Guardian Care and Rehabilitation Center

Inspectors wroteBased on interview and record review, the facility failed to demonstrate that they developed, maintained and implemented a training program for an existing Social Services Designee/Assistant (SSA, a support professional who works under the direction of a licensed social workers to help individuals and families in need, connecting them with the resources and services they need to improve their lives), as the facility was unable to provide documentation verifying that the SSA had completed the required training. This failure had the potential to result in the SSA lacking the knowledge and skills necessary to safely and effectively provide social services and meet the needs of residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate assistance with activities of daily living (ADLs-normal daily functions required to meet basic needs such as bathing, toileting, eating, dressing, and including nail care) for one of three sampled residents (Resident 1) when, Resident 1's fingernails were untrimmed with a brown substance found underneath the nails on 6/23/26. This failure had the potential to cause discomfort, skin impairment, infection, and could negatively affect Resident 1's self-esteem and psychosocial well-being.

Inspectors wroteBased on observation, and interview, the facility failed to ensure a clean, comfortable, and home-like environment for a census of 99 when: 1. Shower room [ROOM NUMBER] contained black discoloration on the flooring tiles and in the cracks where the floor met the wall, the shower head and handle contained areas of white discoloration, the emergency call light string had brown and pink discoloration and was stuck to the wall, the metal container that held the soap had orange rust on the right side, 2. The baseboard on the hallway shared by station 1, station 2 and the kitchen, was pulling away from the wall and was compacted with dust and debris, the baseboard appeared water damaged; and, 3. The plastic protective covering on the wall in room [ROOM NUMBER] behind bed B, was peeling away from the wall with gaps containing dust. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1)'s Responsible Party (RP, person responsible for making health care decisions), was informed and consented to the use of psychotropic medication (medication that alters perception, mood, consciousness and behavior) prior to administration of the medication. This failure deprived Resident 1's responsible party RP of the right to make an informed decision regarding Resident 1's care and resulted in Resident 1 receiving seven doses of a psychotropic medication against the RP's wishes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide infection prevention and control measures to prevent the possible spread of Clostridioides difficile (C. diff- a bacterium causing severe, often hospital-acquired, diarrhea, and colitis, frequently triggered by antibiotics disrupting normal gut flora) for a census of 93; when staff failed to perform appropriate hand hygiene (act of cleaning one's hands to remove harmful and unwanted substances) between residents. This failure put residents at risk of contracting C. diff, with the potential of causing illness or death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure professional standards of quality care were met for one of three sampled residents ( Resident 1) when Resident 1 did not receive care for her urinary incontinence (lack of bladder control) in a timely manner. This failure placed Resident 1 at risk for skin breakdown and infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement preventative measures to discourage drug seeking behavior/drug use for one of three sampled residents (Resident 1) when Resident 1's urine test results was positive for Cocaine (an addictive drug used as an illegal stimulant) on 7/18/25, and Cannabis (commonly known as marijuana, weed, and pot, which is a psychoactive drug that produces effects, ranging from relaxation to altered perception) on 7/18/25, 8/21/25, 9/25/25 and 12/6/25. These failures posed potential risks to Resident 1's safety, risked potential drug interactions with prescribed medications, and risked changes in level of consciousness for Resident 1 which put Resident 1, and other residents at the facility, at risk for accidents/injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accommodate the needs for one out of three sampled residents (Resident 1), when Resident 1's call light (device used to contact staff for assistance) was not within Resident 1's reach. This deficient practice placed Resident 1 at increased risk for unmet care needs, delayed staff response, and potential for accidents or injury.

Inspectors wroteBased on interview, and record review, the facility failed to submit a summary of investigation of an alleged unusual incident/injury report to the Department within five (5) working days, as required, following a fracture incident for one of three sampled residents (Resident 1). This failure placed Resident 1 at potential risk for further injury.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide food storage, as well as maintain kitchen equipment and food contact surfaces in accordance with professional standards for food safety for the 93 residents who ate facility prepared meals when:1. Four sheet pans (sheet pan, a flat, rectangular metal pan with a raised rim on all four sides, used in ovens for baking, roasting, and broiling foods) were found with dark brown build-up; and,2. A food item (pie) in the freezer was not labeled with a use-by date and expiration date. These failures had the potential to expose 93 residents to foodborne illnesses (illnesses caused by the ingestion of contaminated food or beverages).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the use of supplemental oxygen was provided in accordance with professional standards of practice for two out of three sampled residents who received oxygen therapy (Resident 2, and Resident 3) when, oxygen in use signage was not posted at Resident 2's, and Resident 3's doorway. This failure had the potential to result in negative impacts on the health and safety of Resident 2, Resident 3, other residents in the facility, staff, and visitors.

Inspectors wroteBased on interview, and record review, the facility failed to provide adequate supervision and ensure an accident-free environment for one of three sampled residents (Resident 103) when, Resident 103 fell while left unsupervised and partially secured in her gurney, in a transportation vehicle during transportation to a dialysis clinic (outpatient facility that provides dialysis treatment to residents with end-stage renal disease (ESRD) or chronic kidney failure, helping to clean their blood of waste and excess fluid when their kidneys cannot) on 7/3/25. This failure potentially resulted in Resident 103 sustaining a mild compression fracture (when the bone is crushed or compressed but not completely broken) in the L3 (the third lumbar vertebra (bone) in the spine located in the lower back that supports body weight).

Inspectors wroteBased on interview and record review, the facility failed to implement and maintain a comprehensive QAPI (QAPI- a data driven and proactive approach to improvement used to ensure services are meeting quality standards) program and plan when the facility did not adhere to its QAPI policy and did not provide documentation or evidence of ongoing QAPI activities. These failures had the potential to impede the facility's ability to identify and correct quality of care issues which could place the residents at risk for unmet physical, psychosocial, and overall health needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive care plan when:A care plan was not developed for Resident 62's face and neck swelling; and,Resident 102's care plan intervention for two person assist with activities of daily living (ADL, skills required for self-care and independent living, including bathing, dressing, toileting, transferring, continence, and feeding) care was not followed. These failures resulted in Resident 62 not having interventions and goals for his face and neck swelling and the potential for injury to Resident 102, negatively impacting Resident 62 and Resident 102's health, safety, and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure professional standards of quality care were met for 2 of 32 sampled residents (Resident 83 and Resident 10), with the potential to affect the full census of 92 when: 1. Resident 83's bilateral foot pain was not assessed for over 24 hours after the licensed nurse (LN) was notified,2. Wounds on Resident 10's right forearm were not assessed for over 48 hours; and,3. Staff providing resident care could not communicate in English. These failures resulted in a delayed assessment, treatment, and pain control for Resident 83 and delayed assessment and treatment for Resident 10. In addition, these failures had the potential to negatively affect Resident 83 and Resident 10's health and well-being and had the potential for all residents in the care of non-English speaking staff to have unmet care needs.

Inspectors wroteBased on interview, and record review, the facility failed to ensure allegations of abuse were thoroughly investigated for one resident (Resident 72) in a census of 92. This failure had the potential for Resident 72 to experience further abuse, negatively affecting their physical and psychosocial well-being.

Inspectors wroteBased on interview, and record review, the facility failed to ensure medications were administered to meet professional standards of practice for 1 out of 32 sampled residents (Resident 7), when Resident 7's medication Midodrine (a blood pressure medication used to treat low blood pressure) was administered outside of physician ordered parameters (standard guidelines from the physician, used to categorize a patient's blood pressure reading and determine the proper course of treatment). This failure had the potential for Resident 7 to experience hypertension (high blood pressure, can damage the arteries and increase the risk of heart disease, and other health problems).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the provision of care and services to ensure 1 of 32 sampled residents ( Resident 80) maintained his highest level of function when staff did not provide range of motion (ROM, the full movement of a joint) exercises to his extremities or hand hygiene to his contracted (shortening or hardening of muscles, tendons, or other tissue leading to a deformity and rigidity of joints) right hand. This failure had the potential for Resident 80 to experience a physical decline, worsening of right arm and hand contractures, and infection to his right hand.

Inspectors wroteBased on interview, and record review, the facility failed to ensure that physician-ordered weekly weights were completed for 1 out of 3 sampled residents (Resident 43) when Resident 43's weekly weight order was not carried out by staff. This failure resulted in Resident 43 experiencing an unmonitored 10-pound weight loss over one month (from 132 pounds on July 3, 2025, to 122 pounds on August 3, 2025), placing the resident at risk for further nutritional compromise and decline.

Inspectors wroteBased on interview, and record review, the facility failed to provide the necessary behavioral health care and services for 1 of 32 sampled residents (Resident 81) when a referral was not made to a psychiatrist (psych, a medical doctor who can diagnose and treat mental health conditions) or psychologist (psych, scientific discipline that studies mental states and processes and behavior in humans) for Resident 81 who had a behavior of food hoarding (keeping or storing food for long periods of time before consuming or discarding the food). This failure had the risk for Resident 81's behavioral health care needs being unmet. It also had the potential for Resident 81 to eat spoiled food and cause a food borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe medication handling practices with a resident census of 92 based on the facility's policy and standards of practice when:1. Medication delivery documents from the provider pharmacy were not consistently signed and documented upon receipt from delivery courier for accuracy and accountability of prescription medication receipt; and, 2. Non-controlled prescription (non-opioid drugs that only prescribed by a doctor) medication destruction and disposition were not consistently documented with co-signature witness by two licensed staff. These failed practices could contribute to unsafe drug handling and risk of drug diversion (drug loss due to unauthorized use).

Inspectors wroteBased on interview, and record review, the facility failed to assess and review the long-term use of two medications, part of a class of drugs called Protein Pump Inhibitors (or PPI, a class of drugs that reduce stomach acid production and works by inhibiting the enzyme known as the proton pump, which is responsible for generating acids for food digestion), on two out of five residents reviewed for unnecessary medications (Resident 7 and Resident 36) based on FDA (or Food and Drug Administrations, a federal agency that addresses safety of medication use) and the manufacturer warnings on long term use of PPI medications. These failures could pose risks of adverse drug effects on vulnerable elderly residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe medication storage practices in one out of two medication rooms (a locked room used to store medications and supplies) and one out of four medication storage carts (a mobile cart stored medications and supplies needed for administration) with a resident census of 92 when:1. Unlabeled discontinued prescription medication box called Kristalose (or lactulose, a laxative drug in power packet form also used to treat liver disease) was stored in the active storage areas of the medication room at Station 1.2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to have 1 of 32 sampled residents (Resident 48) ready in time for a neurologist (medical specialist in the treatment of disorders of the nervous system) appointment. This failure resulted in Resident 48 feeling upset and frustrated due to the missed appointment and had the potential to delay his treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe infection prevention and control practices for 5 of 12 residents (Resident 45, Resident 67, Resident 39, Resident 102, and Resident 49) observed for medication administration when shared glucometers (a device used to measure how much glucose (sugar) is present in the bloodstream at a given moment in time) were not cleaned and sanitized in between resident use. These failures had the potential to spread infection and cause health problems for residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepared, distribute and serve food in accordance with professional standards for food service safety when .1. Dishes were stacked on top of each other while wet; and,2. Pots, pans, and food holding containers were dirty and damaged from use; and,3. A container of scoops, serving ladles, and utensils were left open; and,4. A steamer container had a yellowish residue located inside of it; and,5. A stove top had black sticky grime and food residue on top of it. These failures had the potential of leading to food borne illness in the 94 residents eating facility prepared meals.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure garbage and refuse was properly contained when 1 of 2 outside dumpster lids were observed to be propped open with a stick for a census of 91. This failure had the potential to expose the residents' environment to pests, odors, or diseases.

Inspectors wroteBased on interview and record review the facility failed to use safe and appropriate transfer methods according to resident care needs for one of three sampled residents (Resident 3) when Resident 3 was transferred from a shower chair (a waterproof chair on wheels used to transport residents to and from the shower room) into his bed without the use of a mechanical lift (a device used to safely transfer Resident 3 from one surface to another). This failure could have been the cause of Resident 3 ' s right proximal tibia (upper part of the shin bone where it widened to help form the knee joint) fracture and right lower leg skin breakdown, which could have negatively affected his health and well-being.

Inspectors wroteBased on interview and record review, the facility failed to report a change in condition and/or medical treatment to the physician and the Responsible Party (RP, the person responsible to direct the care of a loved one admitted into a nursing facility) for one of four residents (Resident 4) when: 1. Resident 4 refused her medications on multiple days; 2. Resident 4 refused fingerstick blood sugar monitoring (FSBS, poking a finger to apply a drop of blood to a test strip. The test strip is inserted into a small electronic device which measures blood sugar levels) tests on multiple days; and 3. Resident 4 refused her physical therapy treatments on multiple days. These failures resulted in Resident 4 ' s physician and RP being uninformed of a change in condition, and did not allow for the RP to participate in medical decisions and/or treatment options. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete the required steps prior to discharging one of one sampled resident (Resident 1) from the facility when the reason for discharge was not documented in Resident 1 ' s medical record. This failure resulted in Resident 1's facility initiated discharge not being properly documented in Resident 1's medical record and had the potential to not reflect the actual experience of Resident 1 while in the facility.

Inspectors wroteBased on interview and record review, the facility failed to complete the required steps prior to discharging one of one sampled resident (Resident 1) from the facility when the discharge notice issued to Resident 1 ' s Responsible Party (RP) and sent to the long-term care ombudsman (resident advocate) did not include the correct information on how to appeal the discharge. This failure resulted in Resident 1 ' s RP being uninformed of how to appeal the decision of a facility-initiated discharge and had the potential to cause Resident 1 psychosocial distress.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the right to return to the facility was protected for one of one sampled resident (Resident 1) when Resident 1 was sent to the hospital on [DATE] and was not allowed to return to the facility on [DATE], when the hospital was ready to discharge Resident 1 back to the facility. This placed Resident 1 at risk for emotional distress, depression, and anxiety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Licensed Nurses (LNs) had competencies and skill sets necessary to provide treatment for one of four sampled residents (Resident 4) when milking [massage to help with swelling] of Resident 4's right leg was not done consistently by licensed staff. This deficient practice placed Resident 4 at a potential risk for potential worsening of edema on Resident 4's right leg.

Inspectors wroteBased on interview, and record review, the facility failed to ensure ongoing medication refusals were communicated to the medical doctor in a timely manner for 1 out of 25 sampled residents (Resident 16). This failure could contribute to adverse health consequences and an untreated medical condition when prescribed medication was not administered over a long period of time.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure training, including a written policy and procedure (P&P) was provided for licensed staff regarding the use of continuous glucose monitoring (CGM, tracks your blood sugar levels in real time on a Reader, which captures the data from a sensor inserted under the skin) for nine of nine residents who used CGMs in the facility. This failure had the potential for staff not being competent in the implementation of CGM and increased the risk of residents with CGMs receiving improper blood glucose management and nursing care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe medication labeling and storage practices for a census of 97 when: 1. The medication refrigerator contained undated medication, the sealed Emergency Kit (Ekit- a box containing medications for urgent use) contained drugs covered with white material, and the medication cart in Station 2 contained undated products; 2. Resident 27's chemotherapy medication called capecitabine (or Xeloda, a cancer treatment drug) was not properly labeled, stored, and dispensed as an identifiable hazardous (dangerous) medication; 3. Resident 27's prescribed inhaler was not properly secured or labeled with Resident 27's name or other identifier on the medication; and, 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 of 25 residents (Resident 27) was assessed for the ability to independently use her prescribed inhaler (a device used to administer inhaled medication). This failure had the potential to result in an unsafe self- administration of medication by Resident 27.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the Physician Orders for Life-Sustaining Treatment [POLST- a legal document communicating the resident's medical wishes for end-of-life care] was completed accurately for 1 of 25 sampled residents (Resident 27) when Resident 27's POLST was not signed by the physician. This failed practice could result in Resident 27 not having her choices being honored.

Inspectors wroteBased on interview, and record review, the facility failed to ensure 1 of 25 sampled resident's (Resident 20) Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNFABN-a document that provides information of the potential liability for payment of services not covered by Medicare A, a federal insurance program for specialized services requiring skilled nursing or rehabilitation services) provided the estimated cost of services Resident 20 could be held responsible for. This failure increased the risk of Resident 20 and her representative not having adequate information to make financial decisions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure privacy was protected for one of ten residents observed during medication pass (Resident 37), when a licensed nurse (LN) used a personal phone to take a picture of Resident 37's medication labels which displayed the drug and Resident 37's name. This failure and unauthorized photography of resident's medical information with a personal phone violated medical privacy.

Inspectors wroteBased on interview, and record review, the facility failed to protect the rights of 1 of 25 sampled residents (Resident 45), when Resident 45 informed staff he was missing 25 dollars and the loss was not investigated. This failure had the potential to cause Resident 45 to feel vulnerable and to suffer psychosocial distress.

Inspectors wroteBased on interview, and record review, the facility failed to protect 1 of 25 sampled residents (Resident 62) from misappropriation (the unauthorized use of funds or other property for purposes other than that for which intended) of property and personal belongings, when Certified Nursing Assistant (CNA) 6 took Resident 62's wallet containing money, Automated Teller Machine (ATM) card, health insurance card and ID (Identity Document) without Resident 62's consent. This failure caused Resident 62 emotional distress and had the potential for continued loss and/or theft of other residents' property/money.

Inspectors wroteBased on interview, and record review, the facility failed to report an allegation of stolen property to the facility Administrator and the Department within twenty-four hours for 1 of 25 sampled residents (Resident 22) when, Resident 22 reported to staff her suspicion that staff stole 200 dollars during the first week of July 2024, and the facility reported the incident to the Department on 7/19/24. This failure resulted in Resident 22 feeling upset by the loss, caused a delay in the facility and the Department's investigation of the alleged incident, and placed other residents at risk for abuse by the accused employee.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the comprehensive care plan (an individualized plan for the nursing care) was resident centered, when 1 of 25 sampled resident's (Resident 87) care plan for refusal to wear a smoking apron (protection to prevent burns) while smoking was not revised and updated in a timely manner. This deficient practice had the potential for Resident 87 to not receive education about the risks associated with his expressed choices, and had the potential Resident 87 would be injured while smoking.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 of 25 sampled residents (Resident 89) received activities that met their interests and needs, when Resident 89 did not attend group activities and in room activities were offered infrequently. This failure had the potential to adversely affect the psychosocial needs and well-being of Resident 89.

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure one of seven residents (Resident 38) would remain free of urinary catheter (medical device that helps drain urine from your bladder) complications, when Resident 38's urinary catheter drainage bag was on the floor in his room. This failure had the potential to cause infection and urinary complications for Resident 38.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate care to one of ten residents (Resident 76) who received enternal nutrition (the use of a medical device called a feeding tube to provide liquid nourishment, liquids, and medications directly into the stomach) when Resident 76's enteral tube feeding liquid nourishment was not discontinued approximately five hours past its expiration This failure increased the potential for complications, including, but not limited to; nausea, vomiting, diarrhea, and stomach cramping for Resident 76.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 of 26 residents receiving oxygen (Resident 27) received respiratory care according to professional standards when: 1. Resident 27's nasal cannula (NC- tubing that delivers oxygen into your nose) was not labeled with a date when it was changed; and, 2. Resident 27's oxygen humidifier bottle (a plastic bottle filled with water which moistens the oxygen) was not labeled when it was changed. These failures had placed Resident 27 at risk for infection.

Inspectors wroteBased on interview, and record review, the facility failed to ensure safe use and accountability of controlled narcotic medications (prescription opioid drugs of abuse) when: Resident 91's Norco (Hydrocodone-APAP; an opioid pain medication) was removed from the Controlled Drug Record (CDR, an accountability sheet that tracks narcotic removal with the nurse's initial, date, and time) without the corresponding administration documentation in Resident 91's MAR (Medication Administration Record- a legal document that lists the drugs given to a resident). This failure could contribute to unsafe drug handling, poor pain control, and risk of drug diversion (medication taken by someone other than for whom it is prescribed).

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure the safe use of psychotropic medications (mind altering drugs) for 2 of 25 sampled residents (Resident 45 and Resident 92) when: 1. Resident 45's documented diagnosis of bipolar disorder (a chronic mood disorder that causes intense shifts in mood, energy levels and behavior) in the medical record for use of the mind-altering psychotropic medication called risperidone (or Risperdal, a drug used to treat mental health or behavior issues) was not reflected in the medical doctor's progress notes and assessments. 2. Resident 92's use of PRN (as needed) anti-anxiety medication called alprazolam (or Xanax, a drug used to treat anxious feelings) was not evaluated and re-assessed by the facility and medical doctor despite frequent use. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe food storage for 92 residents who received food service from the kitchen when: 1. Food items were not dated and were not labeled with a use-by date in the refrigerator and freezer; and, 2. Thawing bacon trays were not labeled with a pulled-out date. These failures had the potential to expose residents to food borne illnesses (illnesses caused by the ingestion of contaminated food or beverages).

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection prevention practice for a census of 97 when, 1. Staff placed a dirty cup on the same cart with the clean water pitchers; and, 2. Resident 65's urinal was not labeled with a resident identifier such as his room number or name.

Inspectors wroteBased on interview and record review, the facility failed to ensure the sufficient supply of prescribed medications for one of five sampled residents (Resident 1). This failure resulted in Resident 1 not receiving 43 routine and PRN (as needed) medications during the month of January 2024 and could have resulted in uncontrolled pain and increased discomfort.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe practices in handling hazardous medication (Drugs that pose short-or long-term harm upon exposure to human via skin or inhalation) during storage and administration for a resident census of 85. This failure resulted in the unsafe handling of hazardous medications which could pose health risks to staff and residents.

Inspectors wroteBased on interview and record review, the facility failed to maintain complete and accurate medical records for 2 of 28 sampled residents (Resident 3 and Resident 60) when the hospice (specialized in end-of-life care for all residents with an advanced, life-limiting illness) agency's nurse progress notes were not contained in the clinical record. This failure had the potential to not provide sufficient information that reflected the condition, care, and services provided for Resident 3 and Resident 60.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were followed when a disinfectant cleaning solution to clean the shower chairs after every use was not supplied to five out of five shower rooms in the facility. This failure had the potential for cross-contamination of equipment used in the shower room that could lead to the spread of germ-causing diseases.

Inspectors wroteBased on observation, interview, and facility record review, the facility failed to ensure 1 of 28 sampled residents (Resident 68) had a physicians order, a care plan, and an assessment ordered and developed for safe self administration of medication. Resident 68 and Resident 68's Family Member (FM) 1's wishes were not honored for Resident 68 to continue self administration of medication. These failures had the potential to negatively impact Resident 68's sense of independence, when the medication was removed from his bedside.

Inspectors wroteBased on observation, interview, and record review, the facility failed to report to the Department an injury of unknown origin for 1 of 28 sampled residents (Resident 20) when Resident 20 had a nondisplaced fracture (broken bones that were not moved far enough during the break to be out of alignment) of the left tibia (the shinbone, the larger of the two bones in the lower leg) and fibula (calf bone, the outer and smaller of the two bones in the lower leg between the knee and ankle) on 6/29/23. This failure resulted in a delay in the Departments investigation into Resident 20's fractures, and had the potential for an occurrence of abuse to go undetected.

Inspectors wroteBased on interview, and record review, the facility failed to develop all of the identified components of a baseline care plan, within 48 hours of admission as required, to address resident-specific care needs for 1 of 28 sampled residents (Resident 74) when Resident 74's peripherally inserted central catheter (PICC, a type of long catheter that is inserted through a peripheral vein, often in the arm, passed through to larger veins near the heart and used to give fluids, nutrition, drugs, or other treatments) care plan was not created. This failure had the potential to result in unmet PICC line needs for Resident 74.

Inspectors wroteBased on interview, and record review, the facility failed to implement a comprehensive person-centered care plan (tool that outlines the plan of action that will be implemented during a resident's care) intervention for 1 of 28 sampled residents (Resident 85) when Resident 85's psychological evaluation (psych eval, an assessment by a professional used to determine a resident's mental state and guide recommendations for the best treatment) was not completed. This failure had the potential for Resident 85 to not receive adequate care and unmet psychosocial needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 of 28 sampled residents (Resident 93) was assisted with nail care as a part of Activities of Daily Living (ADLs, normal daily functions required to meet basic needs) when staff did not trim Resident 93's toenails. This failure had the potential for Resident 93 to sustain injury and/or for the resident to acquire an infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a physician's order and person centered care plan for one of four residents (Resident 79) when, Resident 79 did not receive one-to-one feeding assistance during the breakfast meal. This failure could potentially place Resident 79 at risk for health problems related to aspiration (inhaling of food into the airways) including choking and pneumonia.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respiratory care provided was consistent with professional standards of practice for 1 of 28 sampled residents (Resident 57) when: 1. Oxygen therapy was provided without a physician order for Resident 57; and, 2. An oxygen in use sign was not posted outside of Resident 57's room. These failures placed Resident 57 at risk for respiratory distress and inadequate treatment.

Inspectors wroteBased on interview and record review the facility failed to ensure safe monitoring and assessments of high-risk medication (medications that pose harm when not monitored or prevented) use in 3 out of 28 sampled residents (Resident 5, Resident17, and Resident 33) when: 1. The facility did not monitor safety parameters for a blood thinner medication called apixaban (or Eliquis an anticoagulant medication that could cause bleeding) for Resident 5; and 2. The facility did not monitor or provide parameters for safe monitoring of diabetic medications (medications used to treat blood sugar disease) for Resident 5, Resident 17, and Resident 33. These failures could contribute to unsafe medication use and further side effects for Resident 5, Resident17, and Resident 33.

Inspectors wroteBased on observation, interview, and facility record review, the facility failed to ensure 1 resident in a sample of 28 (Resident 83) had a call light that was in working order consistently. This failure resulted in waiting long periods of time for care and had the potential to result in Resident 83's physical and emotional needs to go unmet.