Greenhaven Healthcare Center

Inspectors wroteBased on observation, interview and record review the facility failed to eliminate accident hazards in the resident's environment for one of three sampled residents (Resident 1) when: Resident 1 sustained a hematoma (localized collection of pooled blood that gathers outside of a blood vessel, usually caused by injury, trauma, or surgery) after a chair was removed from the secure wall mount by a staff member and left leaning against Resident 1's room wall. Resident 1 later bumped into the chair, which then fell onto her left knee causing the accident. This failure resulted in an avoidable accident with a minor injury to Resident 1's left knee. According to the admission Record, the facility admitted Resident 1 in February 2022 with multiple diagnoses including heart failure and glaucoma (eye condition). Resident 1 was discharged in June 2026. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the employed social worker met the minimum qualifications of the position as per federal regulations for a census of 143 residents, when the social worker had no bachelor's degree since hiring to meet the required minimum qualifications of the position for a facility with more than 120 beds. This failure decreased the facility's potential to provide social services that meet the residents' individualized needs.

Inspectors wroteBased on interview and record review, the facility failed to implement a comprehensive person-centered care plan for one of three sampled residents (Resident 1) when a care plan for Resident 1's peripheral IV [(PIV) intravenous line-delivers fluids, medications or nutrients directly into a vein] was not developed. This failure had the potential to cause an increased risk of infection and bleeding.

Inspectors wroteBased on interview and record review, the facility failed to ensure a peripheral IV (PIV- intravenous line-delivers fluids, medications or nutrients directly into a vein) for one of three sampled residents (Resident 1) was discontinued prior to being discharged from the facility. This failure had the potential for inadequate monitoring of Resident 1's PIV and could have resulted in an infection or bleeding for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to allow one (Resident 1) out of four sampled residents to return to the facility after hospitalization. This failure resulted in the resident remaining in the hospital despite being medically stable for discharge and created the potential for the resident to have no safe discharge location once hospital-level care was no longer required.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and effective medication management, when:1. Two of six randomly selected residents' (Resident 12 and Resident 111) controlled medications (those with high potential for abuse and addiction) were not accurately accounted for on the Medication Administration Record (MAR) and the Controlled Drug Record (CDR, an accountability record); and 2. Automated dispensing cabinet (ADC) medication discrepancies, including those involving controlled substances were not identified, reported and resolved in a timely manner for a census of 144 residents. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were properly stored, labeled, and maintained according to the facility's policy and/or manufacturer's specifications for a census of 144 residents, when:1. A treatment cart containing supplies and medications was left unlocked and unsupervised; 2. Resident 74 and Resident 12 had expired medications stored in two of four medication carts;3. Resident 54 had one opened and undated foil pouch containing levalbuterol (a medication to relieve shortness of breath) stored in one of five medication rooms; and 4. Resident 32 had a compounded intravenous (IV; administered into a vein) medication, daptomycin (a potent antibiotic) stored in one of five medication refrigerators after being discontinued. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure texture modified diets were prepared to the correct texture in accordance with the International Dysphagia Diet Standardization Initiative (IDDSI) guidelines, when pureed and minced and moist trays did not meet required texture standards. This deficient practice placed the 17 residents on the pureed diet and the eight residents on the minced and moist diet at risk for choking and aspiration (food or liquid entering the airway).

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the food preparation and storage areas in a sanitary condition for a census of 144 residents, when:Ice buildup was present on a pipe in the walk-in refrigerator and on the ceiling and cooling unit of the freezer;Racks holding food products were found coated with a rust-colored substance;Dirty dishes and mugs were left on clean nourishment room counters;Holes were found in kitchen wall along with chipping paint; andItems in the residents' refrigerator were not labeled and dated. These failures had the potential to allow contamination of food and food-contact surfaces, increasing the risk of bacterial growth and foodborne illness (illness caused by consuming contaminated food) for residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident food and beverages brought from outside of the facility were consistently stored and managed under sanitary conditions for a census of 144 residents, when staff demonstrated inconsistent knowledge regarding storage timeframes and reheating practices. This failure had the potential for allowing bacterial growth and cross-contamination, consumption of food beyond safe storage timeframes and limiting resident food options.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper infection control measures for two of 31 sampled residents (Resident 37 and Resident 157), when:1. Licensed Nurse (LN) 10 did not maintain proper hand hygiene practices during wound care for Resident 37; and2. Two Certified Nurse Assistants (CNAs) did not wear the required personal protective equipment (PPE, protective clothing/gown, gloves, facemasks/face shields designed to protect the wearer from injury or the spread of infection) while providing care to Resident 157 who was on enhanced barrier precaution (EBP, an infection control method). These failures decreased the facility's potential to prevent spreading an infection among vulnerable residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure a copy of advance directives was obtained for one of 31 sampled residents (Resident 87), when a copy of Resident 87's advance directive was not available in the facility's medical records. This failure decreased the facility's potential to honor the end-of-life wishes of its residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 31 sampled residents (Resident 72) was free from abuse, when Resident 91 verbally abused Resident 72 for three nights. This failure decreased the facility's potential to protect Resident 72 from verbal abuse and maintain residents' psychosocial wellbeing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services according to accepted standards of quality for two of six sampled residents (Resident 74 and Resident 148), when: 1. Licensed Nurse (LN) 1 administered Xeljanz (tofacitinib; an immune suppressant medication) to Resident 74 without following the required hazardous drug handling procedures; and 2. LN 1 did not remain with Resident 148 to ensure MiraLAX (a powdered laxative) was taken as prescribed. These failures decreased the facility's potential to prevent hazardous drug exposure, incorrect dosing, wrong ingestion, and adverse effects due to lack of monitoring for residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure ancillary services were provided for one of 31 sampled residents (Resident 44), when Resident 44's eyeglasses prescription was not carried out as ordered by the physician and a hearing consultation was not scheduled promptly. These failures had the potential for a delayed delivery of care to help improve Resident 44's vision and hearing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe environment for one of 31 sampled residents (Resident 3), when floor mats were not placed beside Resident 3's bed as ordered. This failure increased Resident 3's potential to sustain injury after fall.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pain management for one of 31 sampled residents (Resident 12), when Licensed Nurse (LN) 10 did not assess Resident 12's pain and administer pain medication prior to wound care. This failure decreased the facility's potential to provide Resident 12 with an effective pain management.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent a significant medication error for one resident (Resident 74) of a census of 144, when Resident 74 received 12 doses of insulin (a medication to regulate blood sugar) from a pen used past the manufacturer's opened expiration date. This failure resulted in the administration of expired medication to Resident 74, creating the potential for reduced potency, elevated blood sugar levels, adverse effects, and bacterial contamination.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision to ensure safety for one of three sampled residents (Resident 1) when Resident 1 fell when alone and unsupervised outdoors. This failure resulted in Resident 1's fall and subsequent transfer to the acute care hospital for further evaluation. This evaluation indicated that Resident 1 had widespread bleeding on his head and later died in the hospital.

Inspectors wroteBased on interview and record review, the facility failed to ensure physician orders were followed in accordance with professional standards of care and per facility policy for Resident 1, when Resident 1's physician ordered a CT scan (medical imaging technique used to obtain detailed internal images of the body) that was not implemented timely. This failure had the potential to negatively affect Resident 1's health and their ability to achieve their highest practical well-being by delaying ordered care.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from physical abuse for one out of four sampled residents (Resident 1) when Resident 2 punched Resident 1 on his left arm. This failure resulted in Resident 1 not free from physical abuse by Resident 2.

Inspectors wroteBased on interviews, and record review, the facility failed to protect one of seven sampled residents ' (Resident 1) right to be free from physical abuse when Resident 2 struck Resident 1 on her left arm and Resident 2 continued to have access to Resident 1 after the altercation. This failure resulted in Resident 1 being fearful to leave her room or attend activities.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 of 5 sampled residents (Resident 2) was protected from physical abuse when Resident 2 was slapped by Resident 1 on the left cheek and head. This failure had the potential to cause injury, fear, and distress to Resident 2.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure call light was placed within easy reach for 1 of 5 sampled residents (Resident 3). This failure had the potential for Resident 3 being unable to call for assistance with care needs. Additionally, Resident 3 was assessed to be at high risk for falls.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure professional standards of care was provided for one of 4 sampled residents (Resident 1) when skin assessment (involves visual and tactile examination of the skin to identify potential issues such as change in skin color) was not conducted prior to resident's discharge. This failure to conduct skin assessment increased the potential for Resident 1 to not receive immediate treatment and prevent further skin breakdown.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a comprehensive assessment, treatment and care was provided in accordance with professional standards of practice for one of three sampled residents (Resident 1), when treatment orders were not obtained, and a nursing care plan was not developed and implemented for a newly sustained skin tear. This failure had the potential for Resident 1 ' s wound to have delayed or compromised healing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure necessary care was provided when the ordered liquid consistency was not followed as ordered by the physician for one of four sampled residents (Resident 1). This failure increased the potential for Resident 1 to experience aspiration (when food or liquid enters the airway and into the lungs by accident).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the order and care plan for the use of left hand splint was documented in a consistent manner for one of four sampled residents (Resident 1). This failure had the potential for Resident 1 to experience further loss of function on the left hand.

Inspectors wroteBased on interview, and record review, the facility failed to ensure accurate accountability of controlled medications (those with high potential for abuse or addiction) for three of five sampled residents (Resident 1, Resident 2, and Resident 3) when: 1. Controlled medications delivered by the pharmacy for Resident 1, Resident 2, and Resident 3 were missing and unaccounted for; and, 2. Two doses of Resident 1's Hydrocodone-Acetaminophen (Norco, a medication used to relieve moderate to severe pain) were missing and unaccounted for. These failures resulted in the facility not having accurate accountability of controlled medications, the potential for abuse or misuse of these medications, and the potential for not meeting the residents' therapeutic needs or worsening of their medical conditions.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident representative for one of 3 sampled residents (Resident 1) was informed of resident's rights when the admission agreement (a legally binding contract between the facility and a new resident or their representative which outlines the terms and conditions of their stay including the services provided, costs, and the rights and responsibilities of both parties involved) was not signed. This failure had the potential for Resident 1's representative not to receive information inorder to make informed decisions for resident 's care and treatment.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure on investigating allegations of abuse/mistreatment for one of three sampled residents (Resident 1) when an allegation of mistreatment was not investigated. This failure decreased the facility's potential to protect vulnerable residents and provide a safe environment.

Inspectors wrote4c. A review of Resident 77's admission Record, indicated Resident 77 was admitted to the facility in August 2023 with multiple diagnoses including congestive heart failure (heart does not pump blood as well as it should), diabetes (too much sugar in the blood) and anxiety disorder (mental health disorder characterized by fear or dread out of proportion to the situation). A review of Resident 77's Minimum Data Set (MDS- a federally mandated assessment tool), Cognitive Patterns, dated 8/12/24, indicated Resident 77 had a Brief Interview for Mental Status (BIMS- tool to assess cognition) score of 13 out of 15 that indicated Resident 77 was cognitively intact. During an interview on 11/6/24 at 9:31 a.m. with Resident 77, Resident 77 stated food was cold night before last. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the recipe for the preparation of pureed bread rolls was followed for 25 residents, who had chewing or swallowing difficulties and were on pureed diet (texture-modified, pudding like consistency), when the pureed bread served to residents was observed dry and lumpy. This failure had the potential to result in chewing difficulties and increase residents' risks for choking and/or aspiration (a condition in which food is breathed into the airway).

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper infection control practices for four (Resident 349, Resident 97, Resident 79, and Resident 13) of 30 sampled residents when: 1. A Certified Nursing Assistant (CNA) did not don a gown when performing resident care; 2. Resident 97's enteral feeding pump (pump used to deliver liquid nutrition into the digestive tract) and pole (used to hold pump up) had brown crusted material; 3. Resident 79's CPAP (continuous positive airway pressure/a breathing machine designed to increase the air pressure, keeping the airway open when the person breathes) nasal face mask was not cleaned as ordered, and; 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat residents with dignity and respect, when staff referred to residents, who required assistance with eating, as feeders. This failure had the risk potential to minimize the residents self-worth and self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a homelike environment for one of 30 sampled residents (Resident 106) when the wall at the head of the bed was in disrepair. This failure had the potential to negatively impact Resident 106's psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect one of 30 sampled residents (Resident 14) from abuse when Resident 93 inappropriately touched Resident 14's breast. This failure had the potential to result in Resident 14 experiencing discomfort and feeling unsafe in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 30 sampled residents (Resident 79) received treatment and care in accordance with professional standards of practice when the licensed staff did not accurately document the BG (blood glucose is simple sugar- the body's primary source of energy from food) reading and notify the physician of BG readings below 100 as ordered for a total of 9 days. This failure had the potential to result in Resident 79's care being compromised, and necessary medication adjustments not being addressed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote and maintain ability to perform ADL's (Activities of Daily Living) for one of 30 sampled residents (Resident 348) when Resident 348 was not assisted to his wheelchair prior to meals. This failure had the potential to affect Resident 348's oral intake and ability to feed himself.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure there was coordination of care for one of 30 sampled residents (Resident 66) when Resident 66's ulcer [shallow lesion, center was yellowish with redness on the border] on the tongue area was not communicated to the physician. This failure increased the potential for Resident 66 to experience pain and discomfort due to lack of coordination with care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the orders and the care plan for use of a left hand splint were clear and documented in a consistent manner for one of thirty sampled resident's (Resident 97). This failure had the potential for Resident 97's left hand splint to be used incorrectly causing further loss of function.

Inspectors wroteBased on observation, interview, and record review, the facility failed to document glucometer (machine to measure how much sugar is in the blood) calibration (ensures glucometer is working properly). This failure had the potential for residents' glucose readings to be inaccurate causing errors in residents' blood glucose management.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of 30 sampled residents (Resident 18 and Resident 117) were free of unnecessary psychotropic medications (drugs that affects behavior, mood, thoughts or perception) when residents were prescribed antipsychotic medication without adequate indication and target behaviors. These failures resulted in the use of unnecessary psychotropic medications that could cause adverse consequences.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement their medication storage policy when expired medications were not removed from a medication cart. These failures had the potential for residents to receive medications with unsafe and reduced potency from being used past their discard date.

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident 49) of 30 sampled residents' records were accurate when Resident 49's admission assessment note did not reflect Resident 49's health status. This failure had the potential to result in Resident 49 receiving care not suited to their health status.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI, a data-driven proactive approach to improve quality of care and life for nursing home residents) Committee met with the required members for a census of 134, when the Medical Director (MED) did not attend the QAA meetings. This failure had the potential to negatively impact the quality of care for residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe environment when a raised round plate was loose with a large center bolt extending above the plate in the center of the floor of the resident hallway. This failure had the potential for residents to trip and fall in the hallway with resulting injury.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide adequate monitoring and supervision for one of three sampled residents (Resident 1), when Resident 1 eloped from the facility. This failure had the potential to cause harm to Resident 1.

Inspectors wroteBased on interview and record review, the facility failed for one of three sampled residents (Resident 1) to ensure Resident 1's physician was notified when Resident 1 ' s Blood Glucose (main sugar in the body that gives you energy) was below 70 mg (milligram-dosage)/dl (deciliter-unit of measurement)(normal blood glucose level is 70-100mg/dl), as ordered. This failure had the potential to delay medical care and treatment for Resident 1.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide supervision to ensure safety for one of three sampled residents, (Resident 2) when Resident 1 slapped Resident 2 on the face while both residents were in their wheelchairs at the nurse's station. This failure had the potential to cause Resident 2 physical injury and emotional distress.

Inspectors wroteBased on interview and record review, the facility failed to ensure an allegation of abuse was reported to the authorities as required by their abuse policy/procedure and as stipulated by the regulations when a Licensed Nurse (LN 2) failed to report an allegation of Resident 1 being touched inappropriately by Resident 2 as reported to her by the victim. This failure resulted in 4 (four) days delay in investigations and caused Resident 1 to be fearful of living in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 of three sampled residents (Resident 1) was treated with dignity and respect when a Certified Nursing Assistant (CNA 1) failed to honor her wish not be changed and re-approach her later. This failure resulted in Resident 1 being accidentally hit on the face by her dirty diaper (incontinent brief) while CNA 1 was providing care to her and had the potential to minimize her dignity and self-esteem.

Inspectors wroteBased on interview, and record review, the facility failed to ensure adequate supervision and assistive devices were provided to prevent falls for 1 of 4 sampled residents (Resident 2) when Resident 2 had an unwitnessed fall. This failure resulted in Resident 2 being admitted to the acute care hospital for scratches on left face and left hip and left rib pain.

Inspectors wroteBased on interview and record review the facility failed to issue a written bed hold notice for one resident (Resident 1) out of 3 sampled residents, when Resident 1 was transferred to the hospital on [DATE], 12/19/23, and 12/20/23. These failures had the potential for Resident 1 to be prevented from returning to the facility which could cause emotional and psychological stress.

Inspectors wroteBased on observation, interview and record review the facility failed to follow infection control guidelines for two of five sampled residents (Resident 4 and Resident 5) with confirmed Covid (+) infection (highly contagious respiratory infection), when: 1. Certified Nursing Assistant 2 (CNA 2) did not wear the full required Personal Protective Equipment (PPE) while in Resident 5's isolation room when she delivered his lunch tray; and 2. Occupational Therapist (OT) did not wear the required full PPE while in Resident 4's isolation room when he brought in the wheelchair for the resident's use. These deficient practices had the potential to spread infection and disease among residents, staff, and visitors.

Inspectors wroteBased on interview, employee file, and policy review, the facility failed to ensure their policy on background screening was followed for four of five sampled newly hired employees (consisting of Certified Nursing Assistants and Licensed Nurses), for a census of 137, when reference checks and background screening were not consistently done. This failure had the potential to put the residents' health and safety at risk.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were stored locked for a census of 132, when a medication cart was left unlocked and unattended. This failure had the potential for medication misuse and drug diversion.

Inspectors wroteBased on interview and record review, the facility failed to complete training for dementia (loss of memory, language, problem-solving and abstract thinking, with personality change) for a Certified Nursing Assistant (CNA) to assure the resident received the highest practicable mental and physical well-being for one of three sampled residents (Resident 1) when CNA 1 did not have a record of dementia training. This failure had the potential to reduce the mental and physical well-being for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to provide a safe environment and ensure one of three sampled residents (Resident 1) was free from abuse when Resident 2 kicked Resident 1's wheelchair and yelled at her. This failure resulted in Resident 1's reporting being emotionally abused and had the potential to further affect her psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide food storage and preparation, and maintain kitchen equipment and food contact surfaces in accordance with professional standards for food safety for the 101 residents who ate facility prepared meals when: 1. One out of nine cutting boards was found with stain and deep scratches; 2. One out of two electric wall fans was found with gray particles on its blade edges; 3. A package of turkey in the refrigerator, a package of corn and a package of sausage patties (with ice crystals build-up) in the freezer were all found open and exposed to air; 4. A bag of lettuce and a bag of parsley that had changed its original color were in the refrigerator; 5. A box of bacon that was past its safe refrigeration time was in the refrigerator; 6. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement their medication storage policy when: 1a. A medication storage refrigerator was left unlocked and unattended, with the potential for access by unlicensed staff or facility residents. 1b. One medication cart was left unlocked and unattended, with the potential for access by unlicensed staff or facility residents. 2a. Medications requiring storage at room temperature were kept in a medication room without monitoring the room temperature, a thermometer, or a temperature log with the potential for negative impact on potency of the stored medications. 2b. Medications requiring storage in the refrigerator were kept at a temperature lower than the recommended temperature range, with the potential for a negative impact on effectiveness of the medications stored in the refrigerator. 3a. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff had the specific competencies of the dietary function when: 1) Maintenance department was unfamiliar with cleaning of ice machines, and 2) Two out of 2 dietary staff were unable to correctly state the sanitizing procedure of manual dish washing. This had the potential of leading to food borne illness for the 101 residents who ate facility prepared meals.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the dignity and privacy of 1 of 22 (Resident 360) sampled residents when Resident 360's nephrostomy (a tube inserted into the kidney to drain urine) drainage bag was not covered. This failure had the potential to result in Resident 360 experiencing embarrassment.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Significant Change in Status Assessment (SCSA) (part of the MDS, an assessment tool) was completed within 14 days of enrollment in a hospice program for one resident (Resident 34), for a census of 102. This failure had the potential for plan of care not to be updated to meet the current needs of Resident 34.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the Minimum Data Set (MDS - a resident assessment tool used to guide care) was accurate for 1 of 22 sampled residents (Resident 26) when the Skin Conditions section did not indicate that Resident 26 had a venous stasis ulcer (wound on the leg caused by damaged veins). This failure had the potential to result in Resident 26 not receiving appropriate care and interventions.

Inspectors wroteBased on interview, and record review, the facility failed to develop a comprehensive person-centered care plan for 1 of 22 sampled residents (Resident 1) when she did not have a Care Plan that addressed her hospice needs after being admitted to hospice services. This failure placed the resident at risk for unmet hospice and nursing care needs.

Inspectors wroteBased on observation and interview, the facility failed to ensure services provided met professional standards for one resident (Resident 64) of 22 sampled residents when staff did not use two resident identifiers during medication pass. This failure reduced the facility's potential to prevent medication errors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 22 sampled residents (Resident 50) received treatment and care in accordance with professional standards and practice, when: 1. The physician's orders to notify him of resident's weight gain were not followed consistently; 2. The physician was not informed of Resident 50's refusals to be weighed every morning; 3. Resident 50's refusals of daily weights were not addressed in his personalized at risk for impaired fluid balance care plan; and 4. Nurses performed manual disimpaction (digital evacuation of a fecal mass) without a physician order. These failures had the potential to contribute to Resident 50 being admitted to the hospital with fluid overload (a condition where you have too much fluid volume in your body) and had the potential to put Resident 50's health at risk for injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent 1 of 22 (Resident 357) sampled residents from developing a Stage 3 (full thickness skin loss that extends to the subcutaneous, fat layer) Pressure Ulcer (PU-injury to skin and underlying tissue due to pressure). This failure caused Resident 357 to have a worsening PU with the potential to develop infection or experience pain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate did not exceed 5% (percent) for two sampled residents (Resident 64, and Resident 57) when: 1. For Resident 64, a licensed staff was stopped from administering a double dose of prescribed cetirizine (a medication used to treat allergy symptoms). 2. For Resident 57, a licensed staff did not follow auxiliary pharmacy label warning to administer diltiazem extended-release capsule (a medication used to treat heart condition) on an empty stomach and administered medication after breakfast. These failures resulted in two errors identified out of 28 opportunities during the observation of medication administration; the facility medication error rate was 7.14 %.

Inspectors wroteBased on observation and interview the facility failed to ensure infection prevention and control practices were followed when: 1. Staff did not perform hand hygiene during medication administration. 2. Staff did not disinfect the blood pressure cuff between use on different residents. These failures had the potential of increased transmission of infections among staff and residents. Findings 1. During observation on the C wing on 6/6/23 at 8:32 a.m., Licensed Nurse (LN 1) administered medications to Resident 64. LN 1 failed to wash or sanitize her hands prior to room entry, after changing gloves, and upon exiting the resident's room. In an interview with the LN 1 on 6/6/23 at 12:30 p.m., LN 1 acknowledged not conducting hand hygiene during medication pass with Resident 64. LN 1 stated that she did not conduct hand hygiene when gloves were removed. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide adequate time to fully review the Arbitration Agreement (a document that designates a third party to resolve a dispute between others) for 3 of 3 sampled residents or their representative (Resident 356, Resident 404 and Resident 403's RPs) when the Arbitration Agreement they signed did not include the verbiage that they had the right to rescind the agreement within thirty (30) calendar days of signing. This failure had the potential for the residents to not fully understand the agreement.