five sampled residents (Resident 30) who was taking Lorazepam (medication used to treat anxiety) 1 milligram (mg) and verify the order with the physician as indicated in the facility's policy and procedure. These deficient practices had the potential for Resident 30 to experience adverse side effects without adequate monitoring.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure call light (used in healthcare facilities as an alerting device for nurses or other nursing personnel to assist a resident when in need) was within reach for two out of 22 sampled residents (Resident 29 and Resident 7) as indicated in the facility's policy and procedure. These deficient practices had the potential not to meet the residents' needs and preference.

Inspectors wroteBased on interview and record review, the facility failed to provide interventions to prevent a fall (to move unintentionally or unexpectedly onto or toward the ground from a higher place) for two of two sampled residents (Resident 1 and 7) by failing to ensure the residents' bed was kept in low bed position (bed closer to the ground). These deficient practices resulted in Resident 1 suffering a fall on 9/29/23 and was transferred to the general acute care hospital (GACH). It also placed Resident 7 at risk of falling from the bed on 10/3/23.