Gladstone Sub-Acute and Rehab Center

Inspectors wroteBased on interview and record review, the facility failed to provide the necessary care and services for one of four sampled residents (Resident 1) who was high risk for developing pressure injuries (areas of damaged skin caused by staying in one position for too long which reduces blood flow to the area and cause the skin to die and develop a sore) by failing to ensure Resident 1 was turned every 2 hours on 06/11/2026 at 4:00 p.m., 6:00 p.m., and 10 p.m. This deficient practice had the potential to cause further skin breakdown and delay of wound healing for Resident 1. During a review of Resident 1's admission Record (AR). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the tracheostomy tube (TT-a curved hollow tube placed through a surgical opening in the neck into the windpipe to help a person breathe) was changed monthly for one of four sampled residents (Resident 1), This failure had the potential to result in a respiratory infection (an illness affecting the airways or lungs) to Resident 1. During a review of Resident 1's admission Record (AR). [...]

Inspectors wroteBased on interview and record review, facility's nursing staff failed to follow the facility's policies and procedure (P&P) on medication administration for one of four sampled residents (Resident 1). This deficient practice resulted in Resident 1 did not swallowing the pain medication that was administered and ineffective pain management for Resident 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled resident's (Resident 4) head of the bed (HOB) was kept between 30 to 45 degrees when Resident 4's gastrostomy tube (GT - a tube inserted into an artificial external opening in the stomach for nutritional support) feeding was running (Resident 4 received nutrition), the facility failed to turn off Resident 4's GT feeding when Resident 4's HOB was lowered to a flat position. This deficient practice had the potential to result in aspiration pneumonia (a serious complication of GT feeding when food, liquid, or other materials enter the lungs causing an infection) and a physical decline to Resident 4.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a sanitary environment for one of one sampled resident (Resident 1) when Certified Nursing Assistant 1 provided pericare (process of gently washing a person's private parts, performed daily) to Resident 1 and used the sink instead of a wash basin in accordance with the facility's Policy and Procedure (P&P) titled Perineal Care. This deficient practice had the potential to result in the development and spread of infections (the invasion and growth of germs in the body) and the potential to result in a urinary tract infection (UTI - an infection in the bladder/urinary tract) to Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 6) with tracheostomy tube (a curved tube inserted into a surgically created opening in the neck [stoma] and into the windpipe [trachea] to provide an alternative airway for breathing) received necessary care and services when:1. The cause of Resident 6's accidental decannulation (accidental removal of tracheostomy tube from the stoma) on [DATE] was not investigated.2. A care plan (CP - summary of a person's health condition, care needs, treatments, goals of treatment, and specific interventions for each identified condition or care need) regarding Resident 6's accidental decannulation was not developed and implemented. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Residents 4) had a comfortable and homelike environment when the facility failed to repair Resident 4's malfunctioning television (TV). This failure resulted in Residents 4 feeling frustrated and had the potential to negatively affect Resident 4's health and wellbeing.

Inspectors wroteBased on interview and record review, the facility failed to provide the notices of discharge to the ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities) in a timely manner for three of three sampled residents (Residents 1, 2, and 3) These deficient practices increased the risks of unsafe discharge and violation of resident's rights.

Inspectors wroteBased on observation, interview, and record review, the facility (SNF 1) failed to ensure one of three sampled residents (Resident 1) was readmitted to the first available bed, after Resident 1 was transferred to General Acute Care Hospital 2 (GACH 2) on [DATE], in accordance with the facility's Policy and Procedure (P&P) titled Readmission. Resident 1 was admitted /transferred from GACH 2 to GACH 1 on [DATE]. The facility failed to readmit Resident 1 from GACH 1 for seven days from [DATE] through [DATE]. This violation resulted in Resident 1 remaining in GACH 1, delayed Resident 1's return to SNF 1 and had the potential to negatively impact Resident 1's care and services.

Inspectors wroteBased on interviews and record reviews, the facility failed to provide activities of daily living (ADLs) related to hygiene and bathing in accordance with residents' needs and preferences to 4 out of 5 sampled residents. These deficient practices resulted in residents not receiving showers as preferred, substitution of bed baths for showers, delays in morning care routines, late arrival to activities, and negative impact on residents' dignity and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure adequate respiratory supply in the facility for 14 of 14 sampled residents (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8, Resident 9, Resident 10, Resident 11, Resident 12, Resident 13, and Resident 14) who had a tracheostomy tube (a tube inserted in a surgically created hole in the windpipe to provide an alternative airway for breathing) and on a mechanical ventilator (a form of life support that helps a person breathe (ventilate) when they can't breathe on their own) in accordance with the facility's policy and procedure (P&P) titled, Heat and Moisture Exchange (HME-a device that helps maintain the temperature and humidity of exhaled air, preventing it from becoming too dry and irritating to the airways) when there were 8 HMEs left in the facility for 14 residents on [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure three of three resident's (Resident 57, 85, and 60) advanced directives were obtained according to the facility's policy and procedure (P&P) titled, Advance Directives, dated 4/30/2021.a. Resident 57's advanced directive was not found in the Resident's medical record.b. and c. Resident 85 and Resident 60, the facility failed to provide written information about Advance Directives (AD, legal document which specifies the health-relation actions in accordance with the resident's wishes, that is obtained when the resident is able to make decisions for oneself). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement individualized care plan interventions for three (3) of 3 sampled residents (Resident 8, 37, and 90). The facility failed to:A. Ensure padded landing mats were placed at the bedside for Resident 37, who was identified as a high fall risk. B. Implement fall precautions for Resident 8 in accordance with physician orders and the resident's care plan. C. Develop a care plan for Resident 90's scratching and skin-picking behavior. As a result, the facility failed to ensure that residents received care and services consistent with their identified needs and risks, which increased the potential for avoidable injuries, unmet psychosocial needs for Residents 8, 37, and 90.

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet professional standards of care for one of three sampled residents (Resident 10) observed during medication administration by:1. Pushing medications through a gastrostomy tube (g-tube: a feeding tube that's surgically placed into the stomach) with a g-tube syringe (a medical device used for feeding and medication delivery via g-tube) instead of administering the medications by gravity.2. Failing to administer Omeprazole per manufacturer's specifications through a g-tube.3. Failing to flush five milliliters (mL- a unit of liquid measurement) of water between medications administered through a g-tube.4. Failing to administer Pro-Stat (a protein supplement) per manufacturer's specifications through a g-tube to dilute the medication with water prior to administration. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure three of three sampled residents (Residents 253, 2, and 90) received treatment and care in accordance with professional standards of practice and the facility's policies and procedures (P&P) by failing to ensure:A. Resident 253's peripheral intravenous (IV - into or within a vein) Heplock (Heparin Lock [H/L] - a medical needle or tube catheter device placed in a vein to administer medication, fluid or nutrients directly into the bloodstream) was discontinued. B. Resident 90 received treatment for a self-inflicted scratch on the nose. C. Resident 2 was evaluated for self-administration of medications. On 6/23/2025, an unprescribed and unlabeled tube of hydrocortisone 1% cream was observed on Resident 2's bedside table. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to,A. implement a care-planned intervention to provide a padded landing mat at bedside for one of three sampled residents (Resident 37), who was identified as a high fall risk. B. Remove an oxygen condenser (a medical device that concentrates oxygen from room air for use in oxygen therapy), from one of three sampled resident's (Resident 87) room. This failure had the potential to result in falls and injuries such as fractures or head trauma for Resident 37 and the potential to result in Resident 87 receiving additional oxygen and leading to hyperoxemia (condition characterized by abnormally high levels of oxygen in the blood). Cross Reference F656Findings: A. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the oxygen humidifier was labeled for two of two sampled residents (Resident 11 and 85). This failure had the potential to result in infection and complications associated with oxygen therapy to Resident 11 and 85.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure its medication error rate was less than five percent (%, unit of measurement). The facility had 12 medication errors out of 27 opportunities which resulted in an overall medication error rate of 44.44%, affecting three of three residents (Residents 40, 51, and 10) observed during medication administration (pass). [...]

Inspectors wroteBased on interview and record review, the facility failed to provide an arbitration agreement that provided for a selection of a neutral arbitrator and a venue with both parties agreed upon for three of three sampled residents (Resident 28, 48, and 54.)This deficient practice had the potential to infringe on residents' rights.

Inspectors wroteBased on interview and record review, the facility failed to ensure the facility/QAA (Quality Assessment and Assurance) committee measured the success of actions implemented and tracked performance to ensure improvements were realized and sustained. This deficient practice could potentially result in the facility to miss opportunities to identify and address weaknesses in resident care processes, leading to a higher chance of medical errors, resident harm, and negative outcomes and hinder the improvement of resident safety measures, leaving residents vulnerable to preventable risks.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care in a manner that maintained the dignity of one (1) of three (3) residents (Resident 15) when Resident 15 did not have a privacy bag over Resident 15's urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) bag. This failure violated Resident 15's right to receive care in a manner that maintained dignity and privacy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light (a device used by a resident to signal the need for assistance) was within reach for one of one sampled resident (Resident 74), in accordance with Resident 74's multiple care plans (CP). This failure had the potential to result in Resident 74 not having Resident 74's needs met in a timely manner and/or injury to Resident 74 if Resident 74 was unable to alert staff during an emergency.

Inspectors wroteBased on interview and record review, the facility failed to inform the physician of a change of condition in one of one sampled resident (Resident 90) when Resident 90 removed his tracheostomy (self-decannulated (the removal of a tracheostomy tube [a curved plastic tube inserted into a surgically created opening in the neck to help with breathing] from a patient's airway) on 5/14/2025 and 5/28/2025. This deficiency had the potential to result in physical trauma to Resident 90's airway and infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident's (Resident 35) overbed light was in working condition in accordance with Resident 35's care plans (CP). This deficient practice could potentially make it difficult for Resident 35 to navigate Resident 35's surroundings, potentially increasing the risk of falls or result in accidents. Additionally, this deficient practice could also hinder the staff's ability to observe and monitor Resident 35 effectively, potentially leading to missed signs of distress or complications.

Inspectors wroteBased on interview and record review, the facility failed to adequately monitor one of one sample resident (Resident 91) psychotropic (drug or substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings and behavior) medications by failing to indicate specific anxious behavior and monitor side effects of lorazepam (medication used to treat anxiety.)This failure had the potential to result in Resident 91 receiving unnecessary medication and experiencing adverse (unwanted) effects from lorazepam.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one (1) of two (2) sampled residents (Resident 41) had a completed and accessible 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) ) Level II evaluation available in the medical record, as required for individuals with newly evident or possible serious mental disorder, intellectual disability (ID), developmental disability (DD), or related conditions (RC). This failure resulted in Resident 41's specialized behavioral health and support needs not being clearly identified to staff, potentially impacting care planning and delivery of services.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure and provide appropriate treatment and sufficient services for one of four sampled residents (Resident 38) who had a clinically-justified indwelling catheter (a medical device that drains urine from your bladder into a bag outside your body) by failing to monitor Resident 38's supra-pubic catheter (a type of indwelling catheter) closely for changes in condition, recognizing, reporting and addressing such changes. This deficient practice could potentially result in Resident 38 to develop a recurrence of a urinary tract infection (UTI - an infection in the bladder/urinary tract) leading to more serious complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to label and date a tube feed water flush bag for one of one sampled resident (Resident 83) who was receiving enteral feeding (nutrition taken through the mouth or through a tube that goes directly to the stomach or small intestine). This failure could potentially lead to infections (the invasion and growth of germs in the body) and other complications in Resident 83's digestive system (a group of organs that work together to digest and absorb nutrients from the food you eat).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and distributed under sanitary conditions for all the residents in the facility by failing to:A. Ensure opened food containers in one (1) of two (2) refrigerators were labeled with a 'best by' or 'use by' date. B. Ensure 1 of four (4) chemical sanitizing buckets maintained the regulated concentration range for 24 of 25 days in June 2025. These deficient practices placed all the residents in the facility at risk for foodborne illnesses (caused by the ingestion of contaminated food or beverages).

Inspectors wroteBased on interview and record review, the facility failed to document one of one sampled residents (Resident 91) diagnosis of anxiety in Resident 91's admission Record (AR). This failure had the potential to result in Resident 91 not receiving medication and services related to anxiety.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain and implement its Infection (the invasion and growth of germs in the body) Control Program by failing to ensure:a. A personal toiletry was labeled and not stored inside the [NAME] and [NAME] restroom (a restroom that has two doors and is sandwiched between two bedrooms and is accessible by both bedrooms) for two of four sampled residents (Resident 47 and Resident 51.)b. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow the public health nurse (PHN) guidance intended to reduce the transmission of Covid-19 (infectious disease caused by the SARS-CoV-2 virus) in the facility during a Covid-19 outbreak by failing to: a. Ensure the proper signage was displayed in front of the rooms with residents presumed to be infected with Covid-19 for 4 of 4 sampled residents (Resident's 8,7,5 and 4). b. Test newly admitted and re-admitted residents to the facility for Covid-19 on day 0, 3, and 5 per the PHN guidance for 4 of 4 sampled residents (Residents 8, 7, 9, 5 and 4) c. Ensure one of eleven facility staff (LVN 2) ensured their Covid-19 rapid antigen test (RAT -quick test done to find out if one has Covid-19) was negative prior to entering patient care areas at the beginning of the 3-11PM shift on 6/3/2025. [...]

Inspectors wroteBased on interview and record review, the facility failed to adequately monitor one of two sampled residents (Resident 1) psychotropic (drug or substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) medication by failing to monitor Resident 1's anxious behavior and side effects of Ativan (brand name psychotropic drug used for anxiety) from 5/9/2025 to 5/23/2025. This deficient practice had the potential for Resident 1 to experience adverse (unwanted) effects from Ativan.

Inspectors wroteBased on interview and record review, the facility failed to document one of one sampled resident's (Resident 1) diagnosis of mood disorder in Resident 1's admission Record (AR). This failure had the potential to result in Resident 1 to not receive medication and services related to a mood disorder.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement Care Plan (CP, a form where one can summarize a person's health conditions, specific care need, and current treatments) interventions for two of 12 sampled residents (Residents 1 and 5), in accordance with the facility's policy and procedure (P&P) titled, Care Planning, by failing to: 1. Obtain an order for Resident 1's left heel splint (medical device used to support and protect an injured part of the body) and failing to assess pedal pulses every shift as indicated in the CP. 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care and services for one of 12 sampled residents (Resident 12), to prevent the develop of new pressure injury (PI- localized injury to the skin and/or underlying tissue usually over bone prominence as result of pressure or pressure in combination with shear [mechanical force that cause the skin to break off] and/or friction [movement of one surface of the skin against others]) by failing to: 1. Ensure licensed nurses (LN) and certified nursing assistants (CNA) changed Resident 12's position in bed every two hours as indicated in the facility's policy and procedure (P&P) titled, Positioning and Body Alignment. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to accurately document restorative nursing services (RNS- specialized nursing interventions provided by a restorative nursing aide [RNA] focused on helping to maintain or regain functional abilities to achieve the highest level of well-being, often after rehabilitation or to prevent decline) on the Restorative Nursing Record (RNR) for four out of 12 sampled residents (Residents 5, 7, 8, and 10), in accordance with to the facility's policy and procedure (P&P) titled, Documentation- Nursing Manual- Restorative Nursing Program, by failing to: 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to accurately document restorative nursing services (RNS- specialized nursing interventions provided by a restorative nursing aide [RNA] focused on helping to maintain or regain functional abilities to achieve the highest level of well-being, often after rehabilitation or to prevent decline) on the Restorative Nursing Record (RNR) for four out of 12 sampled residents (Residents 5, 7, 8, and 10), in accordance with the facility's policy and procedure (P&P) titled, Documentation- Nursing Manual- Restorative Nursing Program, by failing to: 1. [...]

Inspectors wroteBased on observations, interview, and record review, the facility failed to ensure all staff had updated N95 respirator (N95 mask- filtering face mask designed to protect the wearer from breathing in airborne [transmitted by air] particles such as viruses) fit test (verifies that a respirator creates a tight seal with the wearer's face, ensuring proper protection from airborne particles), according to the Centers for Disease Control (CDC) and the National Institute of Occupational Safety and Health (NIOSH). As a result of this failure, 101 staff had expired fit tests, 37 of which were working at the facility on [DATE] between 7 am and 3 pm. This failure had the potential to result in staff spreading infectious agents throughout the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure certified nursing assistant (CNA) 3 worked within their scope of practice (the legal and ethical boundaries within which a health care professional is permitted to practice) by not handing one of 12 sampled residents (Resident 12) gastrostomy tube (G-tube- tube inserted through the belly that brings nutrition directly to the stomach) (medical device used to deliver liquid nutrition, medications, or special formulas to residents who cannot eat by mouth). This failure had the potential to place Resident 12 at risk for G-tube dislodgement (accidental removal, a serious issue that can lead to several complications) and pump malfunction.

Inspectors wroteBased on interview and record review, the facility failed to designate an individual as the infection preventionist nurse (IPN- oversees the facility Infection Prevention and Control program) on 5/21/2025 and while the facility was having a COVID-19 (an infectious disease caused by the SARS-CoV-2 virus) outbreak (at least three COVID-19 positive cases in the facility within a seven-day period among residents and/or staff). This failure had the potential for the facility ' s Infection Prevention and Control program to not be implemented which could result in residents (in general), staff, and visitors contracting and spreading COVID-19.

Inspectors wroteBased on observation, interview, and record, review facility failed to follow its policy and procedure (P&P) titled, Physician Orders, and Care Planning (CP), for one of five sampled residents (Resident 5) by failing to: 1. Ensure licensed nurses (LN- registered nurses [RNs] and licensed vocational nurses [LVNs] followed Resident 5's physician order, dated 11/14/2024 for Resident 5 to wear Thrombo-Embolic Deterrent (TED) hose stockings (specially designed knee-high, thigh-high or waist-high stockings that help prevent blood clots and swelling in the legs). 2. Ensure licensed nurses implemented Resident 5's untitled CP, dated 6/12/2024. 3. Ensure Licensed Nurses were monitoring and documenting Resident 5 wearing the TED hose. As a result of these failures, facility staff were not applying TED hose to Resident 5's left and right legs. [...]

Inspectors wroteBased on observation, interview, and record review facility failed to follow its policy and procedure (P&P) titled, Care Planning, by failing to: Ensure licensed nurses (LN- registered nurses [RNs] and licensed vocational nurses [LVNs]) implemented Resident 5's untitled care plan (CP) for the potential for fluid volume overload (occurs when there is an excessive accumulation of fluid in the body) related to left and right lower extremities (limb) pitting edema, plus four [+ 4, severity of edema, the edema grading scale measures how quickly the dimple goes back to normal (rebound) after a pitting test. The scale includes grade +4: 8-millimeter (mm) of depression, rebounding in 2-3 minutes], and left upper extremity pitting edema plus one [+1, the edema grading scale measures how quickly the dimple goes back to normal (rebound) after a pitting test. The scale includes grade 1: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide documentation of resident status and care given by nursing staff for one of five sampled residents (Resident 5), according to the facility's policy and procedure (P&P) titled, Documentation- Nursing, by failing to: Ensure the licensed nurses (LN- registered nurses [RNs] and licensed vocational nurses [LVNs]) documented when Resident 5 wearing the Thrombo-Embolic Deterrent (TED) hose stockings (specially designed knee-high, thigh-high or waist-high stockings that help prevent blood clots and swelling in the legs) when Resident 5 had a physician order, dated 11/14/2024 for Resident 5 to wear TED hose to bilateral (both) lower extremities for leg swelling/edema. As a result of this failure, facility staff were not applying TED hose to Resident 5's left and right legs. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure physician's orders were timed and carried out or noted timely for three of nine sampled residents (Resident 6, Resident 8, and Resident 9) when: 1. An Optometrist (eye care specialist who diagnose and treat injuries and health conditions that affect the eyes and vision) ordered to administer antibiotic (medication used to prevent and treat infections) eye ointment to Resident 6 on 3/31/25, the order was carried out on 4/3/25, but the antibiotic eye ointment was not administered to Resident 6 until 4/4/25. This failure resulted in delay in providing medication to Resident 6 and had the potential to delay Resident 6's relief from eye discomfort due to blepharitis (inflammation of the eyelids). 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent the spread of infections for 4 of 6 sampled residents (Resident 1, Resident 2, Resident 3, and Resident 4) when failing to ensure hand hygiene was performed appropriately. This failure had the potential to increase the risk of healthcare-associated infections, including the transmission of multidrug-resistant organisms for Resident 1, Resident 2, Resident 3, and Resident 4.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Sub-Acute unit medication room refrigerator was free from unauthorized and unlabeled items preventing a safe and sanitary environment. This deficient practice had the potential to cause cross-contamination that could lead to the spread of infections to residents of the facility.

Inspectors wroteBased on interview and record review, the facility failed to notify the physician of one of five sampled residents (Resident 1) regarding Resident 1's missed hemodialysis (HD, a process of filtering the blood of a person whose kidneys are not working normally) on 1/15/2025 and 1/16/2025. This failure had the potential for Resident 1 to not receive HD treatment and to experience a decline in Resident 1's health and well-being.

Inspectors wroteBased on interview and record review, the facility failed to monitor one of five sampled resident's (Resident 1) condition following an acute change of condition (ACOC- a sudden, clinically important deviation from a resident's baseline in physical, cognitive [relating to or involving the processes of thinking and reasoning], behavioral, or functional domains) on 1/16/2025. This failure had the potential for Resident 1 to not receive the necessary care and treatment which could result in a decline of Resident 1's health.

Inspectors wroteBased on interview and record review, the facility failed to ensure a chest X-ray (an imaging test that uses X-rays to create detailed pictures of the organs) was completed for one of five sampled Residents (Resident 1) as ordered by Resident 1's physician on 1/16/2025. This failure had the potential for Resident 1 to not receive the necessary services to meet the medical needs of Resident 1.

Inspectors wroteBased on interview and record, the facility failed to accurately assess one of three sampled residents (Resident 3) health status according to the facility's policy and procedure (P&P) titled, Resident Assessment Instrument [RAI] Process, by failing to ensure Resident 3's Minimum Data Sets (MDS- a resident assessment tool) dated 2/28/2022, 7/7/2023, and 10/7/2024, did not include a diagnosis of seizure (sudden, controlled electrical disturbance in the brain that can cause temporary changes in behavior, movement, consciousness, or sensation) disorder or epilepsy (disorder in which nerves in the brain are disrupted, causing seizures). This deficient practice placed Resident 3 at risk for receiving unnecessary medication and services from an incorrect diagnosis.

Inspectors wroteBased on interview and record review, the facility failed to develop a resident-centered comprehensive care plan (CP-a document that describes a resident's needs and how the nursing home will meet them) for one of three Residents (Resident 1) as indicated in the facility's policy and procedure titled, Care Planning. This failure resulted in Resident 1 was not provided with a timely care plan for the administration Trazodone (antidepressant medication).

Inspectors wroteBased on interview and record review, the facility failed to ensure complete and accurate documentation for one of three sampled residents (Resident 1). This failure had the potential for Resident 1 to not get the appropriate care and treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a comfortable temperature level in the room of one of nine sampled residents (Resident 1). The room temperature was 87 degrees Fahrenheit (F-Unit of temperature measurement). This failure resulted in Resident 1 feeling uncomfortable and hot and had the potential to result in hyperthermia (dangerously overheated body, usually in response to prolonged, hot, humid weather).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a sanitary (clean) environment to prevent the spread of infections for six of eight sampled residents (Residents 2, 3, 5, 6, 7, and 8) by failing to: 1. Ensure Hospitality Aide 1 (HA 1 - staff who accompanies residents to appointments and assists in answering call lights and monitoring residents) performed hand hygiene (cleaning hands by either washing hands with soap and water, or by using an alcohol-based hand sanitizer) according to the facility's policy and procedure (P&P) titled, Hand Hygiene, when HA 1 went inside Resident 3's, Resident 7's, and Resident 8's room. 2. Ensure Certified Nursing Assistant 5 (CNA 5) removed CNA 5's soiled gloves and performed hand hygiene in between residents and before touching clean linens. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide care and services to prevent a fall (move downward, typically rapidly and freely without control, from a higher to a lower level) for one of two sampled residents, (Resident 1) who was assessed as needing contact guard assistance (CGA, place one or two hands on the resident's body to help with balance) with ambulation, by failing to: 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a care plan (CP) that addressed individual assessed needs for one of two sampled resident (Resident 1) by failing to include Physical Therapy 1's (PT 1) assessments and recommendation and Resident 1's behavior of getting up (from wheelchair or from Resident 1's bed) without calling for assistance from staff as indicated in the facility's Policy and Procedure (P&P) titled Care Planning. This deficient practice had the potential to result in unmet individualized needs, inconsistent provision of treatment and services for Resident 1, and the potential to affect Resident 1's physical and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to protect the rights of four of four sampled residents (Residents 18, 29, 36, and 49) or inform the resident's representatives (RPs), of their right to formulate an advanced directive (AD) when: a. For Resident 18, The Social Service Director (SSD) failed to provide information regarding AD to Resident 18's RP. b. For Resident 29, the SSD failed to document in Resident 29's medical record that the SSD discussed with Resident 29's RP about the right to formulate an AD for Resident 29. c. For Resident 36, the SSD failed to provide information regarding the right to formulate an AD to Resident 36's RP. d. Resident 49's AD was not kept in Resident 49's Medical Chart (medical record). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician was notified of a change in condition for two of two sampled residents (Resident 19 and 40) when: a. Resident 19 was noted to have mild work of breathing (working harder to breathe, the amount of energy required to overcome the elastic and resistive elements of the respiratory system and move gas into and out of the lungs during spontaneous breathing) on 2/24/2024 and Resident 19 was hospitalized the next day on 2/25/2024 for shortness of breath. b. For Resident 40, the facility failed to inform Resident 40's physician regarding Resident 40's significant weight loss of 12.06% within six months. These failures had the potential to result in physical declines for Residents 19 and Resident 40.

Inspectors wroteBased on interviews and record review, the facility failed to ensure four of five sampled residents (Residents 90, 49, 84, & 69) did not receive unnecessary psychotropic medications (drugs used to treat mental health disorders that alter neurotransmitters [transmit messages from neurons to muscles] in the brain) by failing to: a. Limit Resident 90's as needed (PRN) Alprazolam (a psychotropic medication used for the treatment of anxiety [a feeling of fear, dread, and uneasiness]) order to 14 days as indicated the facility's policy and procedure (P&P) titled, Psychotherapeutic Drug Management. b. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food preferences, such as nuts and foods that did not contain oil, were served and followed for one of one sampled resident (Resident 40) as indicated in the facility's policy and procedures (P&P). This failure resulted in further weight loss to Resident 40 and had the potential to result in a physical decline to Resident 40.

Inspectors wroteBased on observation, interview, and record review, the facility failed to remove one unopened expired milk carton and 22 apples, received 4/18/2024, from one of one walk-in refrigerator (Refrigerator 1). This failure had the potential to result in food poisoning (illness caused by food contaminated with bacteria [living organism that can cause an infection]) from serving spoiled foods to the residents who were able to consume the food items.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the right to a dignified existence for one of one sampled resident (Resident 95) by failing to accommodate Resident 95's needs. On 6/10/2024, Resident 95 requested incontinence (having no voluntary control over urination or defecation [discharge of feces from the body]) care and Certified Nursing Assistant (CNA) 1 did not attend to Resident 95's needs timely due to Resident 95's roommate having a meal. This deficient practice resulted with Resident 95 feeling confused and uninformed and had the potential to result in Resident 95 feeling unsupported with Resident 95's care and had the potential to affect Resident 95's psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 40) had a resident-centered comprehensive care plan (CP, provides direction on the type of nursing care an individual needs that include goals of treatment, specific nursing interventions [actions, treatments, procedures, or activities designed to meet an objective and an evaluation plan]) developed to address Resident 40's progressive weight loss in accordance with the facility's policy and procedure (P&P), titled, Care Planning. This deficient practice had the potential to result in Resident 40 not to receive the necessary care and services in accordance with Resident 40's specific needs and the potential for continued weight loss and a physical decline to Resident 40.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Residents 17) was provided proper interventions for edema (swelling caused by too much fluid trapped in the body's tissues) when the facility failed to elevate Resident 17's upper extremities (shoulders, elbows, wrists, or hands) to decrease edema as indicated in Resident 17's care plan (CP), titled, [Resident 17] is at Risk for Impaired Skin Integrity as evidenced by edema . This failure had the potential to result in worsening or unresolved edema for Resident 17 and placed Resident 17 at an increased risk of developing blood clots and/or skin injuries, additionally, the failure had the potential to result in a physical decline to Resident 17.

Inspectors wroteBased on interview and record review, the licensed nursing staff failed to offer the pneumococcal vaccine (vaccination against pneumonia [inflammation of the lungs]) to five of ten sampled residents (Residents 5, 6, 7, 8, and 9). This failure placed Residents 5, 6, 7, 8, and 9 at high risk of acquiring and transmitting pneumonia to other residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of six sampled residents (Resident 3) remained free from physical restraints (any manual method, physical or mechanical device, equipment, or material that is attached or adjacent to a resident ' s body, cannot be easily removed by a resident, and restricts the resident ' s freedom of movement or access to their body) for use of convenience (the result of any action that has the effect of altering a resident ' s behavior and requires a lesser amount of care or effort, and is not in a resident ' s best interest) by failing to: 1. Ensure Certified Nurse Assistant (CNA) 1 did not restrain Resident 3 during patient care (prevention, treatment, and management if illness and preservation of physical and mental well-being through services offered by health professionals) witnessed by CNA 3 (unable to recall specific date). [...]

Inspectors wroteBased on interview and record review the facility failed to implement the facility's policy and procedures (PP) titled, Abuse Prevention and Prohibition Program, by failing to: 1. Ensure Licensed Vocational Nurse (LVN) 2 reported Resident 3 restrained with a bed sheet by CNA 1 when providing patient care (prevention, treatment, and management of illness and preservation of physical and mental well-being through services offered by a health professionals), to the administrator (ADM/abuse coordinator, designated staff within a skilled nursing facility [SNF] responsible for coordinating efforts to prevent resident abuse) (unable to recall specific date). 2. Ensure CNA 4 reported Resident 3 restrained with a bed sheet by CNA 1 to the ADM (unable to recall specific date). As a result of these failures, Resident 3 was restrained by CNA 1 during patient care over a period of 6 months. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure one of two residents sampled residents (resident 1) had a person-centered comprehensive care plan developed and implemented to address the resident ' s medical, physical, mental and psychosocial needs. This failure had the potential to negatively impact Resident 1 ' s quality of life as well as the quality of care and services received. Cross Reference:

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two residents (Resident 1) received a psychological evaluation (psych eval - a method to assess an individual's behavior, personality, cognitive abilities, and several other domains by a mental health professional, including a psychologist, psychiatrists, or family doctor) service per Resident 1 ' s physician order. This failure had the potential to negatively affect Resident 1 ' s psychosocial well-being. Cross Reference:

Inspectors wroteBased on interview and record review, the facility failed to expediate the readmission of Resident 1 by failing to readmit Resident 1 on [DATE] when the facility had a room available for Resident 1. This failure had the potential for Resident 1 to suffer psychosocial (mental, emotional, social, and spiritual effects) harm and deny Resident 1's rights.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for six of 26 sampled residents (Residents 71, 13, 31, 46, 31, and 21) by failing to: a. For Resident 71, the facility failed to develop a care plan to reflect the resident's vegetarian (a person who does not eat meat) preferences. b. For Resident 13, the facility failed to implement a care plan to address edema (swelling caused by excess fluid). c. For Resident 31, the facility failed to implement a comprehensive person-center care plan when the resident was not wearing the tab alarm (a pull-string that attaches magnetically to the alarm with garment clip to the resident). d. For Resident 46, the facility failed to have a care plan pertaining to self-administering medications. e. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide treatment and services to maintain or improve the ability to perform activities of daily living for two of 42 sampled residents (Residents 70 and 288). a. For Resident 70, the facility did not perform sit-to-stand exercises per physician's order and did not report Resident 70's improvement in the ability to perform sit-to-stand exercises to the therapy department. This deficient practice prevented Resident 70 from receiving intervention in preparation for walking with a prosthetic (device designed to replace a missing part of the body) leg. b. For Resident 288, the facility did not assist the resident out-of-bed daily and did not dress Resident 288 in appropriate clothing. Resident 288, who was used to sitting up in a wheelchair daily, yelled multiple times per day in the bedroom without redirection. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of three sampled residents (Residents 57, 136 and 13) receive quality of care. a. For Resident 57, the facility could not provide documented evidence that various medications were restarted upon the resident's readmission on [DATE]. b. For Resident 136, there was no documented evidence that the lidoderm (medication for pain) patch was removed at 11 pm and reapplied at 9 am, the next day. c. For Resident 13, the facility failed to identify the presence of edema on bilateral lower extremities. These deficient practices had the potential to result in Residents 57, 136 and 13 not receiving the care necessary to thrive at their highest practical level.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure correct weights were programmed on mattress settings for three of four sampled residents (Residentz 137, 136, and 53). These deficient practices had the potential to result in reoccurrence of pressure sores for Resident 137 and delayed wound healing and worsening of pressure sores for Residents 136 and 53.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residential environment remained free of accident hazards for three of three sampled residents (Residents 31, 72, and 288). a. For Resident 31, the facility failed to ensure the environment remained free of accident hazards when the resident was not wearing the tab alarm as ordered. b. For Resident 72, the facility failed to ensure the right floor mat was in place and that a chair was not positioned next to the resident's bed instead of the floor mat. This could result in injuries to the resident if he fell out of bed. c. For Resident 288, the facility performed an unsafe transfer from the bed to the wheelchair. These deficient practices had the potential to result in injury and harm to Residents 31, 72, and 288 in the event of a fall.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate pain management for two of three sampled residents (Resident 32 and Resident 48). As a result, Resident 32 and Resident 48 experienced severe pain, placing them at risk for decreased mobility, isolation, and possible depression.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure it was free of medication error rate of five percent or greater, as evidence by the identification of two medication errors out of 30 opportunities, to yield a facility error rate of ten percent. 1. For Resident 50, Lisinopril (a blood pressure medication) was administered to the resident prior to checking her blood pressure. Resident 50's physician's order indicated to hold if her systolic blood pressure was below 110. 2. For Resident 17, two of two medications were observed crushed and administered together. These deficient practices increased the risk for Resident 50 and Resident 17 to experience adverse effects (unwanted, uncomfortable, or dangerous effects that a medication may have) related to their medication therapy.

Inspectors wroteBased on observation and interview, the facility failed to provide safe and secure storage of medication for four of 26 sampled residents (Residents 46, 136, 57 and 286). a. Resident 46 had four plastic tubes of Ipratropium-Albuterol Solution (used to prevent and treat wheezing and shortness of breath), and two plastic tubes of DuoNeb Solution (an inhaled steroid used to can treat asthma) were observed unlabeled and unattended on the resident's bedside table. b. Resident 136 had an unlabeled medication patch on the left lower back. c. Resident 57 had one unlabeled sore throat Lozenges in her room. d. Resident 286's unlabeled medication (albuterol inhaler) was observed at the resident's bedside. These deficient practices had the potential for the residents to receive medications not intended for them.

Inspectors wroteBased on observation, interview, and record review, the facility failed to compare meal trays in three carts (carts 1, 2, and 3) with the physician's orders prior to serving meals to the residents. This deficient practice had the potential for the residents to receive meals inconsistent with physician's orders for therapeutic diets (meal plan that controls the intake of certain foods or nutrients).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate snacks for residents at night after the kitchen was closed. This deficient practice had the potential for residents to feel hungry at nighttime.

Inspectors wroteBased on observation and interview, the facility failed to ensure no expired foods were stored in one of two refrigerators (Refrigerator 1) and in the walking freezer. This deficient practice could place the residents at risk for ingesting contaminated food and could result in illness to the residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure accuracy of medical records Residents 75 and 136, and failed to have accurate documentation for Restorative Nursing (RNA, nursing aide program that helps residents to maintain their function and joint mobility), on the flowsheets (record of RNA sessions). 1. The RNA flowsheets for 44 residents were blank from 12/1/2021 to 12/6/2021. 2. The RNA flowsheet for Resident 21's documentation did not match the RNA performing the range of motion or RNA sessions were performed on a different day. These deficient practices resulted in incomplete and inaccurate documentation of RNA sessions and had the potential to result in wrong level of oxygen administration for Resident 75 and uncontrolled pain for Resident 136.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow infection control practices as indicated in the facility's policy and procedure for five of 26 sampled residents (Residents 63, 30, 75, 53, and 136) out of 26 by failing to: a. Ensure to label Resident 63's intravenous help-lock (IV, a catheter inserted into a vein to administer fluids or medications) to indicate the date of insertion or dressing change. b. Ensure to change Resident 30's peripheral intravenous central catheter (PICC, a flexible tube inserted to a vein to administer fluids or medications) and the resident's suction machine (used to remove liquids) filter. c. Ensure to label Resident 75's tracheostomy (is a surgically created hole in the windpipe that provides an alternative airway for breathing) tubing. d. Ensure to label Resident 53's intravenous fluid tubbing and intravenous site dressing. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a dignified environment for one of two sampled residents (Resident 57) as indicated on the facility policy. Resident 57 was not able to sleep at night due to loud noises at the facility. This deficient practice resulted with Resident 57 feeling horrible.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of 26 sampled residents (Resident 46), was assessed and had an order to self-administer medications. Resident 46 was observed with four plastic tubes of Ipratropium-Albuterol Solution (used to prevent and treat wheezing and shortness of breath) and two plastic tubes of DuoNeb Solution (an inhaled steroid used to can treat asthma) at the bedside. This deficient practice had the potential for Resident 46 not to have the right to self-administer medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure the right to formulate advanced directives was exercised for four of 26 sampled residents (Residents 136, 10, 66, and 49). This deficient practice had the potential to result with inability to make medical decisions for residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the assessment accurately reflected the status of two of 26 sampled residents (Residents 41 and 71). a. For Resident 71, the facility dietary staff failed to accurately assess the resident's food preferences and indicate the resident was a vegetarian (a person who does not eat meat). b. For Resident 41, the Minimum Data Set Nurse failed to accurately assess the resident as being incontinent of urine (urinary incontinence, leaks urine by accident). [...]

Inspectors wroteBased on interview and record review, the facility failed to create an admission baseline care plans for one of one sampled resident (Resident 87). This deficient practice had the potential to result with a delay of individualized care for Resident 87.

Inspectors wroteBased on observation, interview, and record review, the facility failed to revise the care plan for one of 26 sampled residents (Resident 48), as indicated on the facility's policy. Resident 48's care plan for pain was not revised to include pain in his left great toe (big toe). This deficient practice had the potential for Resident 48 to not receive specific interventions to address his pain, which could result in harm and injury and could lead to a decline in functional well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide ongoing sensory stimulating activities program designed to meet the interest for one of one sampled resident (Resident 236). Resident 236 who preferred to stay in his room, listen to music or watch television. This deficient practice had the potential to decreased Resident 236's quality of life; cause boredom, loneliness, and frustrations resulting in distress and agitation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide one of 42 sampled residents (Resident 21) with appropriate services for active assistive range of motion (AAROM, use of muscles surrounding the joint to perform the exercise but requires some help from the therapist or equipment) to both arms and legs. This deficient practice had the potential for Resident 21 to experience a decline in ROM in both legs and mobility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 26 sampled residents (Resident 41), who is incontinent of bladder (urinary incontinence, leaks urine by accident), received appropriate treatment and services to prevent urinary tract infections (UTI, an infection in any part of your urinary system, which includes your kidneys, ureters, bladder and urethra) and to restore continence (the ability to control movements of the bladder) to the extent possible when they failed to trial her on a toileting program (scheduled regular bathroom trips to facilitate bladder training and to avoid bladder accidents). This deficient practice had the potential to negatively impact Resident 41's psychosocial well-being and increase the potential for the resident to develop a UTI or to experience skin breakdown.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that nutritional care and services were provided for one of two sampled residents (Resident 21). Resident 21 was observed with gastrostomy tube (G-tube, a tube inserted through the abdomen that delivers nutrition directly to the stomach) feeding running. The G-tube formula label did not have the resident's name, date, time hung, and G-tube feeding rate, as indicated on the facility policy. This deficient practice had the potential for G-tube administration error.

Inspectors wroteBased on interview and record review, the facility failed to ensure the consultant pharmacist medication regimen review recommendations for one of five residents (Resident 70) with recommendation for a blood test to assess for magnesium levels in the blood. This deficient practice had the potential for Resident 70 to have low blood magnesium levels that do not increase even with the use of magnesium supplements.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of four dryers were cleaned for lint in the laundry room. This deficient practice had the potential to place residents, staff, and outpatients, at risk for fires.