Graduate Post Acute

Inspectors wroteBased on a review of facility policy, review of clinical records, review of facility documentation, and interviews with residents and staff, it was determined that the facility failed to protect one resident from verbal abuse for one of 10 residents reviewed (Resident R1).

Inspectors wroteBased on interviews with staff, review of grievances, and review of facility policy, it was determined that the facility did not ensure that prompt efforts were made to resolve residents' grievances related to missing items for 2 of 3 residents interviewed (Residents R7 and R8).

Inspectors wroteBased on closed clinical record review, and staff interview, it was determined that the facility failed to ensure that enteral feeding supplies were provided and available to be obtained at the time of discharged for one of two closed records reviewed. (Resident CL1)

Inspectors wroteBased on review of clinical records, and staff interview, it was determined that the facility failed to maintain accurate records for one of two closed records reviewed (Resident CL2).

Inspectors wroteBased on staff interviews and the review of clinical records, it was determined that the facility failed to ensure a person-centered plan of care for a resident who the facility reported as refusing to get out of bed for 1 out of 2 residents reviewed (Resident R1).

Inspectors wroteBased on review of personnel records and interviews with staff, it was determined that the facility failed to complete annual performance reviews for nurse aide staff as required for five of five nurse aide personnel files reviewed (Employees E11, E12, E13, E14 and E15).

Inspectors wroteBased on observations, review of facility policy and interviews with staff, it was determined that the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety.

Inspectors wroteBased on clinical record review and staff interviews, it was determined that the facility failed to ensure that the rationale and duration for continuing as needed (PRN) psychotropic medication orders beyond 14 days were documented by the prescribing practitioner for one of five residents reviewed. (Resident R123). [...]

Inspectors wroteBased on observation, staff interview, and clinical record review, it was determined that the facility failed to ensure that interventions related to effective communication for a resident who spoke a language other than English were implemented or one of two residents reviewed (Resident R84). Findings Include: On September 23, 2025, at 10:59 am. observation revealed Resident R84 was unable to speak English and was observed pointing toward their brief, attempting to indicate a need for assistance. There was no evidence of an interpreter line or communication board being used during the interaction. An interview with Nurse Aide, Employee E7, conducted on September 23, 2025, revealed that the resident just uses gestures, and confirmed that the interpreter line and communication board were not utilized with the resident. [...]

Inspectors wroteBased on a review of clinical records, and interviews with residents, and staff, it was determined that the facility failed to provide the necessary assistance with activities of daily living (ADLs) to maintain proper grooming for two of the two residents reviewed (Residents R6, R94)

Inspectors wroteBased on review of clinical records, facility documentation, and resident and staff interviews, it was determined that the facility failed to provide quality care related to wound care and medication administration for two of eight residents reviewed (Residents R100, R151).

Inspectors wroteBased on clinical record review and staff interviews, the facility failed to ensure that resident weights were obtained as ordered to monitor nutritional status for one of 25 residents reviewed (Resident R7)Findings Include:Record review for Resident R7 dated June 3, 2025, revealed that the physician recommended to monitor weight. Record review for Resident R7 dated July 11, 2025, revealed that the physician recommended to monitor weight and it was revealed an order was placed for monthly weights. Review of physician order for Resident R7 dated July 9, 2025, revealed an order for monthly weights on 15th of every month. Review of the resident's weight documentation showed that no weights were recorded for the months of June 2025, July 2025 and August 2025, as ordered. Review of weight for Resident R7 revealed that on May 7, 2025, the resident weighed 137.6 lbs. [...]

Inspectors wroteBased on observations, reviews of clinical records and review of facility policies and procedures, it was determined that the facility failed to provide adequate treatment, assessment and monitoring for the care and maintenance of mid line catheter line in accordance with professional standards of practice for one of one residents reviewed for intravenous catheter care. (Resident R30).

Inspectors wroteBased on the review of clinical record, staff interviews and observations, it was determined that the faciity failed to obtain physician orders to administer oxygen via nasal canula for two fo two residents reviewed for respiratory care. (Resident R158 and Resident R100)

Inspectors wroteBased on the review of clinical records and interviews with staff and resident, it was determined that the facility failed to ensure that pain management was provided consistently as ordered by the physician for one of two residents reviewed for pain management. (Resident R123)

Inspectors wroteBased on review of clinical records, staff and resident interviews, it was determined that the facility failed to provide culturally competent, trauma care in accordance with professional standards of practice, accounting for the resident's past experiences and preferences in order to eliminate and/or mitigate triggers that may cause re-traumatization of the resident for two of two residents sampled for post-traumatic stress disorder(PTSD). (Resident R4 and R104).

Inspectors wroteBased on review of clinical records and staff interviews, it was determined that the facility failed to ensure a response to the consultant pharmacist's recommendation related to the potentially unnecessary medications in a timely manner for one of five residents reviewed. (Resident R7)

Inspectors wroteBased on observations and an interview with staff it was determined that the facility did not ensure that garbage and refuse was disposed of properly.

Inspectors wroteBased on review of facility policies and documentation, clinical record review and interviews with staff, it was determined the facility failed to provide adequate supervision to one of ten residents reviewed (Resident R1), who did not have a leave of absence (LOA) order. This failure resulted in Resident R1 exiting the third floor via elevator and walking out the front entrance of the facility. Resident R1 was located two hours after the resident exited the facility approximately 1.2 miles away from the facility in a busy [NAME] area. This failure placed the resident at high risk for injury and was identified as an Immediate Jeopardy past non-compliance. (Resident R1)

Inspectors wroteBased on review of job's descriptions, review of facility documentation and interviews with staff, it was determined that the Nursing Home Administrator and Director of Nursing failed to effectively manage the facility to ensure that adequate supervisor was provided to one of 10 residents reviewed (Resident R1). This failure resulted in Resident R1 exiting the third floor via elevator and walking out the front entrance of the facility. Resident R1 was located two hours after the resident exited the facility approximately 1.2 miles away from the facility in a busy [NAME] area. This failure placed the resident at high risk for injury and was identified as an Immediate Jeopardy of past non-compliance. (Resident R1)

Inspectors wroteBased on observations, interview with staff and residents, it was determined that the facility failed to ensure an effective pest control program resulting in presence of rodents on one of four units observed (2nd floor unit)

Inspectors wroteBased on observation, staff interview, and clinical record review, it was determined that the facility failed to administered medications timely in accordance with physician orders, for one of one resident observed during medication administration. (Resident R2)

Inspectors wroteBased on observation, clinical record review, review of facility policy and staff interview, it was determined that the facility failed to provide appropriate respiratory care and services for one of seven residents reviewed (Resident R3).

Inspectors wroteBased on review of facility policy, review of clinical record, and resident interview it was determined that that the facility failed to ensure dependent residents received the necessary assistance to maintain personal hygiene for one of six residents reviewed (Resident R1). Findings Include: Review of facility policy Activities of Daily Living (ADL) revised March 2018 revealed appropriate care, and services will be provided for residents who are unable to carry out activities of daily living (ADLs) independently, with the consent of the resident and in accordance with the plan of care. Review of Resident R1's clinical record revealed the resident was admitted to the facility on [DATE], was alert and oriented x 3 (alert to person, place, and time) and able to make needs known. [...]

Inspectors wroteBased on interviews with staff and resident representatives, review of facility documentation,and clinical records, it was determined that the facility failed to inform a resident of facility policy of cannabis use/administration in the facility prior to the admission which resulted in a resident who was on cannabis for seizure disorder did not receive the prescribed medication as ordered by the physician. Findings Include: Review of facility admission documentation signed by the resident and facility representative dated 1/31/2025 revealed that viii.) Pharmacy Services. Federal law requires the Facility to contract with a licensed pharmacist and provide pharmaceutical services to meet the needs of residents. Physicians prescribe medications to residents, and pharmacists fulfill medication orders. [...]

Inspectors wroteBased on review of clinical records, and staff interviews, it was determined that the facility failed to ensure under the Transfer and Discharge Facility requirements, that the information provided to the receiving provider included necessary information, including a copy of the resident's discharge summary, to ensure a safe and effective transition of care one of five resident records reviewed. (Resident R2) Findings Include: Review of the clinical record revealed that Resident R2 was admitted to the facility on [DATE] and discharged to another facility on 12/13/2026. Resident was admitted with diagnosis of cervical stenosis and laminectomy Review of hospital discharge summary for Resident R2 dated 12/6/2024 revealed that the resident was scheduled for a post operative orthopedic visit on 12/16/2024. [...]

Inspectors wroteBased on review of facility policies and documentation, clinical record reviews and interviews with staff, it was determined that the facility failed to provide adequate supervision to one of one resident reviewed (Resident R1) who was at risk for elopement. This failure resulted in Resident R1 exiting the third floor via elevator and walking out the front entrance doors. Resident R1 was unable to be located for over 24 hours. This failure placed the resident at high risk for injury and was identified as an Immediate Jeopardy of past non-compliance. (Resident R1)

Inspectors wroteBased on review of clinical record, review of job's descriptions and interviews with staff, it was determined that the Nursing Home Administrator and Director of Nursing did not effectively manage the facility to ensure that adequate supervision was provided to on one of one resident reviewed (Resident R1) at risk for elopement. This failure resulted in Resident R1 exiting the third floor via elevator and walking out the front entrance doors. Resident R1 was unable to be located for over 24 hours. This failure placed the resident at high risk for injury and was identified as an Immediate Jeopardy of past non-compliance. (Resident R1)

Inspectors wroteBased on review of clinical records, as well as resident and staff interviews, it was determined that the facility failed to maintain clinical records that were complete and accurately documented for one of four residents reviewed (Resident R1) .

Inspectors wroteBased on staff interviews and a review of employee credentials, it was determined that the facility failed to employ a qualified director of food and nutrition services, as required (Employee E8)

Inspectors wroteBased on interview with staff and review of facility provided documentation, it was determined that the facility activities program was not directed by a qualified professional as required.

Inspectors wroteBased on a review of personnel files and interviews with staff, it was determined that the facility did not ensure that nursing staff had specific competencies and skills sets necessary to care for residents' needs for three out of five personnel files reviewed. (Employees E9, E18, E16)

Inspectors wroteBased on observation, interviews with staff and residents and review of facility documentation, it was determined that the facility did not maintain an effective pest control program to ensure that the facility was free of pests for one of four floors. (5th floor)

Inspectors wroteBased on review of facility provided documentation and interview with staff, it was determined that facility did not ensure to provide Notice Of Medicare Non-Coverage (NOMNC) to one out of three residents reviewed (Resident R20)

Inspectors wroteBased on review of clinical records, review of facility policy, facility documentation and resident and staff interviews, it was determined that the facility failed to ensure that residents were free from misappropriation and exploitation of property related to authorized use of resident's funds for two of two residents reviewed. (Resident R1 and Resident R22).

Inspectors wroteBased on review of facility policy review of clinical records and staff interview it was determined that the facility failed to conduct and complete a thorough investigation to rule out misappropriation of resident funds for two of two resident records reviewed. (Resident R 1, and Resident R 22)

Inspectors wroteBased on a review of clinical records, review of the Resident Assessment Instrument and staff interviews, it was determined that the facility failed to conduct a significant change Minimum Data Set Assessments (MDS - a federally mandated standardized assessment process conducted at specific intervals to plan resident care) for a resident who had a deterioration in Range of Motion (ROM) and in Activities of Daily Living (ADL) for one of twenty residents reviewed (Resident R67).

Inspectors wroteBased on observations, clinical record review, it was determined that the facility failed to develop a baseline care plan within 48 hours of admission related to oxygen therapy for one of 20 residents reviewed (Resident R75).

Inspectors wroteBased on review of facility policy, review of clinical records, observation, and staff interview, it was determined that the facility failed to develop and implement a comprehensive care plan related to indwelling catheter for one of 20 residents reviewed (Resident R22).

Inspectors wroteBased on review of facility provided documentation, review of clinical records and interview with staff, it was determined that facility failed to update care plans related to bleeding, weight loss, tube feed occlusion, advanced directives, and hospice care for three out of 22 residents reviewed. (Resident R63, R86, R15)

Inspectors wroteBased on observations, review of clinical records, review of facility policy and interview with staff, it was determined that the facility failed to administer oxygen as ordered by the physician for one of three residents on oxygen therapy. (Resident R75)

Inspectors wroteBased on observations, review of facility policies, review of clinical record and interviews with staff, it was determined that the facility failed to maintain effective infection control practices related to barrier precautions and personal protective equipment for one of one resident observed (Residents R52).

Inspectors wroteBased on observations, resident and staff interviews, and a review of facility documentation, it was determined that the facility failed to provide food and drink that was palatable and served at palatable temperatures for five of five residents. (Residents R3, R4, R5, R6, R7)

Inspectors wroteBased on observations, resident and staff interviews and review of the pest control logs and pest control company invoices, review of facility policies and documentation, it was determined that the facility failed to maintaining an effective pest control program in four of four nursing units. (2nd Floor, 3rd Floor, 4th Floor and 5th Floor)

Inspectors wroteBased on clinical record review, interviews with staff, and review of facility policy, it was determined that the facility failed to ensure that a resident's representative informed of the falls sustained by the resident for one of 7 residents reviewed (Resident R1).

Inspectors wroteBased on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific care needs for 1 of 7 residents reviewed (Residents R1).

Inspectors wroteBased on review of clinical record review, and staff interviews, it was determined that the facility failed to provide a transfer notice to the State Office of the Long-Term Care Ombudsman for three of three months reviewed. (July, 2024, August 2024 and September 2024).

Inspectors wroteBased on observations, staff and resident interviews, and review of facility documentation, it was determined that the facility failed to ensure a comfortable air temperature levels for 4 out of 4 residents reviewed receiving dialysis treatment (Resident R5,R6, R7an R8).

Inspectors wroteBased on staff interviews, review of facility documentation, and the state survey reporting system, it was determined that the facility failed to ensure that allegations of abuse and neglect were reported to the state survey agency for 4 out of 4 residents reviewed (Resident R1, R2, R3 and R4).

Inspectors wroteBased on staff interviews and review of facility documentation, it was determined that the facility failed to conduct a complete and thorough investigation regarding allegations of abuse/neglect for 4 out of 4 residents reviewed (Resident R1, R2, R3 and R4).

Inspectors wroteBased on staff interviews, and review of clinical records, it was determined that the facility failed to ensure that residents received care and services for dialysis treatment that was consistent with professional standards of practice for dialysis care for 2 out of 4 residents reviewed for dialysis treatment (Resident R6 and R8).

Inspectors wroteBased on observations, resident and staff interviews and a review of facility policies and documentation, it was determined that the facility failed to maintaining an effective pest control program in four of four nursing units. (2nd Floor, 3rd Floor, 4th Floor and 5th Floor)

Inspectors wroteBased on review of clinical records, facility documentation and interviews with staff, it was determined the facility did not ensure proper supervision for one of three residents reviewed (Resident R1).

Inspectors wroteBased on observation, interview with residents, review of facility provided documentation and test tray, it was determined that the facility did not ensure to provide food that is at a safe and appetizing temperature during lunch meal for one of four units observed (Unit 5, 5th floor Nursing Unit)

Inspectors wroteBased on observations, interview with staff and review of facility provided documentation, it was determined that the facility did not provide a sanitary environment to help prevent the development and transmission of communicable diseases and infections related to hand hygiene and maintaining an effective prevention program related to infection surveillance. (Unit 3, 3rd floor). The facility failed to conduct an infection control surveillance for identifying, tracking and monitoring and or reporting infections, communicable diseases and outbreak among residents.

Inspectors wroteBased on resident council interview, staff interviews, and review of the established mealtime schedule, it was determined that the facility failed to ensure a nourishing snack was provided when 14 hours are between a substantial evening meal and breakfast on four of four nursing units. (2nd floor, 3rd floor, 4th floor, and 5th floor).

Inspectors wroteBased on interview with residents and staff and review of facility documentation, it was determined that facility did not ensure residents were treated with dignity and care in a manner and in an environment that promotes the enhancement of their quality of life related to fresh air breaks for nine of 24 residents reviewed (Resident R17, R26, R61, R5, R7, R75, R299, R25, R6)

Inspectors wroteBased on observation, facility policy review, and staff interview, it was determined that the facility failed to provide residents access to grievance information on three out of four nursing units. (2nd, 3rd, 5th Nursing Floor Units).

Inspectors wroteBased on clinical record review and staff interviews, it was determined that the PASRR (Preadmission Screening and Resident Review) was not appropriately completed according to the resident assessment for one of three residents reviewed related to PASRR assessments (Resident R77).

Inspectors wroteBased on review of facility policy, review of clinical records, observations, and staff interviews, it was determined that the facility did not complete a comprehensive care plan for one of 24 residents reviewed (Resident R55).

Inspectors wroteBased on review of clinical records and interviews with residents and staff, it was determined that the facility did not ensure that residents receive treatment and medications in accordance to physician orders related to tube grips and medication via tube feeding for two of 24 residents reviewed (Resident R26 and Resident 47).

Inspectors wroteBased on observation and staff interviews, it was determined that the facility failed to provide appropriate urinary catheter care to prevent urinary tract infections for one of four residents with a urinary catheter (Resident R257).

Inspectors wroteBased on observation and clinical records review, resident and staff interview, it was determined that the facility failed to follow physician orders for tracheostomy care and ensure proper respiratory care for two of two residents reviewed receiving respiratory care. (Resident 55).

Inspectors wroteBased on clinical record review and interview with staff, it was determined that the facility did not provide requested evidence of competency trainings for licensed nursing staff.

Inspectors wroteBased on clinical record review and interview with staff, it was determined that the facility did not provide requested evidence of annual competency trainings and yearly performance reviews for nurse aides.

Inspectors wroteBased on interview with residents and staff and review of clinical records, it was determined that the facility did not provide pharmaceutical services to meet the needs of residents for one of 24 residents reviewed (Resident R26)

Inspectors wroteBased on observation and staff interview, it was determined that the facility failed to properly label and dispense drugs for one out of three carts observed. (4th floor back hall cart)

Inspectors wroteBased on observation, interview with residents, review of facility provided documentation and test tray, it was determined that the facility did not ensure to provide food that is at a safe and appetizing temperature during lunch meal for one of four units observed (Unit 3, 3rd floor Nursing Unit)

Inspectors wroteBased on observation, review of facility records, and interviews with staff and residents, it was determined that the facility did not maintain an adequate pest control program related to mice for four of four units (2nd floor, 3rd floor, 4th floor, and 5th floor).

Inspectors wroteBased on clinical record review and interview with staff, it was determined that the facility did not provide requested evidence of inservice trainings for nurse aides.

Inspectors wroteBased on review of facility documentation, clinical record review, resident and staff interviews, it was determined that the facility failed to ensure that intravenous antibiotic therapy was ordered for a resident was admitted for antibiotic therapy for one of eight residents. (Resident R1)

Inspectors wroteBased on observation, interview with staff, and review of facility provided documentation, it was determined that facility did not ensure that the resident environment remains as free from accident hazards as is possible and each resident receives adequate supervision to prevent accidents related to not following residents care plan for repositioning and bed not locked during repositioning for one of one residents' reviewed (Resident R2)

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to complete a discharge summary, which included a recapitulation of the resident's stay, the course of illness, corresponding treatment, discharge instructions, and a post-discharge care plan for one of three records reviewed (Resident R1).

Inspectors wroteBased on a review of clinical records and staff interview, it was determined that the facility failed to provide care and services regarding bathing for one of three residents (Resident R1).

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure that laboratory studies were promptly obtained as ordered by the physician for one of three clinical records reviewed (Resident R2).

Inspectors wroteBased on clinical record review and interviews with staff, it was determined that the facility did not develop a comprehensive care plan related to the use of a mechanical device for transfers for one of five records reviewed (Resident R1).

Inspectors wroteBased on interviews with staff, review of faciltiy policy and review of the clinical record, it was determined that the facility failed to ensure that a resident's grievance related to medications not administered on time was investigated and resolved, and the resident was notified of the outcome (Resident R1).

Inspectors wroteBased on the review of clinical records, review of facility policy and interview with staff, it was determined that the facility failed to ensure that physician orders were obtained for two residents with bed rails for 2 of 2 residents reviewed with bedrails. (Resident R1 and Resident R3).

Inspectors wroteBased on interviews with staff, review of facility policy and review of clinical records, it was determined that the facility failed to ensure that complete and accurate clinical records were maintained for one out of 3 residents reviewed related to medication administration (Resident R2).

Inspectors wroteBased on clinical records review, and staff interview it was determined that the faciltiy failed to ensure that a bedrails were in a safe operating condition and replaced for one of two residents reviewed. (Resident R1)