Hampton Post Acute

Inspectors wroteBased on interview and record review, the facility failed to ensure psychotropic medication (a medication capable of affecting the mind, emotions, and behavior) was administered with consent of the resident or authorized representative for one of seven sampled residents (Resident 1) when an informed consent (process in which a patient is educated on the risks, benefits, and alternatives to obtain agreement and permission for care) was not obtained from Resident 1's Responsible Party (Health Care Decision Maker) prior to administration of an anti-psychotic medication (used to treat and manage symptoms for several psychiatric disorders) prescribed on 3/6/26. This failure had the potential for not honoring resident right to be informed about Resident 1's medical treatment including risks, benefits, and other alternatives to treatment.

Inspectors wroteBased on interview and record review, the facility failed to ensure psychotropic medication (a medication capable of affecting the mind, emotions, and behavior) was administered with adequate clinical indication for one of seven sampled residents (Resident 1) when the healthcare nurse practitioner's (who has advanced clinical education and training and share many of the same duties as doctors) progress notes were not readily accessible in Resident 1's electronic file for an anti-psychotic medication (used to treat and manage symptoms for several psychiatric disorders) prescribed on 3/6/26. This failure had the potential for Resident 1 at risk for unnecessary anti-psychotic medication use.

Inspectors wroteBased on interview and record review, the facility failed to maintain accurate and complete records for one of seven sampled residents (Resident 1) when, Resident 1's behavioral health visits progress notes for visit dates of 2/27/26, 3/20/26, and 4/14/26 were not readily available in Resident 1's medical record. This deficient resulted in care and services provided to not be known across all disciplines in order to assist in making medical decisions for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to provide written notice at the time of the position change of the Administrator (ADM) and the Director of Nursing (DON) to the State Agency (SA) when:The current DON started the DON position on 4/21/26, and the facility did not report the change of the DON position to the SA.The current ADM started the ADM position in August 2025 and the facility did not report the change of the ADM position to the SA These failures delayed the SA from verifying that the ADM and the DON were qualified to lead clinical services at the skilled nursing facility, which had the potential to compromise resident safety and compliance with federal and state regulation for a census of 109 residents.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure an environment free of accidents or hazards for one out of three sampled residents (Resident 3) when Resident 3 eloped (when a resident leaves a healthcare facility without notice/authorization) from the facility in a wheelchair and was found at a gas station one quarter mile away from the facility. This failure had the potential to result in injury to Resident 3 during an elopement on 2/18/26.

Inspectors wroteBased on interview and record review, the facility failed to implement a known resident staffing preference for one of four sampled residents, when Resident 1 was assigned to Certified Nursing Assistant (CNA) 1, despite the family's prior request to not have CNA 1 provide care to Resident 1 due to concerns related to a prior care encounter involving a skin issue. This failure had the potential to affect Resident 1's dignity, psychosocial well-being, and right to receive care per preferences.

Inspectors wroteBased on observation, interview, and record review, the facility failed to practice appropriate infection prevention and control measures (evidence-based practices designed to prevent the spread of infections) for 1 of 3 sampled residents (Resident 1), when Certified Nursing Assistant (CNA) 2 did not properly wear the required personal protective equipment (PPE, equipment such as protective clothing, gloves, masks or other garments used to prevent or minimize exposure to hazards) while providing high-contact care to Resident 1 who was on Enhanced Barrier Precautions (EBP, infection control steps used in a healthcare setting to prevent the transmission of multidrug-resistant organisms (MDRO, are bacteria often called superbugs, that are resistant to germs that are difficult to treat and spread rapidly in healthcare settings) that are passed by direct contact with a patient or their [...]

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of potential sexual abuse to the state survey agency within two hours as required by law for one 1 of two 2 sampled residents (Resident 1) when Housekeeper (HK) 1 observed Resident 1 being touched inappropriately by Resident 2 on 2/20/26 in the facility's dining room but did not report the incident to the administration staff until 2/27/26. This failure resulted in a delay of the state survey agency and facility administrative staff from investigating an allegation of potential sexual abuse which had the potential to put Resident 1 and other residents within the facility at risk for ongoing abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 1) was provided with reasonable accommodation of needs when Resident 1's call light (system/device used by residents to call staff for assistance) was not answered in a timely manner. This failure resulted in Resident 1's needs not being met and had the potential to affect Resident 1's psychosocial well-being.

Inspectors wroteBased on interview and record review the facility failed to ensure reasonable accommodation of needs were met for one of three sampled residents (Resident 2) when Resident 2's call light (device used to communicate a need for assistance) was tampered with making in nonfunctional. This failure had the potential risk for Resident 2 to have unmet needs and to suffer physical and psychosocial harm due to the inability to call for assistance.

Inspectors wroteBased on interview and record review the facility failed to ensure they had an effective system in place to investigate and compensate residents for missing items when one of three sampled residents (Resident 1) reported missing items on 12/19/25 and the allegation was not investigated until 2/11/26. This failure caused Resident 1's missing items to not be returned or replaced and had the potential to negatively affect her psychosocial wellbeing.

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 2) when Resident 2's blood sugar was not monitored before meals and Resident 2's scheduled medications to control blood sugar were not administered in a timely manner. These failures had the potential to negatively affect the therapeutic benefits of the medications prescribed to Resident 2 and had the potential for Resident 2 to receive unnecessary doses of insulin (injectable medication used to manage blood sugar levels).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure care plans (a written, personalized document that outlines a resident's health needs, goals, and the specific services or actions required to address them) were developed and implemented when three of four sampled residents (Resident 1, Resident 2, and Resident 3), with diagnosed substance abuse disorder (SUD, a chronic disease characterized by the continued, compulsive use of alcohol or drugs despite experiencing severe, harmful, and negative consequences), did not have care plans in place for SUD.These failures placed Resident 1, Resident 2, and Resident 3 at risk for exit seeking behavior (the purposeful, often repeated, and urgent attempt by a resident to leave the facility) related to the urge to get drugs or alcohol, lack of interventions in place to support the possible withdrawal symptoms, [...]

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive care plan for two of four sampled residents (Resident 1 and Resident 2) following a change of condition when: 1. Mucus was found in the stool of Resident 1 on 12/20/25; and, 2. Blood was found in Resident 2's urine (hematuria) on 1/2/26. These failures placed Resident 1 and Resident 2 at risk of not receiving appropriate and individualized care to meet their needs. 1. Review of Resident 1's medical record titled admission RECORD, indicated Resident 1 was admitted to the facility in late 2024 with diagnoses that included mild chronic kidney disease (long term condition when the kidneys are damaged and cannot filter waste and extra fluid from the blood), Parkinson's disease (a movement disorder of the nervous system) and dementia (a progressive state of decline in mental abilities). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the timeliness of laboratory services ordered by the physician for four of four sampled residents (Resident 1, Resident 2, Resident 3 and Resident 4) when:1. Resident 1's stool sample testing result was delayed following a change of condition on 12/20/25; and, 2. Resident 2's STAT order (a physician's order that needs to be done immediately) results for a CBC (Complete Blood Count - a common blood test to check for an infection), BMP (Basic Metabolic Panel - a common blood test to measure fluid balance, blood sugar and certain electrolytes in the blood), and urinalysis with C&S (Culture and Sensitivity - urine testing to check for urinary tract infection and which germs are causing the infection) were delayed following a change of condition on 1/2/26; and,3. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two of four sampled residents (Resident 1 and Resident 2) medical record's contained an accurate representation of their progress and/or their decline in health status after a change in condition when:1. Mucus was found in the stool of Resident 1 on 12/20/25 and nursing staff did not assess and document on the progress and/or decline in Resident 1's condition every shift; and, 2. Blood was found in Resident 2's urine (hematuria) on 1/2/26 and nursing staff did not assess and document on the progress and/or decline in Resident 2's condition every shift. These failures risked missing any changes or deterioration in the physical, mental, or psychosocial conditions of Resident 1 and Resident 2 after their change of condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate care and services to promote healing and prevent pressure ulcers (a localized injury to the skin and/or underlying tissue because of prolonged pressure) for two of three sampled residents (Resident 1 and Resident 2), when both residents were observed lying on low-air loss mattresses (LAL mattress, a mattress designed to prevent and treat pressure wounds that uses a continuous, gentle flow of air through a surface of tiny holes to reduce pressure helping to prevent and treat skin breakdown and pressure wounds) that were not correctly calibrated according to their individual weights. This deficient practice had the potential to delay wound healing and place Resident 1 and Resident 2 at increased risk for developing pressure ulcers and/or skin breakdown.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Dietary Manager met Federal, California, and facility standards for food service manager. This failure had the potential of leading to food borne illness and malnutrition for the 112 residents eating facility prepared meals. During an interview with the Dietary Manager (DM), on 7/21/25, at 7:54 AM, the DM stated she had not completed the Certified Dietary Manager (CDM) program which had been purchased in January 2025, after starting work as the DM for the facility in December 2024. The DM also stated she was currently working 40 hours a week as the DM. A review of the facility provided job description titled, Certified Dietary Manager, dated October 2020, indicated the following: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the nutritive value of food was maintained when:1. The menu recipe was not followed for the baked ziti with meat sauce and when:2. Resident 30 and Resident 98 did not receive all food ordered on their lunch tray. These failures had the potential of leading to nutrient deficiency for the 112 residents receiving facility prepared meals. 1. During a concurrent observation and interview on 7/22/25, at 9:24 a.m., with Dietary [NAME] (DC) 1 in the food preparation area of the kitchen, DC1 prepared the baked ziti for the lunch meal. After straining the pasta, he split it between two large pans and a quarter size pan and proceed to add meat sauce to the pasta. He added 5 containers to one large steam table pan, 4 containers to a second large steam table pan, and 2 containers to the quarter pan. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide food storage and preparation, as well as maintain kitchen equipment and food contact surfaces in accordance with professional standards for food safety for the 112 residents who ate facility prepared meals when:1. Food items were not labeled properly in the food preparation area and reach-in refrigerator;2. Reach-in refrigerator temperature log was found with missing data for July 2025;3. Three out of four kitchen fans were found with dust buildup;4. Food preparation area had chipped paint;5. Soft and moldy zucchinis and potatoes were found in the walk-in refrigerator, and spices were found beyond the use by date;6. Food products were not fully covered in two out of three reach-in freezers; and,7. The resident's refrigerator had the following:a. [...]

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 implement and maintain a comprehensive QAPI program, and did not provide documentation or evidence of ongoing QAPI activities. These failures had the potential to result in the facility's inability to identify and correct deficiencies which could negatively impact the residents' physical and psychosocial health and well-being.

Inspectors wroteBased on interview and record review, the facility failed to use its Quality Assurance Performance Improvement (QAPI- a data driven and proactive approach to improvement used to ensure services are meeting quality standards) program to develop and implement P&Ps for data collection systems, feedback, monitoring, analysis, and action, including adverse event monitoring when the facility did not collect data (information) or identify corrective measures for any issues affecting the facility. These failures had the potential for goals to go unreviewed, issues to go unidentified, and quality care improvement activities not to be evaluated and revised as needed, which could lead to declines in residents' overall quality of care. [...]

Inspectors wroteBased on interview and record review, the facility's Quality Assessment and Assurance (QAA: a proactive process that aims to prevent errors, identify standards of practice that are not being met, and ensure health care services consistently meet or exceed predetermined standards) committee failed to meet quarterly with all required members for a census of 118, when:1. The required quarterly Quality Assurance Performance Improvement (QAPI: a data driven and proactive approach to improve the quality of life, quality of care and services delivered in nursing facilities) meeting was not held in April 2025, and,2. The Director of Nurses (DON) did not attend the January 6, 2025, quarterly meeting and the Administrator did not attend the QAPI meeting held on June 26, 2025. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper hydration (process of providing fluid to the body) for three of 38 sampled residents (Resident 32, Resident 45, and Resident 112), per facility policy and each resident's comprehensive plan of care, and failed to maintain the usual body weight of 1 of 3 sampled residents (Resident 73) with weight loss when: 1. Resident 32 did not have available fluids to drink at bedside; and,2. Resident 45 did not have available fluids to drink at bedside; and,3. Resident 112 did not have available fluids to drink at bedside; and,4. Resident 73 had a weight loss of 11.1% over a 6-month period. These failures had the potential to result in altered hydration status, and complications associated with fluid imbalance (when the body loses or gains too much water/fluids) for Resident 32, Resident 45, and Resident 112; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe disposal of medications and reduce the risk of drug diversion (unauthorized drug loss/use) when:1. Medication disposals in pill form and in liquid form were identifiable and retrievable by hand when discarded into pharmaceutical waste containers in both medication rooms; and,2. Staff's personal backpack was stored in the medication room where controlled and prescription medications were stored. These failures had the potential to result in unauthorized use of medication and increased the risk of drug diversion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe medication storage and labeling practices in one out of two medication rooms and three out of three medication carts when:1. Prescription Patches of medication were available to use in a medication cart and medication storage room without a prescription,2. Three bottles of Drug Buster (an eco-friendly, liquid solution designed for safe and effective disposal of unwanted or expired medications. It dissolves pills, tablets, capsules, and other forms of medication on contact, rendering them non-toxic and safe for disposal in regular trash) were found soiled and in active use in three different medication carts, and 3. An unknown medication was found in a medication cart compartment without packaging. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure their call light system (system/device used by residents to call staff for assistance) was functioning for 5 out of 38 sampled residents (Resident 3, Resident 13, Resident 34, Resident 71, Resident 112) and 1 unsampled resident (Resident 92), per facility policy when:1. Resident 3, Resident 13, Resident 34, and Resident 71 did not have a functioning call light and an alternative means to call for assistance was not provided; and, 2. Resident 112 and unsampled Resident 92 did not have a functioning call light in their room and an alternative means to call for assistance was not provided. These failures resulted in Residents 3, 13, 34, 71, 92, and 112 being unable to call staff for assistance when needed, their physical and emotional needs were not met; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to accommodate the needs of 2 out of 38 sampled residents (Resident 45 and Resident 56) when:1. Resident 45's call light (a device used in healthcare settings to allow patients to remotely request assistance from nurses or staff) was not working and was not within reach; and,2. Resident 56's call light was hanging on the wall behind the bed and was not within reach. These failures had the potential to increase the risk of falls and unmet needs for Resident 45 and Resident 56 due to their inability to request assistance from staff.

Inspectors wroteBased on interview and record review, the facility failed to provide required notices to one of three residents (Resident 4) reviewed for the beneficiary protection notification (residents who received Medicare Part A Services have specific rights and protections related to financial liability and appeal rights which are communicated to beneficiaries through notices given by providers), when Resident 4 was not issued a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN: CMS 10055 a form which gives the choice to continue services under private pay if Medicare does not provide payment) and Notice of Medicare Non Coverage (NOMNC: CMS 10123 a form that Medicare providers must give to beneficiaries when their Medicare-covered services are ending) notices upon changes in his Medicare Part A service coverage. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure activities of daily living (ADLs) were provided to maintain good hygiene for 1 of 38 sampled residents (Resident 45) when:1. Resident 45's fingernails were long and sharp with a brown substance caked underneath them; and,2. Resident 45 had no documented bathing for the month of 7/2025. These failures resulted in Resident 45 not having had a documented bath or shower in 7/2025, with Resident 45's nails being long, sharp, and dirty with a brown substance underneath, hands and nails not being cleansed prior to eating meals, the potential for injury due to long sharp nails, and infection from the nails harboring microorganisms (bacteria, virus, or fungus).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure professional standards of practice were followed in accordance with physician orders for 1 out of 38 sampled residents when nursing staff inserted intravenous lines (IV - a thin tube inserted into a vein for administration of medications, fluids and/or blood products usually in the lower arm or hand for short term use) into Resident 33's arm and then removed the IV's without a physician's order on two occasions. These failures had the potential to expose Resident 33 to unnecessary risks related to IV insertion including developing an infection or other health complications and resulted in Resident 33 receiving services without a physicians order.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure safe medication administration practices when the medication error rate was more than 5% (% or percentage- number or ratio expressed as a fraction of 100) for a census of 118 residents. Medication administration observations were conducted over multiple days, at varied times, in random locations throughout the facility. The facility had a total of two errors out of 26 opportunities which resulted in a facility wide medication error rate of 7.69 % for two out of seven sampled residents (Resident 24 and Resident 119) observed for medication administration observations as follows: 1. Resident 119 was given a medication (sucralfate - a medication often prescribed to treat ulcers and other stomach conditions) prescribed for Resident 20; and, 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain a complete and accurate clinical record for one of 38 sampled residents (Resident 56) when the resident's Physician Orders for Life-Sustaining Treatment (POLST -outlines a patients end-of-life care and wishes) was not readily accessible in Resident 38's electronic health record (EHR -a digital collection of a patient's medical information that is stored and accessed quickly). This deficient practice had the potential to go against Resident 56's wishes to not be resuscitated (revived from unconsciousness or apparent death) if Resident 56 became unresponsive, which could result in serious physical harm to Resident 56.

Inspectors wroteBased on interview and record review, the facility failed to ensure three of three sampled residents (Resident 1, Resident 2, and Resident 3) received care consistent with professional standards of practice to prevent pressure injury (localized damage to the skin and/or underlying tissue caused by staying in one position for too long) when staff failed to document that the functioning of the residents' low air loss alternating pressure mattresses (medical air mattresses designed to reduce pressure on the skin) were checked each shift daily per the physician's orders. These failures had the potential for the residents to sustain pressure injuries and decreased well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident Interdisciplinary Team Care Conferences (IDT, a care plan meeting with the resident and/or family members where interdisciplinary team members from different healthcare disciplines discuss, identify, address, implement and review plans to meet needs regarding the resident's care) were conducted quarterly to review and/or revise care plans for one of three sampled residents (Resident 3), when no IDT Care Conferences were held after quarterly assessments were completed in 2025 for Resident 3. This failure had the potential for unmet care needs for Resident 3.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 2) received proper foot treatment and care to maintain good foot health when podiatry services (medical care and treatment of the foot) were not provided to Resident 2. This failure resulted in Resident 2's family member administering her foot care and had the potential to result in injury, pain, and infection. A review of Resident 2's admission RECORD, indicated she was readmitted to the facility in late 2024 with diagnoses which included type 2 diabetes mellitus (DM 2, a chronic condition in which the body has trouble controlling blood sugar levels which can lead to slow healing of wounds and infections). [...]

Inspectors wroteBased on interview, and record review, the facility failed to provide adequate monitoring and supervision in accordance with accepted professional standards for one of three sampled residents (Resident 1) when: Resident 1 had an instance of elopement (a patient who is incapable of adequately protecting himself, and who departs the health care facility unsupervised and undetected) from the facility on 6/23/25 and staff did not redirect him back in a timely manner; and, 2. Three of six fire alarms were found to be set on a timer as opposed to being in continuous mode. These failures had the potential to cause injury to Resident 1 and other at-risk residents residing within the facility.

Inspectors wroteBased on interview, and record review, the facility staff failed to maintain complete and accurate medical records in accordance with accepted professional standards for one of three sampled residents (Resident 1) when:1. The Elopement Assessment (a process to identify individuals at risk of leaving a supervised environment [like a care facility or school] without permission or supervision, potentially putting themselves in danger) was not completed after Resident 1 had eloped from the building; and,2. The Treatment Administration Record ([TAR] a document used in healthcare settings to keep track of the medications and treatments administered to patients) was not accurately completed for the months of June and July. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the residents' right to be free from verbal and physical abuse by another resident for two of three sampled residents (Resident 9 and Resident 13) when:1 Resident 12 yelled and hit Resident 13 on the back of his head on 1/29/2025; and,2 Resident 12 and Resident 9 yelled and swung at each other on 5/9/25. These failures had the potential to cause physical and psychosocial harm to Resident 9 and Resident 13.

Inspectors wroteBased on interview and record review, the facility failed to submit their investigation results of a resident-to-resident altercation that occurred on 5/9/25 involving two residents (Resident 9 and Resident 12) to the State Survey Agency within 5 working days .This failure had the potential to affect the staff and the residents' safety and had the potential to continue to endanger the wellbeing of the residents.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement person-centered comprehensive care plans (a detailed document outlining a person's healthcare needs, goals, and the specific care and support they will receive) for two of three sampled residents (Resident 12 and Resident 13) when, 1. Resident 12's comprehensive care plan did not include the verbal and physically aggressive behaviors that Resident 12 displayed towards other residents and staff or personalized interventions to prevent or mitigate those behaviors from escalating including when Resident 12 yelled and hit Resident 13 on the back of his head on 1/29/2025, and when Resident 12 and Resident 9 yelled and swung at each other on 5/9/25; and, 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care in accordance with professional standards of practice for one of 14 sampled residents (Resident 7), when required neurological checks (neurochecks - vital signs [heart and respiratory rate per minute, blood pressure, and temperature] and assessments done following a head injury) were not completed per policy. This failure resulted in Resident 7 not receiving the required neurochecks and had the potential to result in neurological issues going unrecognized, which could have negatively impacting Resident 7's health and well-being.

Inspectors wroteBased on interview and record review the facility failed to provide adequate supervision and implement preventative measures to reduce the risk of elopement (when a resident leaves the facility without supervision) for one of the three sampled residents who were at risk for elopement (Resident 1), when Resident 1 left the facility unsupervised on 1/1/25 and on 1/4/25. These failures had the potential for Resident 1 to experience serious harm or injury during an elopement.

Inspectors wroteBased on interviews and record reviews the facility failed to ensure that the nutritional needs were met for one out of nine sampled residents (Resident 4) on a pureed diet (food that is ground, pressed and/or strained to a soft, smooth consistency like a pudding) when Resident 4 was served potato chunks mixed in with mashed potatoes during the dinner meal service on 4/30/25. This failure had the potential for Resident 4 to aspirate (to have trouble swallowing normally when food enters the resident's airways or lungs causing coughing, difficulty breathing, discomfort, and sometimes choking) and could have also resulted in decreased meal intake.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that 1 of 6 sampled residents (Resident 1) was treated with dignity in an environment that promoted and enhanced the quality of life when staff did not answer Resident 1's call light (system/device used by residents to call staff for assistance) in a timely manner. This deficient practice had the potential to affect Resident 1's sense of self-worth and self-esteem.

Inspectors wroteBased on interview and record review, the facility failed to provide adequate assistance with activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily) for one of four sampled residents (Resident 1), when Resident 1's showers were not provided as scheduled. This failure had the potential to negatively impact Resident 1's personal hygiene and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its infection control policy and procedures when there was no sign for Enhanced Barrier Precautions (EBP - infection control intervention to reduce transmission of resistant microorganisms through gown and glove use during high-contact resident care activities) nor a cart with the required personal protective equipment (PPE - gowns, gloves, eye protection, facemasks or respirators used to prevent the spread of germs) outside of Resident 2's room. This failure could have resulted in the spread of a multidrug resistant organism (MDROs, germs that are more difficult to kill with antibiotics) and the need for additional medical interventions (medications and/or treatments) for a census of 115 residents.

Inspectors wroteBased on interview, and record review, the facility failed to ensure Certified Nurse Assistant (CNA) 1 was qualified to provide care and treatment to residents in the facility when CNA 1 was allowed to work with an expired CNA certificate from [DATE] to [DATE]. This deficient practice had the potential to put the residents' care and safety at risk.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the contracted (an agency hired by the facility to provide a service) radiological (x-ray) services were available for a census of 116 when an x-ray ordered ASAP (urgent, stat, as soon as possible) was not performed for one resident (Resident 4). This failure resulted in a delay in care and treatment for Resident 4 with a potential risk for unmanaged pain.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain the dignity and privacy of one unsampled resident (Resident 1) when staff transported Resident 1 from his bedroom to the shower room with his penis and scrotum exposed. This failure violated Resident 1's right to privacy and dignity, with the potential to negatively affect Resident 1's psychosocial wellbeing.

Inspectors wroteBased on interview and record review, the facility failed to provide adequate supervision to prevent an avoidable accident for one of three sampled residents (Resident 3) when, Resident 3 exhibited exit seeking behaviors (type of wandering where residents actively try to leave a designated area, often with the intention of going to a familiar place), Resident 3 was not re-evaluated for risk of elopement (when a resident leaves the premises or a safe area without the facility's knowledge and supervision), and interventions to prevent Resident 3's exit seeking behaviors were not created. [...]

Inspectors wroteBased on interview, and record review, the facility failed to document and investigate the grievances (complaints) of one of three sampled residents (Resident 3), regarding his care concerns. This failure had the potential for Resident 3's care concerns not being addressed timely.

Inspectors wroteBased on interview, and record review, the facility failed to consistently conduct Interdisciplinary Team (IDT, a care team consisting of different disciplines who assess and coordinate care) care plan conferences (a meeting which provides opportunities for the resident and/or his/her representative, and each discipline to revise the resident's care plans) for two of three sampled residents (Resident 1 and Resident 2) when there was no documentation of quarterly IDT care plan conferences held for Resident 1 and Resident 2. These failures had the potential for unmet care needs for Resident 1 and Resident 2.

Inspectors wroteBased on observation, interview, and record review, the facility failed to consistently have sufficient staffing to provide adequate care and services and to assure the residents received care to maintain their highest practicable physical, mental, and psychosocial well-being for 3 of 4 sampled residents (Resident 2, Resident 3, and Resident 4) when: 1. Resident 2 was unable to get out of out bed at the time of his choosing; 2. Resident 3 felt unable to use the call light to be changed when needed; and, 3. Resident 4 was not being turned every two hours per the plan of care and was sitting in wet urine for long periods of time waiting to be changed. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure an environment free of accidents or hazards for one out of four sampled residents (Resident 1) when Resident 1 fell forward to the floor while being pushed in a wheelchair that lacked a footrest. This failure resulted in Resident 1 sustaining injuries to the left knee, left side of the forehead and a fracture (break) of her left leg.

Inspectors wroteBased on interview, and record review, the facility failed to ensure professional standards of practice were maintained for a census of 113 residents when: 1. Licensed nurse (LN) 8 refused to take the keys for the medication cart and take report from the previous shift resulting in residents receiving their medications late (refer to F755); and, 2. LN 3 walked out on her assignment at the beginning of her shift because she did not like her assignment and on two other nights neglected to pass scheduled medications resulting in several residents not receiving their medications (refer to F755). These failures placed the safety of residents at risk.

Inspectors wroteBased on interview, and record review, the facility failed to ensure medications were administered according to physician orders for five of eight sampled residents (Resident 2, Resident 3, Resident 4, Resident 5, and Resident 6) when: 1. Resident 3, and Resident 4 missed medication doses on 12/11/24 and 12/20, and Resident 5 missed a dosage of medication on 12/20/24; and, 2. Resident 2, Resident 3, Resident 4, and Resident 6's medications were administered late. These failures had the potential to negatively affect the health and well-being for Resident 2, Resident 3, Resident 4, Resident 5, and Resident 6, and the efficacy of the medications being administered.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of eight sampled residents' (Resident 1) environment was free of potential hazards when Resident 1's footboard was not in place to keep the mattress secure, and Resident 1's mattress was positioned approximately 6 inches (unit of measurement) over the foot of the bed and left a 12-inch gap at the head of the bed. This failure resulted in Resident 1 experiencing anxiety about sliding out of the bed and had the potential to result in injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store medication safely when a bubble pack of Hydralazine (a medication used to control high blood pressure), containing 24 tablets, was left unsecured on top of the medication cart, and the cart was unattended. This failure had the potential for other residents to take the medication, causing harm to the person ingesting the medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control measures to prevent the spread of germs for six of eight sampled residents (Resident 4, Resident 6, Resident 7, Resident 8, Resident 9, and Resident 10) when, staff did not provide or offer hand washing (hand hygiene) to Resident 4, Resident 6, Resident 7, Resident 8, Resident 9, and Resident 10 prior to the lunch meal on 12/10/24. This failure had the potential for Resident 4, Resident 6, Resident 7, Resident 8, and Resident 9 to get sick from the germs on their hands that may have contaminated the food they were eating.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) prevention interventions for one of two sampled residents (Resident 1) when, in accordance with Resident 1's care plan interventions, Resident 1's incontinence briefs (the inability to control the flow of urine or bowel movement/disposable absorbent underwear that absorb urine and contain bowel movements) were not checked/changed at least every two hours and Resident 1 was not repositioned at least every two hours. These failures had the potential to result in skin issues (such as skin break down, rash, bacterial or fungal infections) and/or pressure ulcer development for Resident 1.

Inspectors wroteBased on interview and record review the facility failed to promote and facilitate one of three sampled residents (Resident 1) right to self-determination (To have the right to make decisions about medical care, including whether or not to accept treatment) when on 9/26/24, Resident 1 was not ensured the right to refuse an intravenous (IV-medication given directly into the blood stream) antibiotic (medication used to treat infections) called Ertapenem that ultimately was prescribed to another resident (Resident 3). This failure resulted in Resident 1 feeling off and confused and upset after being given Resident 3 ' s medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free from a significant medication error when on, 9/26/24, Resident 1 was given an intravenous (IV -medication given directly into the blood stream) antibiotic to treat an infection that was not prescribed to her called Ertapenem. This failure resulted in Resident 1 feeling off and confused after being given the medication and had the potential to result in worsening of her health condition, or an adverse reaction (an undesirable effect of a health product, such as a medication) occurring to the medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe environment for six of 40 sampled residents (Resident 15, Resident 14, Resident 23, Resident 75, Resident 54, Resident 74), and residents who required bathing in the east hall shower room when: 1. Resident 14 and 15-minute elopement risk (a resident who is incapable of adequately protecting themselves, and who departs the health care facility unsupervised and undetected) monitoring was not done; 2. The East Hall shower room's grab bar was detached from the wall with screws exposed. 3. A fall mat (a soft mat laid on the floor to help prevent injury from a fall) was not in place for Resident 75; 4. Resident 54's morning medications were left at the bedside; 5. Resident 74's personal items were stored on the floor causing clutter; and, 6. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received dental services to meet their needs for one of forty sampled residents (Resident 84), when Resident 84 did not receive routine and urgent dental care services which contributed to Resident 84's unintended weight loss of 22.2 pounds over a six month time period (11/2023 - 5/2024). This failure had the potential for muscle loss, loss of resident independence, poor healing, and increased susceptibility to infections for Resident 84.

Inspectors wrote2. A review of Resident 15's medical record indicated Resident 15 was admitted in early 2023 with diagnoses which included but was not limited to cerebral infarction (a result of disrupted blood flow of the brain due to problems with blood vessels that supply it, also used with the term stroke), acute respiratory failure (disease that can cause shortness of breath, anxiety, and confusion) with hypoxia (low levels of oxygen in the body tissues), food in respiratory tract causing asphyxiation (choking), and gastrostomy tube (G-tube- a feeding tube that is surgically inserted into the resident's stomach to allow access for food, fluids, and medications). During an observation on the facility's East Unit on 6/3/24 at 1:25 p.m., CNA 6 walked into room [ROOM NUMBER] without PPE despite an EBP isolation sign posted near the door, and PPE supplies near the door in a cart. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 4 of 40 sampled residents (Resident 19, Resident 84, Resident 28, and Resident 14) were treated with dignity and respect when: 1a. Resident 19 was showered with the shower room door propped open; 1b. Resident 19 was escorted from the shower room to her room with a gown draped over her chest with her left breast and backside exposed; 1c. Resident 19 was dressed in front her roommate following her shower; 2. Resident 84's food preferences were not honored; 3. Resident 28 was brought into the hallway from the shower room, nude (without any clothes); and, 4. Resident 14 was not provided pants and dressed in a loose incontinence brief (protective underwear used by people who are not able to control their bladder or bowel), leaving his private areas exposed while in public view. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide reasonable accommodation of needs for 3 of 40 sampled residents (Resident 42, Resident 74, and Resident 94) when: 1. Resident 94's call light (a device used to call for assistance) was not within reach; 2. Resident 42 was not assessed for and provided wheelchair accommodations; and, 3. Resident 74 requested storage for her personal items that were located on her floor, causing clutter, and the request was not addressed by the facility. These failures had the potential to result in Resident 94 being unable to ask for needed assistance, possible impairment of Resident 42's ability to maintain independent functioning, and had the potential to affect Resident 74's psychosocial well-being and placed Resident 74's safety at risk.

Inspectors wroteBased on interview and record review, the facility failed to ensure emergency treatment documents were available for 4 of 40 sampled residents (Resident 28, Resident 55, Resident 112 and Resident 319) when, 1. A copy of Resident 28's Advance Directive (a written instruction relating to the health care of an individual if they are unable to speak for themselves) was not available in his electronic medical record at the facility; and, 2. Resident 55's, Resident 112's, and Resident 319's POLST (Physician Orders for Life Sustaining Treatment: a medical order signed by both a patient and physician that specifies the types of medical treatment a patient wishes to receive in emergency situations) or the physician's ordered code status (indicates whether or not to resucitate in the event of a person's heart stopping or not breathing) was not completed/available. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect resident privacy and confidentiality when tray tickets (paper tickets served with each meal that include the resident name, room number, diet order, date of meal, resident likes and dislikes, food allergies, special equipment needs, and assistance needs) were thrown into the general trash. This failure had the potential to compromise resident information for the 98 residents receiving facility prepared meals.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a safe and comfortable homelike environment when: 1. Resident 1 and Resident 89's room temperatures were above a comfortable range (71-81 degrees); 2. The East Hall shower room grab bar (a safety device attached to a wall to assist in standing up or maintaining balance) was detached from the wall with exposed screws; 3. room [ROOM NUMBER] had a hole in the bathroom door; 4. room [ROOM NUMBER]B had a large unpainted patched area on the wall beside the bed; 5. room [ROOM NUMBER]A had two unpainted patched areas on either side of the overhead light fixture above the bed; 6. rooms [ROOM NUMBERS]'s shared bathroom had linoleum peeling away from the floor and wall on both sides of the room; and, 7. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure assessments were completed accurately for 2 of 40 sampled residents (Resident 3 and Resident 84), when: 1. Resident 3's Minimum Data Set (MDS, a standardized assessment tool that measures health status in nursing home residents) assessment dated [DATE], did not reflect the use of oxygen; and 2. Resident 84's MDS assessments dated 11/30/23, 3/1/24, and 6/1/24 did not reflect her oral/dental health condition accurately. These failures resulted in inaccurate assessments and had the potential for Resident 84's and Resident 3's needs not being met.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident's care conferences ( a care plan meeting with the resident and family members where interdisciplinary team members from different health care disciplines discuss, identify, address, implement, and review plans to meet needs regarding the resident's care) were conducted upon admission, quarterly, and as requested for two of 40 sampled residents (Resident 84 and Resident 50), when: 1. admission and quarterly (every 3 months) care conferences were not conducted for Resident 84; and, 2. Resident 50's representative's request for a care conference was not honored. These failures potentially resulted in necessary interventions and goals, specific to client needs and care, not being implemented, negatively affecting Resident 50's and Resident 84's health 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 40 sampled residents, (Resident 112, and Resident 319) when: 1. Resident 112 did not have an order for intravenous (IV) catheter (thin tubing placed in a vein of the upper arm for the administration of fluids or medication) dressing changes; and, 2. Resident 319's IV catheter dressing was documented as changed when it was not, and Resident 319 did not have an IV care plan developed. These failures had the potential to increase the risk of infection for Resident 112 and Resident 319.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three residents (Resident 96, Resident 53, Resident 46) in a sample of 40 received care and treatments in accordance with professional standards of practice when: 1. Resident 96's hospice binder and hospice visit documentation were not available; 2. Resident 53's insulin was not administered as ordered and the process for reporting a medication error was not followed; 3. The facility did not perform daily quality control and testing (a test required by device manufacturer to check the device's ability to measure accurate test results) of the glucometer (a device that measured blood sugar in diabetes residents) devices for over one week for both East and [NAME] nursing stations affecting four glucometer devices used on a daily basis to measure residents' blood sugars; and, 4. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure services to prevent los of mobility ordered by the physician, were provided by restorative nursing assistants (RNA) to 3 of 40 residents receiving RNA services (Resident 16, Resident 71, and Resident 84) when there was limited or no documented evidence of RNA services received, and there were insufficient RNA staff to provide the needed services This failure had the potential to result in a decline in physical functioning for Resident 16, Resident 71, and Resident 84, negatively impacting their health and wellbeing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 2 of 40 sampled residents (Resident 112 and Resident 319) who received parental fluids (delivery of fluid or medication through a vein) were provided services consistent with professional standards of practice when: 1. Resident 112 did not have an order for an intravenous catheter (IV, thin tubing placed in a vein of the upper arm for the administration of fluids or medication) dressing changes; and, 2. Resident 319's IV catheter dressing was documented as changed when it was not, and Resident 319 did not have an IV care plan developed. These failures had the potential to increase the risk of infection for Resident 112 and Resident 319.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respiratory care was provided in accordance with professional standards of practice for four of forty sampled residents (Resident 3, Resident 46, Resident 13, and Resident 219) when: 1. Oxygen in use safety signage was not posted outside Resident 3's room; 2a. Resident 46's oxygen was not provided at the prescribed flow rate; 2b. Humidifier connector was not changed weekly for Resident 46; 2c. Humidifier bottle was not labeled and was empty for Resident 46; and, 3. Oxygen tubing was not changed weekly for Resident 3, Resident 46, Resident 13, and Resident 219. [...]

Inspectors wroteBased on observation, interview and record review, the facility staff failed to assist the residents in consuming food at a safe temperature when a microwave was not available at the nursing stations. This failure could result in poor food consumption, weight loss, malnutrition, and food borne illness for the 98 residents receiving facility prepared meals.

Inspectors wroteBased on interview and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices for two of forty sampled residents (Resident 28 and Resident 84), when: 1. Resident 28's record had conflicting Advance Directive (a written instruction, such as a living will or durable power of attorney for health care, recognized under State law relating to the provision of health care when the individual is incapacitated) information; 2. A Social Service Assessment reflected inaccurate cognition level for Resident 28; and 3. Resident 84's food preferences were not reflected/updated in her record. These failures resulted in incomplete and inaccurate medical records and had the potential for a negative impact on Resident 28 and Resident 84's health and well being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote and facilitate resident choices and preferences for care in accordance with professional standards of practice for 1 of 40 sampled residents (Resident 10) when, Resident 10 was not given her preferred method of bathing on her shower day and did not receive her shower when she requested it. This deficient practice had the potential to negatively impact Resident 10's maintaining and/or achieving independent functioning, dignity, and well-being due to not being able to make decisions regarding her care.

Inspectors wroteBased on interview and record review, the facility failed to ensure an allegation of potential abuse was reported to the Department in a timely manner for a census of 113. This failure resulted in a delay in the abuse investigation process and decreased the facility's potential to protect residents from physical and psychosocial harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a baseline care plan for 1 of 40 sampled residents (Resident 25) when a baseline care plan was not developed for Resident 25's nephrostomy (a tube that lets urine drain from the kidney through an opening in the skin on the back into a collection bag) within 48 hours of admission to the facility. This failure had the potential to cause adverse health events for Resident 25 and for Resident 25's care needs to not be met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a comprehensive person-centered care plan was developed for two of 40 sampled residents (Resident 25 and Resident 84), when: 1. A Nephrostomy (a tube that lets urine drain from the kidney through an opening in the skin on the back into a collection bag) care plan was not developed for Resident 25, and 2. A Oral/dental health care plan was not developed for Resident 84. These failures had the potential of care needs not being met for Resident 25 and Resident 84.

Inspectors wroteBased on observation, interview, and record review, the facility failed to offer water to one of forty sampled residents (Resident 34). This failure had the potential for Resident 34 to not maintain adequate hydration and placed Resident 34 at risk for a fall.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a bed rail assessment was completed for one of forty sampled residents (Resident 11) when a new bariatric mattress (wider than a standard hospital bed and are reinforced to support a higher weight capacity than the typical hospital bed) was placed on Resident 11's bed. This failure resulted in Resident 11 being unable to grab the side rails for mobility as the new mattress was above the bed rails.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe medication documentation, and handling of hazardous medications (Drugs that pose short or long-term harm upon exposure to human via skin or inhalation) with census of 113 when: 1. Resident 89's pain medication uses for Norco (a narcotic opioid controlled drug; drug of abuse) was not consistently documented in the Medication Administration Record (or MAR, a document listed the drugs given to residents) when removed from Controlled Drug Record (or CDR, paper-based record with pharmacy label, drug name, resident's name, and lines indicating the number of pills removed or used). 2. Facility did not ensure safe practices in handling hazardous medication during storage and administration. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure Resident 63's medication refusal to take seizure (or epilepsy, a sudden uncontrolled burst of electrical activity in the brain causing uncontrolled body movement and loss of consciousness) medication called Valproic Acid (or Depakote, drug used to treat seizure and used as mood stabilizer) were reported to medical doctor in a sample of 5 residents assessed for un-necessary medications. This failed practice may have contributed to a seizure event and hospitalization.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure Resident 46's medication order for a mind-altering drug called olanzapine (or Zyprexa, used to treat mood disorder) was supported by medical or mental health doctor's diagnosis when a sample of 5 patients were reviewed for unnecessary drug use. This failure could contribute to unsafe and unnecessary drug use with side effects and health safety issues.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 40 sampled residents (Resident 53) was free of significant medication errors when Resident 53 did not receive his morning insulin (medication to control blood sugar levels) as ordered by the physician. This failure resulted in Resident 53's blood sugar increasing from 357 to 371 by the time his lunch time dose was due and resulted in increased anxiety as verbalized by Resident 53, negatively affecting his physical, mental, and psychosocial wellbeing.

Inspectors wroteBased on interview, observation, and record review the facility failed to ensure safe medication storage practices in medication rooms and medication carts including expired and unlabeled medications, unlocked and frosted refrigerator and the storage of staff's personal belonging in the medication storage area. These unsafe medication storage practices and the use of outdated and spoiled medications could contribute to residents' safe medication use and risk of drug diversion (drug Loss).

Inspectors wroteBased on observation, interview, and record review the facility failed to provide food storage and preparation, as well as maintain kitchen equipment and food contact surfaces in accordance with professional standards for food safety for the 98 residents who ate facility prepared meals when: 1. Mixer not wrapped to maintain cleanliness, and plastic fragments found in metal mixer bowl; 2. A can opener was found with a dried red stain on the tip of the blade; 3. Cutting board stored near fruit sink had markings and yellow particles on it; 4. Five of seven muffin pans with dried brown, flaky substance in muffin wells; 5. Large metal strainer with handles with areas of discoloration; 6. Ovens were noted with build-up of black, grimy areas; 7. Two fans inside the dishwashing area were seen with rust-colored buildup on them; 8. [...]

Inspectors wroteBased on interview, and record review, the facility failed to follow their Food and Nutrition Services policy and procedure to meet the professional standards of practice when the dietary profile for 1 of 3 sampled residents (Resident 1) was not completed on admission. This failure had the potential to negatively impact Resident 1's nutritional needs and failed to honor her food preferences.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide grooming and bathing needs for 1 of 3 sampled residents (Resident 1) when showers or bed baths were not consistently done and Resident 1's hair was observed tangled. This failure had the potential to diminish Resident 1's self esteem and denied her the opportunity to have the skin observed for any changes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to carry out activities of daily living to maintain good hygiene for one of three sampled residents (Resident 1) when Resident 1's fingernails on her left hand had a dark brown/black substance underneath them, and her front bottom teeth had a white substance built up on them. These failures had the potential to negatively affect Resident 1's psychosocial wellbeing, cause dental disease, and cause infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide incontinent (little or no control over bladder and bowel function) care in a timely manner for one of 3 sampled residents (Resident 1) when she had to wait for the assigned staff to get more staff to change her wet and/or soiled incontinent brief. This failure had the potential for Resident 1 to develop skin breakdown and made Resident 1 feel uncomfortable and disrespected.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure care was provided to meet professional standards of practice for three of eight sampled residents (Resident 1, Resident 6, and Resident 8) when: 1. a Resident 1's insulin dose was not given on 12/16/23; b. Resident 1 ' s blood sugar was not checked on 12/16/23; c. Resident 1 ' s high blood sugar of 417 on 12/17/23, was not reported to the physician; and, d. There were no parameters in Resident 1's insulin orders for monitoring blood sugar levels and reporting abnormal values. 2. Resident 1's opioid dependency was not addressed upon admission to the facility; 3. Resident 6 and Resident 8's medications were not administered timely; and 4. Resident 8's Phenytoin, a seizure medication was not administered correctly. These failures had the potential for: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were treated with dignity and respect when two of three certified nursing assistants (CNA), CNA 1 and CNA 3, referred to four of four residents (Resident 6, Resident 7, Resident 8, Resident 8) requiring assistance with meals, in the assisted dining room, as feeders (term used for individuals requiring assistance with meals). This failure resulted in residents (Resident 6, Resident 7, Resident 8, and Resident 9) not being treated with dignity and respect and had the potential to negatively impact their self-worth and self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to respect the resident's right to personal privacy, including the right to promptly receive unopened mail/packages, delivered to the facility for one of four sampled residents (Resident 4) when Resident 4's mail/packages were placed in the Social Service Department's storage closet upon delivery to the facility. This failure had the potential to result in feelings of hopelessness and a lack of privacy for Resident 4.

Inspectors wroteBased on interview and record review, the facility failed to ensure that two of two sampled residents (Resident 1 and Resident 2) were provided dialysis (the process of removing excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally) care and services consistent with professional standards of practice when, 1. Resident 1 was unable to attend their scheduled dialysis session due to transport being unavailable; and 2. The facility did not consistently provide and/or complete dialysis communication sheets for Resident 1 and Resident 2. The failure of unavailable transportation led to a delay in dialysis care for Resident 1 with a potential to alter Resident 1's health status. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the kitchen area was maintained in a safe and sanitary manner when: 1. Utensil drawers contained dust and debris; 2. The oven overhead area contained grease, dust, and debris; 3. The stove and oven vent hoods contained grease, dust, and debris; and, 4. The walk-in and reach-in refrigerator temperature logs and freezer temperature logs had not been consistently filled out for January 2024. These failures had the potential to spread food borne illness (caused by consuming contaminated foods or beverages) among 104 residents receiving food from the kitchen, negatively impacting their health and wellbeing.

Inspectors wroteBased on interview and record review, the facility failed to ensure medical records for two of four sampled residents (Resident 1 and Resident 2) were complete and accurate, when skin treatments were not documented as being completed. This failure had the potential for Resident 1's and Resident 2's medical record to have insufficient information to reflect the condition, care, and services provided.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a clean and homelike environment for one of four sampled residents (Resident 2) when there was a coffee spill in Resident 2's room, that had been there for approximately three days. This failure had the potential to attract pests, such as ants and roaches, and negatively impact Resident 2's quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of five sampled residents' (Resident 5) food was at a safe and appetizing temperature, when Resident 5's lunch tray was available for his consumption at 4:10 PM. This failure had the potential to cause foodborne illness in Resident 5, negatively impacting his health and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure garbage was disposed of properly when a trash can in the kitchen by the back door, did not have a lid on it, and two large trash bins in the back of the facility did not have their lids closed. This failure had the potential to cause insect and rodent infestation to these areas, potentially contaminating and spreading bacteria (germs) to the food the facility provides to 104 residents who receive food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a sanitary environment for a census of 109 residents residing in the facility when housekeeping staff were observed dragging a bag of trash and soiled linen on the floor through the hallway, in an area where resident rooms were located. This failure had the potential to contaminate the floor and cause illness for residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement policies and procedures when a nursing care plan (NCP) was not developed and implemented for one of three sampled residents (Resident 1) when Resident 1 developed a blister on their right hand. This failure had the potential to result in Resident 1 not receiving the necessary care to heal their blister, leading to complications.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for two of five sampled residents (Resident 2 and Resident 5) when: 1. Resident 2's care plan for an allegation of touching another resident on the private area on 12/16/23 and Resident 5's care plan for an allegation of being hit and stabbed by a staff on 12/19/23 were not adequately developed; and, 2. Resident 5's care plan for accusative behavior was not addressed properly. These failures placed Resident 2, Resident 5, and other residents in the facility at increased risk for physical and/or psychosocial harm.

Inspectors wroteBased on interview, record and facility policy review, the facility failed to protect residents' personal property from theft or loss for one of three sampled residents (Resident 1) when her inventory list was not updated in a consistent manner. This failure had the risk potential for Resident 1 to have lost valuable personal items.

Inspectors wroteBased on interview and record review, the facility failed to ensure four of 31 sampled residents (Resident 5, Resident 53, Resident 84 and Resident 96) had their rights, related to medical treatment preferences, known and protected when there was no evidence an Advance Directive (a legal document consistent with known requests or desires of a person's medical treatment preferences) was discussed and/or offered to Resident 5, Resident 53, Resident 84 and Resident 96. This failure had the potential to result in Resident 5, Resident 53, Resident 84, and Resident 96 being uninformed of their right to complete an Advance Directive and their treatment preferences not being followed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a comprehensive person-centered care plan was developed for five of 31 sampled residents (Resident 55, Resident 110, Resident 5, Resident 20, and Resident 465) when: 1. Resident 465 did not have a care plan for her indwelling catheter (a tube placed in the bladder to drain urine), 2. Resident 110 did not have a smoking care plan in place, 3. A care plan for oxygen use was not developed for Resident 20 and Resident 55, and, 4. Resident 5's care plan did not reflect an accurate dialysis (a procedure of removing excess water, and toxins from the blood in people whose kidneys can no longer perform these functions naturally) access site. These failures had the potential for safety risk and not to receive adequate care for Resident 55, Resident 110, Resident 5, Resident 20, and Resident 465.

Inspectors wroteBased on interview and record review, the facility failed to consistently provide treatment and services to increase range of motion (ROM) and/or prevent further decline in ROM for seven of 46 residents (Resident 45, Resident 72, Resident 84, Resident 2, Resident 22, Resident 51, and Resident 59) who were on a restorative nursing aide program (to assist the resident in performing tasks that restore or maintain physical function) when, Resident 45, Resident 72, Resident 84, Resident 2, Resident 22, Resident 51, and Resident 59 were not provided RNA services at the frequency ordered. This failure removed the opportunity to potentially improve ROM and had the potential to result in a decline of ROM for Resident 45, Resident 72, Resident 84, Resident 2, Resident 22, Resident 51, and Resident 59.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure respiratory care was provided in accordance with professional standards of practice for five out of five sampled residents who received respiratory therapy (Resident 36, Resident 2, Resident 15, Resident 96, and Resident 20) when: 1. Resident 36's nebulizer mask (used to provide inhaled medication) was not dated; and, 2. Resident 20's oxygen was administered at a higher flow rate than prescribed; and, 3. Oxygen in use signage was not posted at Resident 2's, Resident 15's, Resident 96's, and Resident 20's doorway; and, 4. Resident 96 and Resident 15's oxygen humidifier bottle (medical device used to increase moisture and decrease dryness from supplemental oxygen) was not changed timely; and, 5. Resident 2, Resident 15 and Resident 96's oxygen tubing was not changed at least weekly. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure safe monitoring and assessment of medication use in four out of 31 sampled residents (Resident 73, Resident 55, Resident 59, and Resident 14) when: 1. The facility did not monitor safety parameters for blood thinning medication (a medication that could cause bleeding by thinning the blood) and blood pressure medication (medication to control the force of blood against blood vessel walls) for Resident 14, Resident 55, and Resident 73. 2. The facility did not reassess continued use of a medication used to counter act the side effects of mind-altering medications for Resident 59. These failures could contribute to unsafe medication use and further side effects.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure safe medication storage practices in two out of two medication rooms (a locked room for storage of prescription, non-prescription and controlled medications) and three out of five medication carts (mobile cart that stored resident's medication and supplies) when: 1. Multi dose medication containers and supplies were not dated per manufacturer guidelines. 2. Expired (outdated) medications were stored in active storage areas. 3. Staff's personal belonging were stored in the same room as medication storage. 4. Resident's personal medications were stored in medication cart with no labeling or accountability information. 5. Emergency kit (or Ekit- a box that stored medication for emergency use) was opened and unsealed with no documentation of its use. 6. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents receive and consume foods in the appropriate form and/or the appropriate nutritive content as prescribed by a physician, and/or assessed by the interdisciplinary team to support the resident's treatment, plan of care, in accordance with his/her goals and preferences for a total of 104 who received food from the kitchen when, 1. The facility failed to ensure standardized recipes were followed for puree (smooth texture) food preparation, 2. The facility failed to provide food that was palatable (tastes good and is attractive in appearance and smell). These failures had the potential to result in resident nutritional impairment and food with decreased nutritive value. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store foods in accordance with professional standards for food safety for a total of 104 residents who received food from the kitchen when: 1. There were expired food items, and food items not labeled with a date located in the resident refrigerator; and 2. Food items in the kitchen were not labeled with an expiration date. These failures had the potential to result in foodborne illnesses among residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure adequate infection prevention and control measures were practiced for a census of 108, when, 1. Shared glucometers (a device that measured blood sugar in diabetes residents) were not cleaned and sanitized based on standards of practice or manufacturer guidelines for four residents (Resident 17, Resident 98, Resident 70, and Resident 465), 2. A facility staff placed a contaminated facemask on an open box of clean gloves on the top of the PPE (Personal protective equipment worn to prevent the exposure to infectious materials such as gown, gloves, mask, goggles/face shield) cart prior to entering an isolation room, and, 3. A facility staff did not put on the required PPE when entering a COVID-19 positive resident's room. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide one resident (Resident 103) with a dignified existence and self-determination following a room change, when Resident 103's clothes were left in a large garbage bag on the floor of his new room, Resident 103's wheelchair was not provided to him in his new room, and Social Services did not follow-up with Resident 103 following a room change. These failures had the potential for Resident 103 to experience negative feelings of self-worth and resulted in a loss of independence.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide reasonable accommodation of needs and preferences for 1 of 31 sampled residents (Resident 8) when Resident 8's call light was not within reach. This failure had the potential for Resident 8 to not have her needs met.

Inspectors wroteBased on interview and record review, the facility failed to accurately track, replace, and/or reimburse two of 31 sampled residents (Resident 2 and Resident 59) personal belongings when: 1. An inventory of Resident 59's personal belongings revealed items not on the facility inventory sheets, and personal belongings on the inventory sheets were missing. 2. Resident 2's personal property was not considered for replacement or reimbursement, nor was Resident 2 informed of the outcome of the reported theft and loss of a personal item. These failures resulted in missing and unreimbursed personal belongings for Resident 2 and Resident 59 and had the potential for additional items, not listed on the inventory sheets, to go unreimbursed if they went missing. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Minimum Data Set (MDS- comprehensive mandatory assessment process for facilitating care management for all residents in nursing homes) assessments were completed accurately for one of 31 sampled residents (Resident 34), when Resident 34 was inaccurately coded as not using wanderguard (a device that alerts the staff when a resident at risk of elopement approaches a monitored exit door) on her annual and quarterly MDS assessments. This failure resulted in inaccurate assessments, had the potential of inaccurate care planning, and had the potential for Resident 34 to not receive necessary care.

Inspectors wroteBased on interview and record review, the facility failed to ensure a nutrition care plan was accurate and revised for one of 31 sampled residents (Resident 35), when Resident 35's care plan reflected the incorrect intervention for the use of Total Parenteral Nutrition (TPN: feeding of nutritional products to a person intravenously, bypassing the usual process of eating and digestion). This deficient practice resulted in inaccurate care planning and had the potential for Resident 35 to receive inadequate care.

Inspectors wroteBased on interview and record review the facility failed to adhere to accepted standards of quality, delivery of care, and documentation practices when: 1. The routine quality control tests (a test to ensure accurate functioning and results of a medical device) were not performed on all glucometer devices (device used to measure blood sugar in diabetic residents) actively used on each medication cart (a mobile cart that stored resident's medications, supplies and devices) in the facility's East station (a unit in the facility). 2. The medical doctor did not document or provide clinical justification for a psychiatric diagnosis in one out of 32 sampled residents (Resident 74). These failed practices may result in inaccurate test results, unsafe medication use, or inaccurate monitoring of the residents blood sugar levels.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary care and services for two of 31 sampled residents (Resident 8 and Resident 72 ) when, staff did not offer or assist to get Resident 8 and Resident 72 out of bed. These failures resulted in unmet care needs for Resident 8 and Resident 72, with the potential to remove Resident 8's and Resident 72's ability to achieve their highest practicable well-being and quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an ongoing activity program to meet the needs and interests for two of 31 sampled residents (Resident 88 and Resident 94) to ensure the residents maintained their highest practicable physical, mental, and psychosocial well-being. This failure had the potential to cause feelings of social isolation and depression among the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure treatment and care provided to two out of 31 sampled residents (Resident 88 and Resident 22) was in accordance with quality care and professional standards of practice when; 1. Facility staff failed to document physician ordered repositioning (turning resident from side-to-side in bed at specific intervals) for Resident 88 and, 2. Licensed nurses (LN) did not clarify and carry out verbal physician orders for Resident 22. These failures had the potential to result in Resident 88 developing pressure ulcers (skin wounds), and experiencing increased pain, and resulted in delayed care for Resident 88 and Resident 22.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure necessary care and services were provided to prevent the development of pressure ulcers (injury to skin and underlying tissue resulting from prolonged pressure on the skin) for one of 31 sampled residents (Resident 265), when Resident 265 was lying on an air mattress that was not plugged in and was completely deflated. This deficient practice had the potential to cause discomfort and placed Resident 265 at higher risk of developing pressure ulcers and/or skin breakdown.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the safety of one of one sampled resident (Resident 34) who was an elopement risk, when: 1. Resident 34's wanderguard (a device that alerts the staff when a resident at risk of elopement approaches a monitored exit door) was not checked weekly for proper functioning, and 2. Resident 34's wanderguard placement was not assessed accurately. These failures placed Resident 34 at risk of elopement and possible injury/harm.

Inspectors wroteBased on interview and record review the facility failed to ensure narcotic (or controlled drugs like opioid or medications with potential for abuse) medications for pain control were accurately used and documented in the medical records for one of 31 sampled residents (Resident 74). These failures could contribute to unsafe narcotic drug use, lack of monitoring, and posed a risk for drug diversion (when drugs are abused or stolen).

Inspectors wroteBased on interview, and record review, the facility failed to ensure medication for treatment of high blood sugar called insulin was accurately reconciliated upon admission to the facility from the hospital for one resident (Resident 55) out of 31 sampled residents. This failure may have contributed to uncontrolled blood sugar levels, and missed insulin treatment and monitoring for the high-risk medication (high risk medication could cause adverse outcome without monitoring).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure accurate medical records were maintained for one of thirty-one sampled residents (Resident 34) when Resident 34's wanderguard placement was not assessed and recorded accurately. This failure resulted in an inaccurate medical record for Resident 34.