Grand Valley Health Care Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement and revise a comprehensive person-centered care plan (a document that summarizes a resident's needs, goals, and care/treatment) addressing residents' low air loss mattress (LALM - a specialty bed that alternates pressure to help heal and prevent pressure ulcer/injuries [PU/PI- injuries that breakdown the skin and underlying tissue when an area of skin is placed under pressure]) use for three of three sampled residents (Resident 1, Resident 2, and Resident 3). This deficient practice had the potential to negatively affect the delivery of care and services and miscommunication among the care team for residents with the LALM use.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the proper use of low air loss mattress (LALM - a specialty bed that alternates pressure to help heal and prevent pressure ulcers/injuries [PU/PI- injuries that break down the skin and underlying tissue when an area of skin is placed under pressure]) by: Failing to maintain the LALM in the appropriate operating mode while a resident was in bed for one of three sampled residents (Resident 2). Applying multiple layers of linens over the LALM for two of three sampled residents (Resident 2 and Resident 3), which could interfere with the LALM's pressure-redistribution function. [...]

Inspectors wroteBased on interview and record review, the facility's licensed nurses failed to accurately assess and complete fall risk evaluations for one of four sampled residents (Resident 1). These deficient practices had the potential to place the residents at increased risk for injury related to falls. [...]

Inspectors wroteBased on interview and record review, the facility's licensed nurses failed to accurately assess and complete dehydration (a condition that occurs when the body loses too much water and other fluids that it needs to work normally) risk assessments for one of four sampled residents (Resident 1). These deficient practices had the potential to place the residents at increased risk for dehydration. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to:1. Ensure one of seven (7) sampled residents (Resident 56), who had an order for modified liquid consistency (liquids that have been thickened [drinks such as water, juice, coffee, modified with powders or gels to be easier and safer to swallow] to a specific level to improve swallowing safety per the International Dysphagia Diet Standardization Initiative [IDDSI - framework that provides a common terminology to describe food textures and drink thickness]), was not provided thin (water-like) liquids. The facility failed to: a. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the confidential personal information of residents were protected by failing to ensure documents (diet tickets) containing protected information ([PHI]- any health information that can be used to identify specific individual which must remain confidential to prevent harmful consequences) were shredded prior to disposing in the waste container. This failure had the potential to violate 80 of 82 residents' rights for privacy and confidentiality of personal and medical records.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five (5) percent (%). Three (3) medication errors out of 34 total opportunities contributed to an overall medication error rate of 8.82% affecting two of three residents (Resident 21 and 22) observed for medication administration. The medication errors were as follows: 1. For Resident 21: a. The facility failed to ensure that lidocaine 4% gel (a topical [applied to the skin] pain medication) was applied to Resident 21's left shoulder as ordered. b. The facility failed to ensure diclofenac sodium gel (a topical pain medication) was applied to the correct site when it was applied to Resident 21's left shoulder which was not a site indicated in the physician's order. 2. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to follow the menu and meet the nutritional needs of the residents when [NAME] 1 did not follow the recipe for Puree 3 bean chili. This failure had the potential to result in decrease in food flavor, decrease in food and nutrient intake to 19 of 19 residents on Puree (foods that are smooth with pudding like consistency) /International Dysphagia Diet Standardization Initiative ([IDDSI] a framework for categorizing food textures and drink thickness) Level 4, and puree consistent carbohydrate diet (diet consisting of the same amount of carbohydrates per meal for blood sugar management), resulting in increased blood sugar levels and unplanned weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare food by methods that conserved appearance, flavor and temperature for lunch when: Puree (foods that are soft with pudding like consistency) chili was flat on the plate and puree tossed salad was too watery. Puree tossed green salad's temperature was at 61 degrees Fahrenheit ( F, a degree of temperature), puree Jello's temperature at 51 F, tossed green salad's temperature at 61 F, and citrus chiffon delight's temperature at 55 F during test tray (a process of tasting, temping, and evaluating the quality of food) These failures had potential to result in 80 of 82 facility residents at risk of unplanned weight loss, a consequence of poor food intake, from receiving getting food from the kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Resident 20 received and consumed food in appropriate nutritive content as prescribed by a physician. This deficient practice had the potential to result in ineffective therapeutic diet, decreased in nutrient intake to one (Resident 20) of 82 residents, resulting in weight loss, getting food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: 1, Kitchen equipment and utensils were not free from dirt, dust and food debris. a. Reach in refrigerators one (1), two (2), near the trayline (an area where foods were assembled from the steamtable to resident's plate) and four (4) had dirt, food, dust debris and buildup, juice spills on the shelves and gaskets. b. The toaster had breadcrumbs and burnt bread debris. c. The ice machine side bins had dirt buildup. 2. Milk in two (2) cups at 44 degrees Fahrenheit ( F, a degree of temperature) and 43 F in the Reach in refrigerator 2. 3. The gasket on Reach-in refrigerator 2 was torn. 4. The Reach in refrigerator by trayline had no internal thermometer. 5. The dry storage floor had dirt, food and dust debris. 6. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose garbage and refuse properly by failing to ensure: 1. Two (2) of 2 black dumpsters (a movable waste container designed to be brought and taken away by a special collection vehicle, or to a bin that a specially designed garbage truck lifts) were completely closed while not actively being used. 2. There were no soiled gloves, masks, and a bag of trash on the floor area and surroundings of the facility's dumpster. 3. The dumpster designated for food and organic waste was not leaking fluid on the ground. These failures had potential to attract birds, flies, insects, pests, and possibly spread infection to 82 of 82 facility residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: 1. An unopened box of expired lancets (tiny, sharp needles used to prick the skin to obtain a small blood sample for blood glucose [sugar] monitoring) found in one of one medication storage room was disposed of on the date of expiration This deficient practice had the potential to cause an infection if the expired lancets were used on a resident. 2. One of three sampled resident's (Resident 21) insulin pen (a device used to administer insulin [a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication]) tip was not cleaned with an alcohol pad prior to attaching the needle. This failure had the potential to increase Resident 21's risk of developing an infection at the site of the injection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain sanitary conditions in the food services department when one dead cockroach (a type of insect) was observed in the residents' refrigerator in the staff break room. This failure had the potential to result in 80 of 82 residents, who received food from the kitchen, acquiring food borne illnesses (illness caused by consuming contaminated foods or beverages) by consuming potentially contaminated food.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Licensed Vocational Nurse (LVN 5) knocked on a resident's door and requested permission before entering the room for one of two sampled resident (Resident 114) reviewed under the dignity care area. This deficient practice violated the resident`s rights to be treated with respect and dignity, which had the potential to affect the resident's sense of self-worth and self-esteem.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a plan of care that summarizes a resident's health conditions, specific care and services facility staff need to provide a resident to promote healing and prevent a worsening of a condition, and current treatments) for one of three residents (Resident 11) reviewed under the accidents care area by failing to indicate in the care plan titled, Impaired Physical Mobility and Self-Care Deficit, dated 1/08/2025, the required level of assistance needed to safely transfer Resident 56 from the bed to the and from wheelchair back to the bed. This deficient practice had the potential to place Resident 11 at risk for injuries.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement its policy and procedure titled Residents Who Present with Communication Barriers, by failing to provide a communication device or board (a tool that includes pictures that help residents communicate their healthcare and every-day needs to facility staff) in their preferred language for one of two sampled residents (Resident 55) reviewed under the communication-sensory care area. This deficient practice had the potential to prevent the resident from communicating with the staff and receiving care in a timely manner.

Inspectors wroteBased on interview and record review, the facility failed to draw a resident's hemoglobin (Hgb, is the iron-rich protein in red blood cells that carries oxygen) and hematocrit, (Hct, is the percentage of the total blood volume made up of red blood cells) as indicated in the physician's order for one (Resident 4) of five residents investigated for unnecessary medications. This had the potential for residents to suffer side effects from having low blood counts such as dizziness and syncope (fainting).

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an environment free from potential accident hazards for one of three residents (Resident 21) observed during medication administration when Resident 21's medications were left unattended at the resident's bedside. This deficient practice had the potential to result in an unsafe medication administration to Resident 21.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents who were incontinent (lacks voluntary control over urination) of bladder (organ in the pelvis that stores urine) received appropriate treatment and services to prevent urinary tract infections (UTI, common infections that happen when bacteria infect the urinary tract) by failing to ensure the urinary catheter (a thin flexible tube that is inserted into the bladder to help drain urine) collection bag tubing was not looped or coiled to allow the urine to flow freely into the collection bag for one of two residents (Resident 79) reviewed under the urinary catheter care area. This failure had the potential to result in the backflow of urine into the resident's bladders, which can cause urinary tract infections (UTI- an infection in the bladder/urinary tract).

Inspectors wroteBased on interview and record review, the facility failed to ensure the hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) center completed a pre and post-dialysis assessment (evaluation done after hemodialysis by the hemodialysis licensed nurses) by not ensuring the dialysis center recorded a resident's pre and post dialysis weights (the weight before and after fluid is removed during the dialysis treatment) on multiple days from 9/4/2025 to 12/18/2025 for one (Resident 34) of two residents in the facility who received dialysis treatments. This deficient practice had the potential for Resident 34 to have unidentified complications after dialysis treatment such as abnormal vital signs (pulse rate, temperature, respiration rate, and blood pressure).

Inspectors wroteBased on interview and record review, the facility failed to implement its antibiotic stewardship (actions designed to use antibiotic [medications that fight bacterial infections] medications effectively while reducing the possibility of being prescribed an unnecessary medication) program by failing to conduct and complete an infection surveillance form before antibiotics were initiated for one of two sampled residents (Resident 15). This deficient practice had the potential for Resident 15 to develop antibiotic resistance (not effective to treat infection) from unnecessary or inappropriate antibiotic use for future infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide at least 80 square feet (sq. ft. - unit of measurement) per resident in multiple resident bedrooms for four of 38 resident rooms (Rooms 1, 3, 9, and 11). Rooms 1, 3, 9, and 11 all have two beds in each room. This deficient practice had the potential to result in inadequate useable living space for all the residents and inadequate working space for the health caregivers.

Inspectors wroteBased on interview and record review the facility failed to ensure one of three sampled residents (Resident 1) was treated with dignity and respect by not honoring Resident 1's request that Certified Nursing Assistant (CNA) 1, whom Resident 1 reported as being rough during care, not provide care to Resident 1 upon readmission to the facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents' Notice of Proposed Transfer and Discharge were provided to the resident and/or resident representative at least 30 days prior to discharge or as soon as practicable for three of three sampled residents (Resident 1, Resident 2, and Resident 3). This deficient practice placed the residents at increased risk of an inappropriate discharge and denied the residents the right to file an appeal to the appropriate agency within 10 days of being notified of a proposed transfer and discharge.a. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was actively involved in their discharge planning and had a safe discharge to a lower level of care. This deficient practice resulted in Resident 1 having to be admitted to the general acute care hospital (GACH) within 24 hours of discharge to a lower level of care and had the potential for decreased quality of care, decreased quality of life, and continuity of care. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident's low air loss mattress (a specialized mattress that alternates pressure to prevent skin breakdown) was in the correct setting for one (Resident 1) of three sampled residents. This deficient practice had the potential to place the resident at increased risk for discomfort and development of pressure ulcers (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence).

Inspectors wroteBased on interview and record review, the facility to ensure one of three sampled residents (Resident 2) received care and services in accordance with professional standards of practice by failing to administer Resident 2's Norco (a medication used to relieve severe pain) as prescribed by the physician. This deficient practice had the potential for Resident 2 to experience untreated pain.

Inspectors wroteBased on interview and record review the facility failed to ensure clinical records for one of four sampled residents (Resident 1) were maintained in accordance with accepted professional standards by failing to accurately document the administration of Resident 1's Oxycodone Hydrocholoride (a medication used to treat moderate to severe pain) on the Medication Administration Record (MAR- a report that serves as a legal record of the medications administered to a resident). This deficient practice placed Resident 1 at risk for medication errors, delayed pain relief and the potential for diversion (refers to redirection of prescription drugs from their intended use or disposal to unauthorized purposes) of a narcotic (a substance that dulled the senses and relieved pain) medication.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were provided necessary assistance with activities of daily living, specifically with mobility and getting out of bed for two of two sampled residents (Resident 3 and Resident 4). This deficient practice resulted in residents remaining in bed for prolonged periods and potentially compromise residents ' dignity, preferences and functional well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide oral care for one of three sampled residents (Resident 3). This deficient practice resulted in Resident 3 not being provided with oral care on 5/16/2025 which could lead to potential negative outcomes such as development of oral health issues (discomfort and pain) including tooth decay or gum disease.

Inspectors wroteBased on interview and record review, the facility failed to implement an effective bowel (tube-shaped organ in the abdomen that completes the process of digestion) and bladder (a hollow organ that stores urine) retraining program (B&B retraining program - aim to establish or regain control over bowel and bladder function) for two of three sampled residents (Resident 1 and Resident 3) by not ensuring that the resident ' s bowel and bladder assessment was re-assessed in a timely manner. This deficient practice had the potential to result in Resident 1 and Resident 3 not being accurately assessed as candidates for a B&B retraining program and may have limited their (Resident 1 and Resident 3) opportunity to regain bowel and bladder function. Findings a. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to inform and provide information for two of two sampled residents (Resident 2 and 3) in advance regarding deep cleaning of their rooms. This deficient practice had the potential to affect the residents' sense of self-worth, self-esteem, and the resident's right.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) for one of four sampled residents (Resident 1) when on 1/8/2025, Resident 2 punched Resident 1 in the face several times with a fist (a person's hand when the fingers are bent in toward the palm and held there tightly). This deficient practice resulted in Resident 1 being subjected to physical abuse by Resident 2 while under the care of the facility. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice for one of four sampled resident (Resident 2) by failing to follow-up with the physician to obtain an order to continue monitoring Resident 2's surgical wound with non-removable dressing. This deficient practice had the potential for Resident 2 to have a wound infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure administration of a physician ordered eye drop was accurately documented in the Medication Administration Record (MAR- a daily documentation record used by a licensed nurse to document medications given to a resident) for one of four sampled residents (Resident 3). This deficient practice had the potential to result in confusion in the delivery of care and placed the resident at risk for not receiving the medication as ordered by the physician.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control practices by failing to: 1. Ensure Licensed Vocational Nurse 2 (LVN 2) perform hand hygiene (HH - the practice of cleaning hands to prevent the spread of germs and infections) after checking a resident ' s blood pressure with bare hands for one of four sampled residents (Resident 3). 2. Ensure Treatment Nurse 1 (TN 1) perform hand hygiene between glove changes while providing wound treatment to one of four sampled residents (Resident 4). These deficient practices had the potential to result in the spread of germs placing residents, staff, and visitors at risk for infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents' low air loss mattresses (LALM, a mattress designed to distribute the resident's body weight over a broad surface area and help prevent skin breakdown) were set at the correct setting for three of 23 sampled residents (Residents 88, 11, and 196). This deficient practice had the potential to place the resident at risk for discomfort and development of pressure ulcers/injuries (an injury that breaks down the skin and underlying tissue when an area of skin is placed under pressure).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure leftover food brought from outside by resident's family and visitors were labeled with a resident identifier and use-by date for three of four residents (Resident 76, 83, and 192). This deficient practice had the potential to result in foodborne illness (also called food poisoning, illness caused by eating contaminated food) for the residents.

Inspectors wrote3. During a review of Resident 30's admission Record, the admission Record indicated that the facility initially admitted Resident 30 on 2/22/2024 and readmitted the resident on 8/30/2024 with diagnoses including acute embolism and thrombosis of deep veins of the right lower extremity (a clinical condition in which blood clots [a gel-like clump of blood] are forming and affecting the veins and arteries in the right lower extremity), degenerative disease of nervous system (a condition where the nerves or brain gradually break down or stop working properly over time), and repeated falls. During a review of Resident 30's H&P, dated 2/23/2024, the H&P indicated that the resident did not have the capacity to understand and make decisions. During a review of Resident 30's MDS dated [DATE], the MDS indicated that the resident had severely impaired cognition. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide reasonable services and accommodations for two of three sampled residents (Resident 16 and Resident 28) by failing to: 1. Ensure Resident 16's call light (a device used by a resident to signal his/her need for assistance from staff) was within reach while in bed. 2. Ensure Resident 28 was provided a call light that was adaptive to the resident's needs. These deficient practices had the potential to delay the provision of services and residents' needs not being met.

Inspectors wroteBased on interview and record review, the facility failed to ensure that an advance directive (AD-written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) was discussed and written information was provided to the resident and/or responsible parties for one of two sampled resident (Resident 6). This deficient practice violated the resident's and/or the representative's right to be fully informed of the option to formulate an advanced directive and had the potential to cause conflict with health care wishes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe and comfortable temperature level for one of four sampled residents (Resident 30). This deficient practice had the potential to result in loss of body heat and risk of hypothermia (dangerously low body temperature) for Resident 30.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a person-centered care plan (a written document that summarizes a resident's needs, goals, and care/treatment) for two of three sampled residents (Resident 28 and 50) by failing to: 1. Develop a care plan addressing Resident 28's range of motion (ROM - the amount of movement that a particular joint or series of joints can achieve in a specific direction) limitations. 2. Develop a care plan addressing Resident 50's bowel and bladder incontinence (a problem holding in urine or stool). These deficient practices had the potential to result in failure to deliver the necessary care and services.

Inspectors wroteb. During a review of Resident 30's admission Record, the admission Record indicated that the facility initially admitted Resident 30 on 2/22/2024 and readmitted the resident on 8/30/2024 with diagnoses including acute embolism and thrombosis of the deep veins of the right lower extremity (a clinical conditions in which blood clots [a clump of blood that has changed from liquid to gel-like state, which can block blood flow] is forming and affecting the veins and arteries in the right lower extremity), degenerative disease of the nervous system (a condition where the nerves or brain gradually break down or stop working properly over time), and repeated falls. During a review of Resident 30's History and Physical, (H&P) dated 2/23/2024, the H&P indicated that the resident did not have the capacity to understand and make decisions. [...]

Inspectors wroteBased on interview and record review, the facility failed to comprehensively assess the limited mobility and range of motion (ROM - the amount of movement that a particular joint or series of joints can achieve in a specific direction) for one of two residents (Resident 28) when the resident was readmitted on [DATE]. This deficient practice resulted in Resident 28 not having the appropriate equipment to maintain their maximum practicable independence and had the potential to cause further decline in functional mobility, ROM, and quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure a fall risk evaluation was completed after a fall on 8/29/2024 and ensure the fall risk evaluation completed on 9/6/2024 was accurate for one of four sampled resident (Resident 30). This deficient practice had the potential to negatively affect Resident 30's plan of care and the delivery of necessary care and services. 2. Ensure Licensed Vocational Nurse 5 (LVN 5), who was administering medications to a resident, did not leave the prepared medications unattended at the resident's bedside for one of 23 sampled residents (Resident 197). This deficient practice had the potential to result in unauthorized personnel or residents having access to the resident's medications.

Inspectors wroteBased on interview and record review Licensed Vocation Nurse 1 (LVN 1) failed to ensure that residents who needed respiratory care (the health care discipline that specializes in the promotion of optimum cardiopulmonary function and health and wellness) were provided such care, consistent with professional standards of practice to one out of three sampled residents (Residents 242) by failing to: 1. Ensure that the suction catheter (a flexible hallow tube used to remove secretions from a patient's airway) was covered with a sleeve when not in use. 2. Administer oxygen (a colorless, odorless, and tasteless gas, that support life) to Resident 242 according to the physician order. 3. Label Resident 242's suction tubing with the date for when it was last changed. These deficient practices had the potential to cause respiratory infection to Resident 242.

Inspectors wroteBased on interview and record review, the facility failed to administer pain medication as prescribed by the physician for one of sampled resident (Resident 6). This deficient practice had the potential to result in adverse consequences (undesired harmful effect resulting from a medication or other intervention).

Inspectors wroteBased on interview and record review, the facility failed to complete a post-dialysis (the removing of waste and excess fluid to prevent build up in the body for residents who have loss of kidney [organs that remove waste products from the blood and produce urine] function) assessment for one of one sampled resident (Resident 13). This deficient practice placed Resident 13 at risk for complications of dialysis such as redness at the dialysis access site (way to reach the blood for hemodialysis), edema (too much fluid trapped in the body's tissues), excessive bleeding, and a change in vital signs (clinical measurements that indicate the state of a patient's essential body functions).

Inspectors wroteBased on observation, interview and record review, the facility failed to provide at least 80 square feet (sq. ft. - unit of measurement) per resident in multiple resident bedrooms for four of 38 resident rooms (Rooms 1, 3, 9, and 11). Rooms 1, 3, 9, and 11 all have two beds in each room. This deficient practice had the potential to result in inadequate useable living space for all the residents and inadequate working space for the health caregivers.

Inspectors wroteBased on interview and record review, the facility failed to implement its policy and procedure for an allegation of financial abuse for one of three sampled residents (Resident 1) by failing to: 1. conduct a thorough investigation of the alleged financial abuse. 2. provide documented evidence that a Situation, Background, Assessment and Recommendation (SBAR - a communication tool that helps provide essential, concise information about the condition of a resident) Form was completed. 3. ensure Resident 1 was monitored every shift for 72 hours for emotional distress or negative outcome as a result of the alleged financial abuse. These deficient practices had the potential to place Resident 1 at risk for further abuse and could have resulted in Resident 1 needing care or emotional support which was not provided.

Inspectors wroteBased on interview and record review, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with Section 1150B of the Act by failing to ensure the results of the abuse investigation for the allegation of financial abuse that occurred on 10/3/2024 was reported to the State Survey Agency (SSA) within five (5) working days for one (1) of three (3) sampled residents (Resident 1). This deficient practice had the potential to place Resident 1 at risk for further abuse.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive person-centered care plan (a written course of action that helps a resident achieve outcomes that improve their quality of life) for one of three sampled residents (Resident 1), who was involved in an allegation of financial abuse. This deficient practice had the potential to negatively affect the delivery of care and services to Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from verbal abuse (harsh and insulting language directed at a person) by Certified Nursing Assistant 1 (CNA 1) towards one of five sampled residents (Resident 1). On 9/7/2024, CNA 1 hurled (to utter) an obscene word (a curse word that is a socially offensive use of language) at Resident 1. This deficient practice resulted in Resident 1 being subjected to verbal abuse while under the care of the facility and had the potential to cause emotional harm which could result to a feeling of low self-esteem and self-worth.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the primary care physician (Primary Medical Doctor 1 [PMD 1]) for one of four sampled residents (Resident 1), who had a history of hypothyroidism (a condition where the thyroid gland doesn't release enough thyroid hormone [plays a role in regulating weight, energy levels, growth and metabolism] into the bloodstream), reviewed Resident 1's General Acute Care Hospital 1 (GACH 1) progress notes, including medications essential to Resident 1's medical treatment. PMD 1 failed to prescribed Resident 1 her (Resident 1) routine medication (medication taken regularly) of Levothyroxine (a medication used to treat an underactive thyroid gland [a gland that makes and stores hormones that help regulate the heart rate, blood pressure, body temperature, growth development and energy) upon admission to the facility on 5/26/2024. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four sampled resident ' s (Resident 2) urinary drainage bag (bag that collects a resident ' s urine) was not placed above the resident ' s bladder (organ inside the body that stores urine). This deficient practice had the potential to result in urine flowing back into the resident ' s bladder which would then increase the risk for a urinary tract infection (an infection in any part of the urinary system) that can cause serious health problems such as sepsis (a serious condition in which the body responds improperly to an infection and a potentially life-threatening complication).

Inspectors wroteBased on interview and record review, the facility failed to ensure the hemodialysis (also known as dialysis, the process of removing waste products and excess fluid from the body because the kidneys no longer function) center documented the pre (before) and post (after) dialysis weight of one of two sampled resident (Resident 279). This deficient practice placed the resident at risk for potential unidentified complications after dialysis treatment.

Inspectors wroteBased on interview and record review, the facility failed to ensure: 1. Licensed nurses signed one of three sampled resident's (Resident 14) Medication Administration Record (MAR- a report detailing the medications administered to a resident by a healthcare professional) after administering Hydrocodone-Acetaminophen (Norco- a medication used to treat pain) to the resident on six separate occasions. 2. Licensed nurses signed one of three sampled resident's (Resident 34) MAR after administering Norco to the resident on 10/4/2023. 3. Licensed nurses signed one of three sampled resident's (Resident 24) MAR after administering Acetaminophen-Codeine Number 3 (Tylenol #3 - a medication used to treat pain) to the resident on 10/22/2023 and 10/29/2023. 4. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure: 1. Licensed nurses monitored the behavior of angry outburst for a resident on Olanzapine (a medication used to treat schizophrenia [a serious mental condition of a type involving a breakdown in the relation between thought, emotion, and behavior] and bipolar disorder [a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration]) for one of five sampled residents (Resident 74) investigated for unnecessary medications. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper sanitation and food handling practices by: 1. Failing to ensure a red sanitation bucket (contains sanitizing solutions with a recommended concentration of a chemical sanitizer, usually quaternary [Quat, potent chemical disinfectant] ammonium [an ingredient in many household cleaning products] compounds or chlorine [a type of sanitizing solution]), located in the dish washing area of the kitchen, for the quaternary solution registered at the required 200 parts per million (ppm- unit of measure, 200 ppm indicates the sanitizing solution is effective) as per facility policy. 2. [...]

Inspectors wroteBased on interview, and record review, the facility failed implement the facility's hospice (care designed to give supportive care to a resident in the final phase of a terminal illness [illness that cannot be cured] and focus on comfort and quality of life) policy and procedure for one of one sample residents (Resident 133) by failing to ensure Resident 133's hospice binder (the binder that contains the hospice services calendar, plan of care including interventions, nursing notes for a resident who is on hospice services) was in the facility to ensure communication between the hospice and the facility, and to ensure continuity of care for the hospice resident. This deficient practice had the potential to delay coordination and delivery of hospice services.

Inspectors wroteBased on interview and record review, the facility failed to implement its antibiotic stewardship(the effort to measure and improve how antibiotics [a medication used to treat or prevent infections] are prescribed and used by residents) program by failing to conduct infection surveillance (a tool to monitor the health of the residents) and complete the infection control reporting form once signs and symptoms of infection were identified and antibiotics were initiated for four (Resident 9, Resident 74, Resident 130, and Resident 132) of five sampled residents. This deficient practice had the potential for Resident 9, Resident 74, Resident 130 and Resident 132 to develop antibiotic resistance (when germs like bacteria change over time and no longer respond to medicines) from unnecessary or inappropriate antibiotic use for future infections.

Inspectors wroteBased on interview and record review, the facility failed to promote the resident's right to be informed of by the physician of the risks and benefits of the proposed plan for the administration of a psychotropic medication (medication that affects brain activities to control behavior or treat disordered thought processes) Olanzapine (a medication used to treat schizophrenia [a serious mental condition of a type involving a breakdown in the relation between thought, emotion, and behavior] and bipolar disorder [a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration]) for one of two sampled residents (Resident 62). [...]

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 wounds [injury to skin and underlying tissue resulting from prolonged pressure on the skin]) was on the needed setting per manufacturer's guidelines for one of two sampled residents (Resident 34). This failure had the potential to place Resident 34 at risk for developing or worsening pressure wounds.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's physician's orders were followed by failing to flush a resident's gastrostomy tube (G-Tube - a tube inserted through the abdomen that brings nutrition and medications directly to the stomach) with water in between each medication administration for one of two sampled residents (Resident 41) observed during the medication administration task. This failure had the potential for drug interaction with unknown side effects and for the G-tube to become clogged.

Inspectors wroteBased on interview and record review, the facility failed to ensure the facility's Pharmacy Consultant (PC) conduct a Drug Regimen Review (DRR- a review of the drug regimen of a resident to identify and, if possible, prevent clinically significant medication issues) for the month of October 2023 for one of two sampled residents (Resident 9) investigated under unnecessary medications review. This deficient practice has the potential to miss the identification of any medication irregularities which could lead to the resident receiving an unnecessary medication with adverse side effects (unwanted undesirable effects that are possibly related to a drug).

Inspectors wroteBased on observation, interview, and record review, the facility failed to label and store drugs (medications) and biologicals (a therapeutic substance such as drugs that target specific parts of your immune system to treat disease) in accordance with accepted professional principles as evidenced by: 1. Failure to ensure a bottle of Valproic Acid Oral Solution (a medication used to treat bipolar disorder [a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration] or to prevent one from having a seizure [sudden, uncontrolled burst of electrical activity in brain that can cause changes in behavior, movements, feelings and levels of consciousness]) had the date it was opened documented on the bottle. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure the peripheral intravenous (IV, a medical technique that administers fluids and medications directly into a person's vein) access (the insertion of a flexible and sterile thin plastic tube, or catheter, into a blood vessel to provide medication) dressing was labeled with the insertion date for one of three sampled residents (Resident 132) observed with IV access. 2. Implement infection control practices for one of two sampled residents (Resident 179) by failing to ensure the resident's nasal cannula (a medical device that delivers extra oxygen through a tube and into your nose) tubing was dated to indicate the date it was last changed and that the tubing was not touching the floor. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed ensure that four of 38 resident rooms (room [ROOM NUMBER], 3, 9 and 11) met the square footage requirement of 80 square feet (sq. ft.- unit of measure) per resident. Rooms 1, 3, 9 and 11 had two beds in each room. This deficient practice had the potential to result in inadequate space to provide safe nursing care and privacy for the resident.