Grande Oaks

Inspectors wroteBased on record review, observations, resident and staff interviews, and facility policy review, the facility failed to ensure that a resident with a new right leg injury received timely and thorough assessment, monitoring, treatment, and physician notification following a fall related injury. This resulted in the worsening of the untreated right leg condition, which progressed to an open necrotic wound requiring hospitalization, surgical debridement, and treatment for sepsis. This affected one (Resident #18) of four residents reviewed for hospitalization. The facility census was 42. [...]

Inspectors wroteBased on record review, staff interviews, and policy review, the facility failed to ensure sufficient fluid intake to maintain proper hydration and health and facility failed to monitor and implement interventions to maintain proper nutritional health. This affected two (Residents #18 and #46) of four residents reviewed for nutrition. The facility census was 42. Actual harm occurred on 10/31/25 when Resident #46 was transferred to the hospital for treatment of severe dehydration related complications due to the facility's failure to adequately monitor and assess his hydration status, failure to ensure tube feeding and flush orders were written correctly and implemented as intended, and failure to respond appropriately to his documented change in condition.

Inspectors wroteBased on observation, record review, policy review, and staff interviews, the facility failed to ensure that kitchen and nursing unit refrigerators were maintained in a clean and sanitary condition. This failure had the potential to affect all residents except nine identified by the facility as receiving nothing by mouth (Residents #4, #5, #7, #8, #15, #27, #28, #37, and #38). The facility census was 42.

Inspectors wroteBased on resident record reviews, staff interviews, facility policy review, the facility failed to ensure that residents' advance directives were accurately completed, signed by a practitioner when required, and consistently documented in the medical record. This failure resulted in inaccurate, missing, or conflicting code status information for four residents (Residents #4, #17, #18, and #28) of four residents reviewed for advance directives, creating the potential for staff to provide care inconsistent with the residents' expressed wishes. The facility census was 42.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff spoke to Resident #41 respectfully using her preferred name. This affected one (Resident #41) of five residents reviewed for dignity. The facility census was 42.

Inspectors wroteBased on observation, record review, interviews and policy review, the facility failed to reasonably accommodate Resident #41's longstanding (since June 2024), care-planned preference to maintain an electronic monitoring device in her room. The facility failed to support continuation of the device in accordance with the residents' rights, preference and care plan. This affected one resident (41) of one reviewed for personal property. The facility census was 42.

Inspectors wroteBased on record review, interviews, and facility policy review, the facility failed to ensure that a resident's medical records request was honored in accordance with policy. This failure affected one (Resident #41) of one resident reviewed for records requests. The facility census was 42Findings include:Record review showed that the daughter of Resident #41 sent emails on 03/15/26 and 04/25/26 to verified facility email addresses for the Assistant Director of Nursing (ADON) #563, Social Worker #574, and carbon copied (cc) the Long-Term Care Ombudsman requesting the resident's medical records. She also asked to be sent any required forms needed to complete the requestDuring interview on 04/27/26 at 1:47 P.M., ADON #563 confirmed these emails were sent but stated she did not recall seeing the records request. [...]

Inspectors wroteBased on record review and interview, the facility failed to uphold its responsibility to protect residents' rights to receive care in a manner that maintains their dignity, autonomy, and personal property. This affected one (Resident #41) of one resident reviewed for personal property. The facility census was 42.

Inspectors wroteBased on record review, review of the Ohio Department of Health (ODH) Certification and Licensure website, facility policy review, and interviews, the facility failed to follow established policies for responding to allegations of abuse, neglect, and misappropriation. This affected one (Resident #41) of two residents reviewed for abuse. The facility census was 42.

Inspectors wroteBased on record review, interview, review of the Ohio Department of Health (ODH) Certification and Licensure website, facility policy review, the facility failed to report alleged abuse, neglect, and misappropriation events to State Agency as required. This affected one (Resident #41) of two residents reviewed for abuse. The facility census was 42.

Inspectors wroteBased on record review, interview, review of the Ohio Department of Health (ODH) Certification and Licensure website, and facility policy review, the facility failed to thoroughly investigate all allegations of abuse, neglect, and misappropriation. This affected one (Resident #41) of two residents reviewed for abuse. The facility census was 42.

Inspectors wroteBased on resident record review, staff interviews, and facility policy review, the facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected Resident #18's clinical status. This affected one (Resident #18) of 22 residents sampled during the survey. The facility census was 42.

Inspectors wroteBased on record review, observation, and interview, the facility failed to provide appropriate oral and nail care for dependent residents. This affected one (Resident #28) of three residents reviewed for activities of daily living (ADL). The facility census was 42.

Inspectors wroteBased on record reviews, observations, resident interviews, staff interviews and facility policy review, the facility failed to ensure resident activity preferences were honored. This affected two (Residents #1 and #26) of two residents reviewed for activities. The facility census was 42.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure that a resident with a documented Stage IV (full thickness tissue loss with exposed bone, tendon or muscle) pressure injury received repositioning according to their plan of care and accepted standards of practice. This affected one (Resident #28) of three residents reviewed for pressure sore care. The total census was 42.

Inspectors wroteBased on medical record review, observation, interview and facility policy review, the facility failed to implement therapy ordered contracture care for one (Resident #7) of one resident reviewed for range of motion and mobility. The facility census was 42.

Inspectors wroteBased on record review, observations, resident and staff interviews, and policy review, the facility failed to provide adequate supervision and failed to ensure the safe use of assistive devices during care and transfers. This failure resulted in one resident (#18) falling from bed during single staff incontinent care despite weighing 557.8 pounds and being dependent for activities of daily living (ADL), and one resident (#32) sliding from a mechanical lift pad during transfer due to improper pad placement. This deficient practice affected two residents (#18 and #32) of three sampled residents reviewed for accidents. The facility census was 42.

Inspectors wroteBased on record review, resident interview, staff interviews, and facility policy review, the facility failed to ensure Resident #18's care was adequately supervised by a physician. Specifically, the facility failed to obtain, initiate, and implement physician orders for weight monitoring despite significant, documented changes in nutritional status and body weight. The facility also failed to notify the physician of significant weight gain requiring clinical intervention. This deficient practice resulted in Resident #18 experiencing an undocumented and unmonitored weight increase of approximately 159 pounds over a five month period, with no corresponding physician notifications, no new orders, and no comprehensive assessment or monitoring as required. This affected one (Resident (#18) of four reviewed for nutrition. The facility census was 42.

Inspectors wroteBased on record review, interview and facility policy review, the facility failed to ensure pharmacy recommendations were addressed in a timely manner. This affected one (Resident #2) of five residents reviewed for unnecessary medications. The facility census was 42.

Inspectors wroteBased on record review, observation, review of the facility policy and interview, the facility failed to ensure the correct serving size for the mechanically altered meat was served. This affected three (Residents #6, #22, and #33) of three residents that received a mechanically altered diet. The facility census was 42.

Inspectors wroteBased on resident record review and staff interviews, the facility failed to ensure the accuracy and consistency of the medical record when resident documentation contained conflicting information, including two different mattress orders that were both documented as being in place for the same dates. This affected one (Residents #17) of 22 residents sampled during the survey. The facility census was 42.

Inspectors wroteBased on resident record review, resident interview, staff interviews, review of the hospice contract and facility policy review, the facility failed to ensure requests for hospice services were honored for Resident #18 and failed to ensure a hospice care plans were updated for Resident #7. This affected two (Residents #7 and #18) of two residents reviewed for hospice services. The facility census was 42.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure call lights were left in reach of residents. This affected one (Resident #41) of four residents reviewed for environmental concerns. The facility census was 42.

Inspectors wroteBased on observations, interviews and facility policy review, the facility failed to ensure a clean, safe and homelike environment. This affected three (Residents #8, #29, and #36) of four residents reviewed for physical environment. The facility census was 42.

Inspectors wroteBased on record review and interview, the facility failed to ensure the medical director attended the Quality Assessment and Assurance (QAA) and Quality Assurance and Performance (QAPI) meetings at least quarterly as required. This had the potential to affect all 42 residents residing in the facility.

Inspectors wroteBased on observation, interviews and review of the facility policy, the facility failed to ensure hand hygiene practices were being performed consistently with accepted standards of practices to prevent the transmission of communicable diseases and infections. This had the potential to affect12 (Residents #15, #23, #24, #25, #27, #28, #29, #37, #39, #41, #44, and #46) on the south hallway who did not have functioning soap dispensers in their rooms of 48 residents reviewed for infection control. The facility census was 48.

Inspectors wroteBased on observation, interview and review of the facility policy, the facility failed to ensure room and hall soap and sanitizer dispensers were functioning properly as required and failed to ensure the wall in Resident #14's room was in good repair. This affected 14 (Residents #2, #9, #11, #14, #15, #23, #25, #27, #28, #30, #37, #39, #41, and #46) of 48 residents reviewed for a safe and sanitary environment. The facility census was 48.

Inspectors wroteBased on record review, observation, interviews and review of facility policy, the facility failed to ensure resident preferences were honored as requested. This affected one (Resident #19) of three reviewed for resident preferences. The facility census was 48.

Inspectors wroteBased on closed record review, interviews and facility policy review, the facility failed to ensure documentation of ongoing monitoring and evaluations for the continued use of a restraint and the usage of other interventions for reducing or discontinuing the use of the restraint. This affected one (Resident #50) out of six medical records which were reviewed. The facility census was 48.

Inspectors wroteBased on record review, interview and facility policy review, the facility failed to ensure all ordered treatments/medications were provided to residents as ordered. This affected one (Resident #19) out of four residents who were interviewed for ordered treatments/medications. The facility census was 48.

Inspectors wroteBased on record review, observation, interview and facility policy review, the facility failed to ensure physician orders were followed related to obtaining weights for two (Residents #11 and #19) of three residents reviewed for weight monitoring. The facility census was 48.

Inspectors wroteBased on record review, interview, review of videos provided by Resident #19's daughter and facility policy review, the facility failed to ensure external door ventilator alarms were monitoring and functioning appropriately for the safety for two (Residents #11 and #19). The facility also failed to ensure physician orders were followed related to nasal cannula being on for Resident #19 as ordered. This affected one (Resident #19) who used an Average Volume-Assured Pressure Support (AVAPS) and one resident (Resident #11) who used an Assist Control Volume Control (ACVC) ventilator of three residents reviewed for ventilator care and had the potential to affect eight additional (Residents #1, #5, #9, #10, #17, #18, and #49) identified by the facility as using AVAPS or ACVC ventilators. The facility census was 48.

Inspectors wroteBased on observation, record review, resident interview, staff interview, and review of facility policies the facility failed to ensure medications were secured properly. This affected one (Resident #10) of four residents observed for medication administration.

Inspectors wroteBased on record review, observation and interview, the facility failed to properly disinfect a glucometer after checking blood sugars. This affected one (Resident #13) of one resident observed for blood sugar monitoring and had the potential to affect 17 residents who required blood sugar monitoring residing on the 100 hall.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, interviews, review of hospital records, review of witness statements and wound policy, the facility failed to implement an adequate and effective pressure ulcer prevention program to promote healing and to ensure Resident #154, who was cognitively impaired, dependent on staff for activity of daily living care and incontinent of bowel, received left lateral ankle and foot wound treatments timely when dressings had become saturated with fecal material. [...]

Inspectors wroteBased on record review and interview, the facility failed to use the services of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week as required. This had the potential to affect all 49 residents residing in the facility.

Inspectors wroteBased on observation, interview and review of facility policy, the facility failed to serve meals at a palatable temperature. This had the potential to affect 41 residents who received food from the kitchen. The facility identified eight residents (Residents #107, #110, #113, #115, #116, #117, #119, and #152) who received nothing by mouth. The facility census was 49.

Inspectors wroteBased on observation, staff and resident interviews, and review of facility mealtimes and policy, the facility failed to ensure meals were provided at posted time and residents were offered a snack as required when there was greater than 14 hours between dinner and breakfast. This had the potential to affect all 41 residents receiving meals from the kitchen. The facility identified eight residents (Residents #107, #110, #113, #115, #116, #117, #119, and #152) who received nothing by mouth. The facility census was 49.

Inspectors wroteBased on observation, interview and facility policy review, the facility failed to consistently ensure food was stored and served under sanitary conditions. This had the potential to affect 41 residents who received food from the kitchen. The facility identified eight residents (Residents #107, #110, #113, #115, #116, #117, #119, and #152) who received nothing by mouth. The facility census was 49.

Inspectors wroteBased on observation, interviews and facility policy review, the facility failed to ensure safe handling of resident food brought in from outside the facility. This has the potential to affect 41 residents who received food from the kitchen. The facility identified eight residents (Residents #107, #110, #113, #115, #116, #117, #119, and #152) who received nothing by mouth. The facility census was 49.

Inspectors wroteBased on record review and interviews, the facility failed to ensure accurate direct care staffing information was submitted to the Centers for Medicare and Medicaid Services (CMS). This had the potential to affect all 49 residents residing in the facility.

Inspectors wroteBased on observation, staff interview, repair invoice, and cleaning checklists, the facility failed ensure wheelchairs were being cleaned as required, failed to ensure shower rooms and equipment was maintained in a sanitary manner, and failed to ensure facility phones were in working order. This had the potential to affect all 49 residents residing at the facility.

Inspectors wroteBased on record review, policy review and staff interview, the facility failed to implement care planned interventions were followed to complete quarterly smoking safety assessments to ensure safe smoking practices. This affected two (#150, #153) of three residents reviewed for smoking. The facility identified fourteen current residents (#100, #105, #114, #123, #127, #128, #129, #10, #140, #141, #143, #148, #149 and #150) as smokers. The facility census was 49.

Inspectors wroteBased on medical record review, psychological evaluation, interview and policy review, the facility failed to ensure Resident #153's mental impairment and resident representative concerns were addressed to ensure a safe discharge for one resident (Resident #153) of three reviewed for discharge. The facility census was 49.

Inspectors wroteBased on record review, interviews and policy review, the facility failed to ensure bathing was provided as scheduled for three (Residents #121, #122 and #155) of three residents reviewed for showers. The facility census was 49.

Inspectors wroteBased on record review, interviews and policy review, the facility failed to ensure weights were completed per physician ordered related to Resident #121's congestive heart failure. This affected one resident (Resident #121) of three residents reviewed for weight monitoring. The facility census was 49.

Inspectors wroteBased on medical record review, interview and facility policy the facility failed to ensure physician visits were completed as required. This affected three of three residents (Residents #122, #153 and #154) reviewed for physician services. This had the potential to affect all 49 residents residing at the facility.

Inspectors wroteBased on record review and interviews, the facility failed to ensure Resident #155 was free of significant medication errors. This affected one (Resident #155) of six residents reviewed for medication errors. The facility census was 49.

Inspectors wroteBased on interview, observation and policy review the facility failed to ensure physician ordered diet modified texture was followed as required. This affected one (Resident #122) of three reviewed for diet texture. The facility census was 49.

Inspectors wroteBased on observation, interview and review of facility policy the facility failed to ensure adequate hydration was provided between meals as required. This affected four residents (Resident #121, #122, #125, and #137) and had the potential to affect 41 residents who received food from the kitchen. The facility identified eight residents (Residents #107, #110, #113, #115, #116, #117, #119, and #152) who received nothing by mouth.

Inspectors wroteBased on record review, observation and interview, the facility failed to provide showers for Resident #5 who was dependent on staff for showers and grooming. This affected one resident (Resident #5) out of three residents reviewed for activity of daily living needs. The facility census was 44.

Inspectors wroteBased on observation and interview the facility failed to ensure a medication error rate was less than five percent. Two errors occurred within 22 opportunities for error resulting in a medication error rate of nine percent. This affected two residents (#32 and #40) out of three residents observed for medications administration. The facility census was 44.

Inspectors wroteBased on record review and interview the facility failed to ensure Resident #41 received his anticoagulant medication (apixaban) in a timely manner. This affected one resident (#41) out of three residents reviewed for medication administration. The facility census was 44.

Inspectors wroteBased on record review, observation and interview the facility failed to date vials of insulin medication after opening. This affected one resident (#32) out of three residents observed for medication administration and had the potential to affect 12 residents (#1, #6, #13, #14, #18, #19, #27, #28, #32, #35, #43, #44). who the facility identified as receiving insulin injections in the facility. The facility census was 44.

Inspectors wroteThe facility failed to ensure Resident #40's medications were documented at the time the medications were administered. This affected one resident (#40) out of four residents reviewed for medication administration records. The facility census was 44.

Inspectors wroteBased on record review,observation and interview the facility failed to perform proper hand hygiene during medication administration and/or when using the glucometer for Resident #28, #32 and #41 and when providing incontinence care for Resident #41. This affected three residents (#28, #32 and #41) of five residents reviewed for infection control. The facility census was 44.

Inspectors wroteBased on observation, interview, medical record review, and review of facility policy, the facility failed to ensure appropriate measures were taken which identified Resident #7 as requiring isolation-based precautions for COVID-19 and staff donned appropriate personal protective equipment (PPE) when entering Resident #7's room. This affected 25 residents who resided on the South unit where Resident #7 resided (Residents #2, #9, #10, #12, #15, #16, #18, #19, #20, #21, #25, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, and #41). Facility census was 43.

Inspectors wroteBased on observation, interview, and review of the facility maintenance documents, the facility failed to ensure the building was maintained in a clean, home-like, leak-free environment, or that the building did not have exterior precautions that would prevent insects from coming into the building. This had the potential to affect all 46 residents residing in the facility.

Inspectors wroteBased on observation, interview, review of the facility admission agreement, and review of the facility policy, the facility failed to ensure privacy and dignity were maintained during incontinence care for Resident #12. This affected one resident (#12) of four residents who were reviewed for incontinence care. The facility census was 46.

Inspectors wroteBased on interview, medical record review, and facility policy review, the facility failed to ensure medications were administered per physician orders for Resident #46. This affected one resident (#46) out of four who were reviewed for medication administration. The facility census was 46.

Inspectors wroteBased on interview, record review, resident and staff statements review, the facility failed to ensure staff showing signs of potential impairment was evaluated to ensure they was competent to provide resident care following suspicions of impaired behaviors by co-workers. This had the potential to affect all residents residing at the facility. The facility census was 43.

Inspectors wroteBased on resident and staff interviews, record review and facility investigation records, the facility failed to ensure staff maintained a professional demeanor when interacting with and around residents to ensure they are treated with dignity and respect at all times. This affected two (Resident #103 and #116) of three residents reviewed for dignity and respect. The facility census was 43.

Inspectors wroteBased on record review and interviews, the facility failed to ensure antibiotics were administered as ordered. This finding affected two (Residents #115 and #116) of five residents reviewed for medication administration.

Inspectors wroteBased on interview and record review, the facility failed to ensure a controlled substance medication was administered per physician orders. This affected one resident (#21) out of three residents reviewed for medication administration. This had the potential to affect fifteen residents (#1, #4, #8, #10, #11, #13, #17, #21, #26, #29, #31, #33, #37, #45, and #47) who were ordered controlled substance medication. The facility census was 48.

Inspectors wroteBased on record review, interview, and facility policy review the facility failed to ensure a controlled substance was documented after administered per physician's orders. This affected one resident (#21) out of three residents reviewed for medication administration. This had the potential to affect fifteen residents (#1, #4, #8, #10, #11, #13, #17, #21, #26, #29, #31, #33, #37, #45, and #47) who were ordered controlled substance medication. The facility census was 48.

Inspectors wroteBased on interview and record review, the facility failed to ensure the safety and well being of Resident #51 when they did not return from a leave of absence. This affected one (Resident #51) of one resident reviewed for a leave of absence from the facility. The facility census was 49.

Inspectors wroteBased on observation, review of the census list and staff interview, the facility failed to ensure the resident's environment was kept clean, well maintained, and homelike. This affected six (#2, #10, #12, #21, #37 and #45) residing in the affected rooms and the residents residing on the 100 hall. The census was 47.

Inspectors wroteBased on observation, medical record review, review of the facility's policy and procedure for skin management, interviews with nursing staff, family interview, and Wound Physician #123 interview, the facility failed to implement a comprehensive and effective pressure ulcer treatment program for two residents (Residents #42 and #18). This resulted in Immediate Jeopardy that was actual harm on 08/01/22 when the facility failed to ensure Resident #18's wound care physician orders were transcribed and treatments implemented, skin assessments completed, and pressure relieving interventions were active and functional resulting in the development of pressure ulcers and the declining condition of the existing pressure ulcers to a Stage 4 pressure ulcer and an Unstageable pressure ulcer. [...]

Inspectors wroteBased on interview, record review, observation and policy review, the facility failed to provide wound dressing changes and skin observations as ordered. This affected two of 12 residents with wounds, Residents #21 and Resident #105. This resulted in actual harm to Resident #21 when she developed cellulitis requiring antibiotic therapy. The facility also failed to ensure neurological (neuro) checks were completed post-fall. This affected one resident (Resident #20) of three residents reviewed for falls. The facility census was 54.

Inspectors wroteBased on observation and interview, the facility failed to maintain the dumpster area free from debris and ensure trash was properly stored. This had to the potential to affect all residents. The facility census was 54.

Inspectors wroteBased on record review and interview, the facility failed to ensure quality assurance (QA) meetings were held to address care issues/concerns in the facility. This affected all 54 residents who resided in the facility.

Inspectors wroteBased on observations, interview, and record review, the facility failed to implement infection control practices to prevent the spread of infection. This had the potential to affect all residents. The facility census was 54.

Inspectors wroteBased on observation and interview, the facility failed to maintain a clean, sanitary, and homelike environment that was also in good repair. This affected Residents #16, #39, #49, #35, #50, #105 and had the potential to affect all residents. The facility census was 54.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide timely incontinence care. This affected six residents (#2, #11, #18, #20, #23 and #33) of six observed for incontinence care. The facility identified 31 incontinent residents. The facility census was 54.

Inspectors wroteBased on observation, interview, record review and policy review, the facility failed to ensure oxygen tubing was dated to ensure timely replacement. This affected eight residents (Residents #19, #33, #1, #13, #43, #30, #38 and #22) out of 17 resident rooms checked for respiratory equipment. The facility census was 54 residents.

Inspectors wroteBased on observation and interview, the facility failed to ensure adequate staffing to meet the needs of the residents in a timely manner. This affected six of 54 facility residents (Residents #21, #22, #39, #38, #13, and #18) and had the potential to affect all residents. The census was 54.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the kitchen and the nursing unit refrigerators and microwave were maintained in a clean and sanitary condition and food was stored appropriately on the nursing units. This had the potential to affect all residents except nine residents (#1, #8, #18, #19, #36, #53, #204, #205, and #206) who received nothing by mouth. The facility census was 54.

Inspectors wroteBased on record review, interview, and policy and procedure review, the facility failed to ensure a proper discharge for Resident #55. This affected one resident (#55) of one resident reviewed for discharge to the community. The facility census was 54.

Inspectors wroteBased on record review, observation and interview, the facility failed to ensure knee and arm splints were applied as ordered by physical therapy. This affected one resident, Resident #28 out of one resident reviewed for range of motion. The facility census was 54.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents were assessed for fall risk on a routine basis to prevent the likelihood of further falls. This affected one resident (Resident #49) of three residents reviewed for falls. The facility census was 54 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure tube feedings were administered per physician orders. This affected two of two residents reviewed for tube feeding, Residents #205 and #53. The facility identified 13 residents who received tube feedings. The facility census was 54.

Inspectors wroteBased on interview and record review, the facility failed to ensure proper assessment of dialysis shunt and communication with dialysis center. This affected one resident (#4) of one resident reviewed for dialysis. The facility census was 54.

Inspectors wroteBased on interview and record review, the facility failed to ensure Resident #22's as needed medication was available upon request. This affected one resident (#22) of five residents (#6, #22, #37, #38, and #42) reviewed for unnecessary medications. The facility census was 54.

Inspectors wroteBased on record review and interview the facility failed to ensure pharmacy recommendations were reviewed by the physician and what, if any, action was taken to address the recommendations. This affected two residents (Resident #6 and Resident #22) out of five residents reviewed for unneccessary medications. The facility census was 54.

Inspectors wroteBased on observation and interview, the facility failed to ensure medications stored on the 200 hall medication cart and storage room were properly labeled. This had the potential to affect Residents #1 #5, #8, #14, #15, #19, #24, #25, #33, #36, #42, #46, #51, #53, #204, #205, and #206 whose medications were stored on the 200 hall medication cart and medication room. Facility census was 54.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure collected lab specimens were sent to the lab in a timely manner. This affected two residents (#205 and #42) of two reviewed for lab services. The facility census was 54.

Inspectors wroteBased on record review and interview, the facility failed to ensure complete and accurate documentation of medical records. This affected three residents (#22, #55, and #6) of 20 whose medical records were reviewed. The facility census was 54.

Inspectors wroteBased on record review and interview, the facility failed to ensure influenza and pneumococcal immunizations were offered and/or provided. This affected one resident (#42) of five residents (#6, #22, #37, #38, and #42) reviewed for immunizations. The facility census was 54.