Greenville Health & Rehabilitation Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, which includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs, for 3 of 23 (Residents #13, #11, and #1) residents reviewed for care plans. 1. The facility failed to implement Resident #13's physician recommendation for placement on the secure unit. 2. The facility failed to ensure Resident #11 was care planned for his splint. 3. The facility failed to ensure Resident #1 was care planned for activities. These failures could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure the activities program was directed by a qualified professional who was a qualified therapeutic recreation specialist or an activities professional who completed a training course approved by the State for 1 of 1 facility reviewed for Activity Director qualifications. The facility failed to hire a qualified Activity Director. This failure could place residents at risk of not receiving a program of activities that meets their assessed activity needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment was as free of accident hazards as is possible and each resident receives adequate supervision to prevent accidents for 3 of 22 residents (Resident #2, Resident #7, and Resident #13) reviewed for accidents and hazards. 1. The facility did not have a process to reassess elopement risk and safety for Resident #13 after elopement. 2. The facility failed to ensure Resident #7 did not have insect spray in her room. 3. The facility failed to ensure Resident #2 did not have the purple top microdot disinfectant wipes in her bathroom. These failures could place residents at risk of accidents that could result in serious injury, harm, or impairment.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate dispensing and administering of all drugs and biologicals to meet the needs of each resident for 3 of 6 medication carts (Hall 100, 300 and 400) reviewed for pharmacy services. 1. The facility failed to ensure over the counter medication was not expired on hall 100 cart. 2. The facility failed to ensure Resident #17's Novolog R (a short-acting human insulin used to control blood sugar in adults and children with diabetes) insulin was not expired on Hall 300 nurse's cart. 3. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, included the appropriate accessory and cautionary instructions, for 2 of 23 (Resident # 47 and Resident #2) residents medication reviewed for medications storage. 1. The facility failed to ensure Resident #47 did not have Nystatin powder in her bedside dresser.2. The facility failed to ensure Resident #2 did not have sore throat spray on her personal refrigerator and nystop (nystatin external powder) (fungal powder used for yeast rashes) on her dresser beside her personal refrigerator. These failures could place residents at risk of not receiving the therapeutic benefit of medications, adverse reactions to medications, or expired medications.

Inspectors wroteBased on observations, and interviews, the facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature for 2 of 2 residents (Residents #27 and #38) and one lunch meal reviewed for food and nutrition services. The facility failed to ensure dietary staff provided food that was palatable and had an appetizing temperature on 07/06/26 and 07/07/26. This failure could place residents at risk of decreased food intake, hunger, and unwanted weight loss.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety for 1 of 1 kitchen reviewed. The facility did not ensure:1. Food items were labeled and dated.2. The ice scoop holder was clean.3. The microwave was clean and free of food debris.4. The deep fryer was clean and had clear grease.5. The exterior of the blender was clean.6. Can opener blade was clean.7. Hair restraints were worn.8. [NAME] L had a clean spoon before stirring the pureed chicken. These failures could place residents at risk for foodborne illness.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 6 residents (Resident #1, Resident #2, and Resident #55) room reviewed for infection control practices and enhanced barrier precautions. 1. The facility failed to ensure OT Q used the proper PPE while providing care to Resident #1 on 07/08/2026. 2. The facility failed to ensure CNA C wiped correctly and performed hand hygiene while providing incontinent care for Resident #2 on 07/06/26. 3. The facility did not ensure The Floor Tech used the proper PPE before entering Resident #55's room on 07/06/26. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure Resident #39 had the right to be fully informed in language that he or she can understand of his or her total health status, including but not limited to, his or her medical condition for 1 of 5 residents (Resident #39) reviewed for resident rights. The facility failed to provide communication or translation assistance to effectively communicate with Resident #39. This failure could place residents at risk for declining and diminishing quality of life, and neglect.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain grooming, and personal and oral hygiene for 1 of 6 residents (Resident #5) reviewed for ADL care. The facility failed to ensure Resident #5 was showered on 06/30/26, 07/02/26, or 07/04/26. This failure could place residents at risk of not receiving care/services, decreased quality of life, and loss of dignity.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 1 of 3 (Resident #12) residents reviewed for quality of care. The facility failed to perform wound care for 3 days 7/4, 7/5, and 7/6 for Resident #12 with a toe wound with cellulitis. This failure could place residents at risk for not receiving appropriate care and treatment, a decreased quality of life, and pressure ulcers. Finding including: Record review of face sheet dated 07/09/2026 revealed Resident #12 was a [AGE] year-old female admitted to the facility on [DATE] with the diagnosis of type 2 diabetes mellitus with hyperglycemia (metabolic disorder that affects how the pancreas controls blood sugar with high blood sugar). [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident who was incontinent of bladder received appropriate treatment and services 1 of 3 (Resident #1) residents reviewed for indwelling catheter. 1. The facility failed to ensure Resident #1's indwelling catheter (tube inserted into bladder) was secured on 07/06/26, 07/07/2026, and 07/08/26. These failures could affect residents with an indwelling urinary catheter and place them at risk of urethral tears, discomfort, infection, and lack of dignity.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 2 of 6 residents (Residents #4 and Resident #8) reviewed for respiratory care.1. The facility failed to ensure Resident #4's oxygen was set at 3 liters per nasal cannula on 07/07/26 and 07/08/26 and HHN (handheld nebulizer) was bagged on 07/06/26, 07/07/26, and 07/08/26.2. The facility failed to ensure Resident #8's oxygen was set at 2 liters per nasal cannula on 07/07/26. These failures could place residents who receive respiratory care at risk of developing respiratory complications and a decreased quality of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that its medication error rate was not 5 percent or greater. The facility had a medication error rate of 7.14 %, based on 3 errors out of 28 opportunities, which involved 2 of 5 residents (Residents #59, and Resident #4) reviewed for medication administration. 1. The facility failed to ensure LVN D did not administer insulin to Resident #49 on [DATE]that had expired on [DATE]. 2. The facility failed to ensure MA E administered Potassium (an essential mineral that is needed by all tissues in the body. It is sometimes referred to as an electrolyte), and Slow Magnesium (a dietary supplement formulated with magnesium chloride and calcium to support muscle, nerve, and cardiovascular health) as ordered by the physician for Resident #4 on [DATE]. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure that residents were free of significant medication errors for 1 of 1 resident (Resident #59) reviewed for insulin administration. The facility did not ensure LVN D did not administered Resident #59 expired Novolog (insulin medication) on 07/07/26. This failure could place residents at risk of medical complications and prevent them from receiving the therapeutic effects of their medications.

Inspectors wroteBased on interview and record review the facility failed to provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service for 1 out of 7 (Dietary Aide B) dietary staff. The facility did not ensure Dietary Aide B had a current food handler permit. This failure could place residents who consumed food prepared from the kitchen at-risk of foodborne illness or nutritional deficiencies.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the meals served met the nutritional needs of residents for 1 of 1 meal (the lunch meal) reviewed for meal service. The facility failed to ensure the Dietary Manager followed the recipe for preparing fortified pudding on 07/06/26. This failure could place residents at risk for weight loss, not having their nutritional needs met, and a decreased quality of life.

Inspectors wroteBased on interview and record review the facility failed to accommodate residents' food preferences for 1 of 6 residents (Resident #17) reviewed for nutrition. The facility failed to honor Resident #17's preference for no apples for the lunch meal on 07/06/2026. This failure could place residents at risk for a decrease in resident choices, diminished interest in meals, and weight loss. Finding including:Record review of the face sheet dated 07/09/2026 revealed Resident #17 was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included cerebral infarction due to embolism of right cerebellar artery (dead brain tissue caused by a blocked blood vessel). Observation on 07/06/2026 at 12:25 p.m., Resident #17 had apples on her tray. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food was prepared in a form designed to meet individual needs for 1 of 3 residents (Resident #54) reviewed for therapeutic diets. The facility failed to ensure Resident #54 received a magic shake and fortified pudding as ordered by the physician 07/06/2026. This failure could place residents at risk for poor intake, weight loss, unmet nutritional needs, choking, and aspiration (when food or drinks enter the lungs).

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to provide special eating equipment and utensils for residents who need them and appropriate assistance to ensure that the resident can use the assistive devices when consuming meals for 1 resident reviewed (Resident #54) for special eating equipment and assistance when consuming meals. The facility failed to provide Resident #54's physician ordered plate guard on 07/06/2026. These failures could place residents at risk for weight loss, diminished independence, and self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medical record was complete and accurately documented for 1 of 4 residents (Resident #11) reviewed for resident records. The facility failed to provide documentation of Resident #11's Habilitation Coordination and Behavior Support services. This failure could place residents at risk for not receiving appropriate care due to incomplete/inaccurate information being documented.

Inspectors wroteBased on interviews and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure the quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 2 of 3 (Resident #8 and Resident #9) residents receiving hospice services. 1. The facility failed to obtain Resident #8's most recent updated hospice IDG meeting notes, hospice medication list, and hospice plan of care.2. The facility failed to obtain Resident #9's most current Interdisciplinary Group Meeting. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public, for 1of 6 resident's rooms (Resident #5) and 1 of 4 halls (300 hall) reviewed for physical environment. The facility failed to secure loose flooring under Resident #5's bed and wallpaper behind the headboard in Resident #5's room. The facility failed to secure loose baseboard in the hallway of hall 300. These failures could affect all residents, staff, and the public by placing them at risk of not having a safe, clean, sanitary, and comfortable environment.

Inspectors wroteBased on observations, interviews, and record review the facility failed to follow their own established smoking policy for the 1 of 2 residents (Resident #40) reviewed for smoking policies. The facility failed to follow the smoking policy and ensure Resident #40 had a safe smoking evaluation completed quarterly. This failure could place residents at risk of an unsafe smoking environment and an increased risk of injury related to smoking.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure that residents identified as PASSR received specialized equipment in accordance with their PASRR Comprehensive Service Plan (PCSP) Form and failed to submit a request for specialized services in the LTC (Long Term Care) Online Portal for 1 of 8 (Resident #1) residents reviewed for PASRR services in that: The facility failed to submit for a Customized [NAME] Wheelchair (CMWC) for Resident #1 as deemed necessary in the PASRR Comprehensive Service Plan dated 03/03/2026. This failure could place residents identified as PASRR due to mental illness, developmental delay or intellectual delay at risk for not receiving specialized services and equipment to meet their needs and enhance their highest level of functioning.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident who was unable to carry out activities of daily living, received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 3 of 17 residents (Resident #1, Resident #2, Resident #3) reviewed for ADL care. The facility failed to ensure Resident #1, Resident #2 and Resident #3 were routinely showered/bathed. This failure could place residents at risk of not receiving services or care, decreased quality of life, and decreased self-esteem.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide necessary care and services to ensure a resident who was unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming and personal and oral hygiene for 4 of 5 residents (Resident #1, Resident #2, Resident #3, Resident #4) reviewed for quality of life. The facility failed to provide Resident #1's, Resident #2's, Resident #3's and Resident #4's assigned showers for the month of November 2025. This failure could place residents at risk of not receiving the services and care needed, decreased self-esteem, and a decreased quality of life.

Inspectors wroteBased on interviews, and record review the facility failed to protect the resident's right to be free from physical abuse by a staff member for 1 of 23 residents (Resident #34) reviewed for resident abuse. 1. The facility did not ensure Resident #34 was free from abuse when CNA D grabbed her shirt and pulled her towards her to question her about another resident and then hit her on her left arm on 02/23/25. The non-compliance was identified as PNC. The IJ began on 02/23/25 and ended on 02/24/25. The facility had corrected the noncompliance before the survey began. These failures could place residents at risk at risk of abuse, physical harm, mental anguish, and emotional distress.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the right to be free from misappropriation of resident property for 2 of 23 residents reviewed for misappropriation of resident property. (Resident # 9 and Resident #63) The facility failed to protect Resident #9 from misappropriation of his personal funds when CNA D and CNA E attempted an ATM transaction for $200.00 on 2/21/2025 with unauthorized use of Resident #9's debit card. The facility failed to protect Resident #9 from misappropriation when Resident #63 used Resident #9's debit card and gave it to CNA E and CNA D to withdraw money that was not authorized by Resident #9 to allow CNA E and CNA D to use his debit card. The facility failed to prevent unauthorized transactions on Resident #9's debit card account on 1/27/25, 2/6/25, 2/7/25, and 2/10/25. An IJ was identified on 05/09/25. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. The facility failed to follow their policy on abuse for 1 of 23 residents (Resident #9) reviewed for abuse. The facility failed to implement their abuse policy and failed to protect Resident #9 from misappropriation of his personal funds when CNA D and CNA E attempted an ATM transaction on 02/21/25 using Resident #9's debit card associated with his personal bank account. The facility failed to implement their policy when they failed to conduct an investigation of misappropriation of Resident #9's monies and unauthorized transactions. An IJ was identified on 05/09/25. The IJ template was provided to the facility on [DATE] at 06:29 PM. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, or not later than 24-hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury, to the administrator of the facility and to other officials (which included the State Survey Agency and Adult Protective Services where state law provides for jurisdiction in long-term care facilities) in accordance with State Law through established procedures for 3 of 23 residents (Resident #'s 9, Resident #126, and Resident #54) reviewed for abuse [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 17 resident (Resident #'s 62) reviewed for accidents. The facility failed to have a system in place to identify transfer needs of Resident #62 identified as high risk for falls to prevent injuries. The facility failed to evaluate and revise interventions after Resident #62 who was identified as being at risk for fall and suffered injuires from falls. The facility failed to ensure CNA B used a gait belt during transfer on 01/06/25 which resulted in a fractured left ankle for Resident #62. The facility failed to ensure CNAs B and L performed a correct mechanical lift transfer on 05/05/25 for Resident #62. These failures could place residents at risk of accidents that could result in serious injury, harm, impairment, or death.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. The facility did not ensure: 1. The deep fryer was clean 2. Hair restraints were worn. 3. Microwave was clean 4. The dome covers were stacked with water pooled in between them. 5. Muffin pan was free from food residue. 6. Ice machine was free from hair. These failures could place residents at risk for foodborne illness.

Inspectors wroteBased on interviews and record reviews the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 17 of 17 residents (Resident #'s 62, 58, 7, 2, 46, 275, 65, 18, 42, 54, 17, 52, 69, 39, 31, 5 and 1) reviewed for high risk for falls. The facility failed to develop and implement personalized high fall risk care plans and provide adequate supervision and interventions to prevent falls and injuries for 17 residents identified as being a high fall risk. -Resident #'s 62, 58, 7, 2, 46, 275, 65, 18, 42, 54, 17, 52, 69, 39, 31, 5, and 1 was identified as a high fall risk. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 1 of 2 residents reviewed for quality of care. (Resident #5) 1. The facility failed to provide interventions for Resident #5's right hand contracture on 05/05/25 at 10:02 AM, 11:31 AM, and 2:30 PM. 2. The facility failed to provide interventions for Resident #5's right hand contracture on 05/06/25 at 8:22 AM, 10:48 AM, and 12:07 PM. 3. The facility failed to provide interventions for Resident #5's right hand contracture on 05/07/25 at 09:18 AM and 12:25 PM. These failures could place residents who had contractures at risk of not attaining/or maintaining their highest level of physical, mental, and psychosocial well-being.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure all drugs were stored in a locked compartment, only accessible by authorized personnel for 1 of 6 resident (Resident #15) reviewed for pharmacy services and 2 of 9 (Hall-300 and Hall-200 nurse's) medication carts reviewed for storage of medications. 1. RN WW did not ensure Hall-300 medication cart was locked when medication cart was left unattended on 05/05/25. 2. LVN FF did not ensure Hall-200 medication cart was locked when medication cart was left unattended on 05/08/25. 3. The facility did not ensure Resident #15's Gabapentin (treat pain) label from the pharmacy matched the orders placed in the electronic charting system. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food that was palatable and served at an appetizing temperature for 3 of 23 residents (Residents #3, #28, #19) and 1 of 1 lunch meal reviewed for palatability. The facility did not provide palatable food served at an appetizing temperature or taste to residents who complained the food was cold, bland and did not taste good. This failure could place residents who ate food from the kitchen at risk of weight loss, altered nutritional status, and diminished quality of life.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 3 residents (Resident #20 and Resident #10) and 1 of 1 linen cart (hall 200) reviewed for infection control practices. 1. The facility failed to ensure the Treatment Nurse wore Proper PPE (gown and gloves) while providing wound care to Resident #58 on 05/07/25. 2. The facility failed to ensure CNA N changed her gloves while providing incontinent care for Resident #10 on 05/06/25. 3. The facility did not ensure the clean linen cart on Hall-200 was covered. These failures could place any resident at the facility at risk for cross-contamination and spread of infection.

Inspectors wroteBased on interview and record review, the facility failed to implement, and maintain an effective training program for all new and existing staff consistent with their expected roles for 3 of 13 employees (LVN FF, DON, and ADON XX) reviewed for training. The facility failed to ensure the 2 hour yearly training was provided to licensed staff LVN FF, DON, and ADON XX on pharmacology, emergencies, mental disorders, or legal/ethical aspects. This failure placed residents at risk for unmet needs due to untrained staff.

Inspectors wroteBased on interviews and record review, the facility failed to ensure resident had the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers. for 3 of 21 (Residents #39, Resident #58, and Resident #33) residents reviewed for psychoactive medications. 1. The facility did not ensure a written consent was obtained for Ativan (antianxiety medication) an ingredient used in her order for ABH(Ativan, Hadol and Benadryl) for Resident #39. 2. The facility failed to ensure Resident #58 had signed a psychotropic consent for Clonazepam (antianxiety). 3. The facility failed to ensure Resident #33's paroxetine (antidepressant medication) was discontinued when he did not consent to the medication on 04/01/25. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident was informed before, or at the time of admission, and periodically during the residents stay, of services available in the facility and of changes for those services, which included changes for services not covered under Medicare/Medicaid or by the facility's per diem rate for 1 of 3 residents (Resident #50) reviewed for Medicare/Medicaid coverage. The facility failed to ensure Resident #50 was given a NOMNC (is a notice that indicates when your care is set to end from a home health agency, skilled nursing facility, comprehensive outpatient rehabilitation facility, or hospice) when discharged from skilled services prior to his covered days being exhausted. This failure could place residents at risk for not being aware of changes to provided services.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents had a right to personal privacy and confidentiality of medical records for 1 of 23 residents (Resident #5) reviewed for privacy and confidentiality. The facility did not ensure RN WW closed Resident #5's EMR before entering his room to administer his medications on 05/06/25. This failure could place residents at risk for low self-esteem, loss of dignity, and decreased quality of life due to medical records being accessible to others.

Inspectors wroteBased on interview and record review the facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment, including misappropriation of resident property were thoroughly investigated for 1 of 23 residents (Resident #9) reviewed for abuse. 1. The facility failed to thoroughly investigate and failed to protect Resident #9 from misappropriation of his personal funds when CNA D and CNA E attempted an ATM transaction on 02/21/25 using Resident #9's debit card associated with his personal bank account. 2. The facility failed to thoroughly investigate and failed to protect Resident #9 from misappropriation of his personal funds when staff reported allegations of misappropriation. These failures could place residents at risk for abuse, neglect, exploitation, mistreatment, and further injuries of unknown source.

Inspectors wroteBased on record review and interviews, the facility failed to ensure completion of a discharge summary including a recapitulation of the resident's stay, and final status at discharge for 1 of 2 residents (Resident #73) reviewed for discharge summary. The facility failed to complete a discharge summary for Resident #73. This failure could place residents at risk of not having complete records after permanent discharge from the facility.

Inspectors wroteBased on interview and record review the facility failed to facilitate resident and family participation in the care planning process for 1 of 23 residents (Resident #7) reviewed for care plans. The facility failed to ensure Resident #7 had a care plan meeting. These failures could place residents at risk of not having needs met by depriving them the opportunity to participate in the decision making regarding their care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene for 1 of 23 residents reviewed for ADLs. (Resident #7) The facility failed to ensure Resident #7 received his shower as scheduled. This failure could place residents at risk of not receiving services/care, decreased quality of life, and decreased self-esteem.

Inspectors wroteBased on interview and record review the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise for 1 of 5 residents reviewed for nutritional status (Resident #5). 1. The facility failed to ensure Resident #5's enteral feeding (a form of nutrition that is delivered into the digestive system as a liquid form via the feeding tube) was administered as ordered by the physician on 05/06/25. This failure could place residents at risk for malnourishment, illness, skin breakdown, and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 1 of 1 resident (Resident #5) reviewed for enteral nutrition. The facility did not ensure RN WW checked Resident #5's G-Tube (a tube directly inserted through the skin to the stomach to deliver nutrition) stomach content residual and placement prior to medication administration. This failure could place residents with gastrostomy tube at risk for complications, aspiration, and pneumonia.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure respiratory care was provided with professional standards of practice for 1 of 3 residents reviewed for quality of care. (Resident #5) The facility failed to ensure Resident #5's had a physician's order to receive oxygen. This failure could place residents who receive respiratory care at risk for developing respiratory complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that resident who require dialysis receive such services consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 1 of 4 residents (Resident #7) reviewed for quality of care. The facility failed to ensure Resident #7 had a physician's order for dialysis treatment. The facility failed to ensure there was a physician's order for Resident #7's dialysis catheter and to monitor for complications. These failures could place the residents, who received dialysis, at risk for complications and not receiving proper care and treatment to meet their needs.

Inspectors wroteBased on interviews, and record review, the facility failed to ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for 2 of 3 residents (Resident # 39 and Resident #34) reviewed for trauma-informed care. 1. The facility did not ensure Resident #39 had the diagnosis of PTSD also known as post-traumatic stress disorder (a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event), and the triggers listed on his care plan. Resident #39 had a history of trauma. 2. The facility did not ensure Resident #34's trauma screening was completed upon admission to the facility. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure that licensed staff were able to demonstrate the specific competencies and skill sets necessary to care for residents' needs for 1 of 1 nurse (RN WW) reviewed for nursing services. The facility did not ensure RN WW check residual and placement by aspiration of gastric content of the resident. This failure could place residents with gastrostomy tube at risk for complications, aspiration, and pneumonia.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate dispensing and administering of all drugs and biologicals to meet the needs of each resident for 1 of 6 residents (Residents #5) reviewed for pharmacy services. 1. The facility did not ensure Resident #5 was given Mucinex (expectorant that helps loosen and thin mucus in the airways) DM (cough suppressant) 30-600 mg. This failure could place residents at risk of having an exacerbation of their disease processes.

Inspectors wroteBased on interview and record review the facility failed to ensure that residents were free of significant medication errors for 1 of 6 residents reviewed for pharmacy services. (Resident #30) The facility failed to reorder Resident #30's lorazepam (antianxiety medication) tablet timely resulting in Resident #30 having 6 missed doses. This failure could place the resident at risk of medical complications and not receiving the therapeutic effects of their medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received therapeutic diets that were prescribed by the attending physician for 2 of 21 residents (Resident #10 and Resident #29) reviewed for therapeutic diets. 1. The facility failed to ensure Resident #10 received her fortified food, Ensure Clear, or water on 05/05/25 as indicated on her tray card. 2. The facility failed to ensure Resident #29 received fortified foods with his lunch meal on 05/05/25. The facility did not ensure Resident #29 was given his fortified food on 05/05/25 as indicated on his tray card. These failures could place residents at risk for poor intake, weight loss, unmet nutritional needs, and a loss of dignity. Findings Included: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their own established smoking policy for 2 of 4 residents (Resident #35 and Resident #62) reviewed for smoking. The facility failed to follow the policy on smoking by not completing a smoking screen assessment quarterly on Resident #35 and Resident #62. This failure could place residents at risk of unsafe smoking and injury.

Inspectors wroteBased on observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 6 of 6 residents (Resident #s 1, 2, 3, 5 and 6) and 5 of 5 staff (Staff NA B, NA C, MA D, NA F, and LVN G) reviewed for infection control. The facility failed to follow their policy when they did not ensure the following: -Resident #2 remained on isolation for 10 days and/or wear appropriate PPE when not in his room. -NA B washed or sanitized her hands and donned appropriate personal protective equipment (PPE) when she entered and exited Resident #1 and 2's room. [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for 1 of 1 dining room reviewed for resident rights. 1. The facility did not ensure CNA C and MA D treated residents with dignity and respect by referring to them as feeders. 2. The facility failed to ensure LVN A fed Resident #1 while sitting down. This failure could place residents at an increased risk of embarrassment, isolation, and diminished quality of life.

Inspectors wroteBased on interviews, and record review the facility failed to ensure residents were free from abuse for 7 of 13 residents (Residents #3, #4, #5, #6, #7, #8 and #9) reviewed for resident abuse. 1. The facility did not ensure Resident #3 was free from abuse when Resident #9 shoved Resident #3 on 8/19/24. 2. The facility did not ensure Resident #6 was free from abuse when Resident #5 hit Resident #6 with her silverware packet on 8/28/24. 3. The facility did not ensure Resident #3 was free from abuse when Resident #4 hit Resident #3 on the back of the head 10/17/24. 4. The facility did not ensure Resident #7 was from abuse when Resident #8 hit Resident #7 on the head 12/20/24. These failures could place residents at risk of abuse, physical harm, mental anguish, and emotional distress.

Inspectors wroteBased on interview and record review, the facility failed to implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents, 4 of 13 (Residents #3, #4, #5, and #6) reviewed for abuse. 1. The facility did not implement their policy on reporting abuse to state agency for a resident-to-resident altercation that occurred on 10/17/24 between Resident #3 and Resident #4 2. The facility did not implement their policy on reporting abuse to state agency for a resident-to-resident altercation that occurred on 08/28/24 between Resident #3 and Resident #4. These deficient practices could place residents at risk for abuse, neglect, and not having their needs met.

Inspectors wroteBased on interview, and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source were reported immediately, but no later than 2 hours after the allegation was made, for 4 of 13 (Residents #3, #4, #5, and #6) residents reviewed for reporting. 1. The facility did not report the resident-to-resident altercation between Resident #3 and Resident #4 to the State Survey Agency within 2 hours of been notified. 2. The facility did not report the resident-to-resident altercation between Resident #5 and Resident #6 to the State Survey Agency within 2 hours of been notified. These failures to report could place the residents at risk for abuse.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 1 of 3 (Resident #1) residents reviewed for quality of care. The facility failed to ensure LVN A assessed Resident #1 buttocks after CNA B reported that Resident #1 had skin issues. This failure could place residents of risk for not receiving appropriate care and treatment, a decreased quality of life, and pressure ulcers.

Inspectors wroteBased on interview and record review the facility failed to ensure each resident was informed before, or at the time of admission, and periodically during the residents stay, of services available in the facility and of changes for those services, which included changes for services not covered under Medicare/Medicaid or by the facility's per diem rate for 3 of 4 residents (Resident's #30, 183 and 185) reviewed for Medicare/Medicaid coverage. The facility failed to ensure Resident #30, Resident #183, and Resident #185 were given a Skilled Nursing Facility Advanced Beneficiary notice of non-coverage ({SNF ABN}, which is a document that informs a Medicare beneficiary that Medicare will no longer pay for skilled services) when discharged from skilled services at the facility before covered days were exhausted. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure assessments accurately reflected the resident status for 4 of 24 residents (Resident # 17, Resident #38, Resident #49, and Resident #53) reviewed for MDS assessment accuracy. The facility failed to ensure Resident # 17's, Resident #38's, Resident #49's, and Resident #53's anticoagulant (blood thinner) use was accurately coded. These failures could place residents at risk for not receiving care and services to meet their needs. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs, for 4 of 15 residents (Resident's #44, #51, #5, and #47 ) reviewed for care plans. 1. The facility failed to care plan Resident #44's Lorazepam (antianxiety medication) and interventions. 2. The facility failed to care plan Resident #51's Eliquis (blood thinner medicine that reduces blood clotting) and interventions. 3. The facility failed to care plan Resident #5's fall and interventions. 4. The facility failed to ensure palliative care was care planned for Resident #47. These failures could place the residents at increased risk of not having their individual needs met and a decreased quality of life.

Inspectors wroteBased on observations, interviews, and record review the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this was not possible or resident preferences indicate otherwise for 3 of 8 residents (Resident #1, Resident #34, and Resident #49) reviewed for nutrition. The facility failed to ensure Resident #1 received his magic cup with his meals. The facility failed to ensure Resident #34 received his health shake. The facility failed to ensure Resident #49 received her Nutritious Shake. These failures could place residents at risk for malnourishment, weight loss, skin breakdown, and decreased quality of life.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure that residents requiring respiratory care were provided such care, consistent with professional standards of practice for 6 of 14 residents (Residents #44, #51, #17, #60, #47, and #53) who were reviewed for respiratory care. 1. The facility failed to ensure Resident #44 had an oxygen order. 2. The facility failed to ensure Resident #51's oxygen filter on the oxygen concentrator filter was cleaned. 3. The facility failed to ensure Resident #17's oxygen filter on the oxygen concentrator filter was cleaned weekly and Resident #17's oxygen nasal cannula tubing was bagged when not in use. 4. The facility failed to ensure Resident #60's oxygen concentrator filter was cleaned weekly. 5. The facility failed to ensure Resident #47's nebulizer mask was placed in a bag after use. 6. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure all drugs were stored in a locked compartment, only accessible by authorized personnel and all drugs and biologicals used in the facility were labeled in accordance with professional standards for 1 of 1 treatment carts, 2 of 5 medication carts (100 Hall Nurse Cart, 300 Hall Nurse Cart and the 400 Hall Nurse cart), 1 of 1 medication storage room reviewed for drugs and biologicals, and 3 of 3 Residents. (Resident #49, Resident #233, Resident #52) The facility failed to ensure the Treatment Cart and the 400 Hall Nurse cart were secured and unable to be accessed by unauthorized personnel. The facility failed to label medications with an open date for Resident #49's insulin pen and Resident #52's and Resident #233's inhalers on the 100 Hall Nurse cart. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that menus were followed for the noon time (lunch) meal to meet the nutritional needs for the residents on a pureed food consistency diet ( 5 of 5) residents were reviewed for puree food consistency diet. 1. The facility served the residents on a pureed food consistency diet the wrong scoop size servings on the macaroni and cheese for the noon time (lunch) meal on 3/25/24. 2) The facility failed to follow puree recipe for lunch meal served on 3/26/24. 3) The Dietary Staff failed to serve the puree residents puree bread on the 3/25/24. This failure affected all residents in the facility who required pureed food consistency by placing them at risk of not receiving adequate nutritive food value needed to promote/maintain health.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature for 4 of 4 residents (Resident #23, Resident #49, Resident #47 and Resident #17), 1 of 3 meals were reviewed for palatability, attractiveness, and appetizing. 1) The dietary staff failed to provide food that was palatable and appetizing temperature for Resident #23, Resident #49, Resident #47 and Resident #17. These failures could place residents at risk of decreased food intake, hunger, and unwanted weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in (1 of 1) kitchen reviewed for dietary services. 1) The Dietary staff failed to date all food items. 2) The Dietary staff failed to dispose of expired food items in the refrigerator. 3) The Dietary staff failed to effectively seal, label, and date refrigerated food items. 4) The Dietary staff failed to to repair a leak in the kitchen ceiling. These failures could place residents at risk for food contamination and foodborne illness.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 4 of 4 reviewed (Resident #38 and Resident #47, Resident #14, and Resident #66 ) for infection control practices. 1. The failed to ensure CNA X performed hand hygiene or change gloves while providing incontinent care for Resident #38. 2. The facility staff failed to properly dispose of used PPE in the biohazard bin. 3. The facility failed to ensure CNA D did not leave trash and a sheet in Resident #14's room after providing care to her. 4. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for 1 of 24 residents (Resident #55) reviewed for resident rights. The facility failed to ensure CNA O knocked on Resident #55's door prior to entering his room. This failure could place residents at risk for diminished quality of life, loss of dignity and loss of self-worth.

Inspectors wroteBased on interview and record review the facility failed to ensure residents had the right to be informed of and participate in his or her treatment which included, the right to be informed in advance, by the physician or other practitioner or other professional, of the risks and benefits of proposed care, treatment and treatment alternatives or treatment options to choose the alternative or option he or she preferred for 1 of 4 residents (Resident #38) reviewed for right to be informed The facility failed to obtain an informed consent based on the information of the benefits and risks for Resident #38 before administering Bupropion, an antidepressant medication, used to treat depression. This failure could place residents at risk of receiving medications they had not consented to, experiencing potential adverse reactions, and a potential decline in physical and mental health status.

Inspectors wroteBased on interviews and record review, the facility failed to ensure each resident had the right to make choices about aspects of his or her life in the facility that were significant to the resident for 1 of 24 residents (Resident #23) reviewed for self-determination. The facility failed to ensure Resident #23 was provided showers instead of bed baths per her request. This failure could place residents at risk for being denied the opportunity to exercise his or her autonomy regarding things that are import in their life and decrease their quality of life.

Inspectors wroteBased on interview and record review, the facility failed to immediately notify the resident's representative(s) when there was a significant change in the resident's physical status for one (Resident #62) of 18 residents reviewed for changes in condition, in that: The facility failed to notify Resident #62's RP after she had abnormal hemoglobin lab values and required a blood transfusion. This failure placed residents at risk of a delay in treatment and their responsible party not being informed and involved in care decisions.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the residents' right to privacy during personal care for 1 of 24 residents (Resident #36) reviewed for privacy. The facility failed to ensure LVN F provided privacy for Resident #36 while she administered his g-tube medications (gastrostomy tube is a tube that gives direct access to the stomach for administration of medications and feedings). This failure could place residents at risk of having their bodies exposed to the public, low self-esteem, and a diminished quality of life.

Inspectors wroteBased on interviews and record review, the facility failed to implement written policies and procedures to prohibit and prevent abuse, neglect, and exploitation for 1 of 20 staff (Dietician) reviewed for develop and implement abuse policies. The facility failed to ensure the Human Resource Manager implemented the facility's abuse/neglect policy and procedure when she failed to complete an Employee Misconduct Registry (EMR) check and Criminal History check for the dietician upon hire. This failure could place residents at risk for abuse, neglect, exploitation, and misappropriation of property.

Inspectors wroteBased on observation, interview, and record review the facility failed to review and revise the person-centered care plan to reflect the current condition for 1 of 3 (Resident #44) residents reviewed for care plan revisions. The facility failed to update Resident #44's care plan for her Bipap (a machine that helps you breathe) being discontinued. This failure could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs. 1. Record review of Resident #44's face sheet, dated 03/28/24, indicated a [AGE] year-old female who was admitted to the facility on [DATE] and re-admitted on [DATE] with the diagnoses which included anxiety (a feeling of fear, dread, and uneasiness), diabetes, chronic obstructive pulmonary disease (no airflow for breathing), and stroke. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident who was unable to carry out activities of daily living, received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 24 residents (Residents #23) reviewed for ADL care. The facility failed to ensure Resident #23 was routinely showered/bathed. This failure could place residents at risk of not receiving services or care, decreased quality of life, and decreased self-esteem.

Inspectors wroteBased on interview and record review the facility failed to arrange an appointment with an outside resource for 1 of 24 residents (Resident #66) reviewed for the use of outside resources. The facility failed to ensure Resident #66's appointments with nephrology (specialty for kidneys/kidney disease, function) and with hematology (specialty for blood and blood diseases) were scheduled after she discharged from the hospital on [DATE]. This failure could place residents at risk of not receiving needed medical care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medical record was complete and accurately documented for 1 of 24 residents (Resident #66) reviewed for resident records. The facility failed to ensure Resident #66's allergy to Zyvox (antibiotic) and Heparin (anticoagulant medication) were added to her list of allergies after she re-admitted from the hospital on [DATE]. This failure could place residents at risk of receiving medications they are allergic to and inaccurate medical records.

Inspectors wroteBased on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 1 of 3 residents (Resident #1) reviewed for hospice services. The facility failed to obtain Resident #1's physician's order for hospice services, most recent physician order, and the most recent hospice plan of care. The facility failed to obtain the most recent hospice certification. This deficient practice could place residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs.

Inspectors wroteBased on interview and record review, the facility failed to develop, implement, and maintain annually an effective training program for existing staff, consistent with their expected roles for 1 of 20 employees (Dietician) reviewed for required annual trainings. The facility failed to ensure the Dietician received required dementia training upon hire 07/17/23. These failures placed residents at risk for unmet needs due to untrained staff.

Inspectors wroteBased on observations, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 3 residents (Resident #1) reviewed for comprehensive person-centered care plans. The facility failed to develop and implement a care plan for Resident #1's wound care to the left breast. This failure could place residents at risk of not having individual needs met and a decreased quality of life.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure all drugs were stored in a locked compartment and only accessible by authorized personnel for 1 of 12 (Resident #1) residents reviewed for medication storage. The facility failed to keep medication being administered under the direct observation of the person administering medications. Resident #1 had a medication cup with 1 tablet and 1 capsule sitting on top of his bedside table on 02/15/2024. This failure could place residents at risk for health complications and not receiving the intended therapeutic benefit of their medication.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases or infections and the facility failed to ensure linens were handled, stored, processed, and transported to prevent the spread of infection for 3 of 4 halls (100 hall, 200 hall, and 400 hall), and 3 out of 79 employees (CNA C, CNA D, CNA E) reviewed for infection control practices. 1. The facility did not ensure the clean linen carts (on 100 hall, 200 hall, and 400 hall) were completely covered on 02/15/2024 while not being used. 2. The facility did not ensure CNA E placed soiled linen and trash in the appropriate barrels after providing care on 02/21/2024. [...]

Inspectors wroteBased on interview and record review the facility failed to not employee and individual that was found guilty of mistreatment in a court of law for 1 of 6 employees reviewed (Kitchen Staff A) The facility allowed Kitchen Staff A to work at the facility for about 18 months without accurate criminal history check. Kitchen Staff A had a conviction with an absolute bar to employment. This facility failure put residents at risk for mistreatment.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the resident environment remained free of accident and hazards for 2 of 5 residents (Resident #1 and #2) reviewed for accident hazards. NA B did not obtain the assistance of certified or licensed personnel before using the mechanical lift ( a is used by caregivers to safely transfer patients) to transfer Resident #1 to her bed. CNA C and CNA H did not ensure the brakes were locked on Resident #2's bed before lowering him into the bed with the Mechanical lift. These failures could place dependent residents at risk for falls, significant injuries and decreased quality of life.

Inspectors wroteBased on observations, interviews, and record review the facility failed to treat each resident with respect and dignity and provide care in a manner that promotes maintenance or enhancement of his or her quality of life for 1 of 2 residents (Resident #2) reviewed for resident rights. The facility did not ensure Resident #2's door was closed while performing a mechanical lift transfer. This failure could place residents at risk for diminished quality of life, loss of dignity and self-worth.