Harvest Crossing Post Acute

Inspectors wroteBased on interview and record review, the facility failed to complete a Notice of Discharge (NOD-written notice that explains the reason for discharge, includes the effective date and discharge location, informs the resident of the right to appeal, provides contact information for the Long-Term Care (LTC) Ombudsman - independent advocate who protects residents' rights, and requires a copy to be sent to the LTC Ombudsman) for one of three sampled residents (Resident 1) when the facility did not readmit Resident 1 following hospitalization, resulting in a facility-initiated discharge without a completed NOD, without documented physician clinical justification, and without notification to the LTC Ombudsman. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure an adequate available emergency water supply for a census of 89 residents. This failure had the potential to result in residents not having access to sufficient water for hydration, sanitation, and essential care needs in the event of an emergency.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain sanitary conditions in food handling, storage, and preparation areas for 84 residents whom received meals from the kitchen when:1. A black ice container was stored underneath a soap dispenser;2. A damaged strainer was available for use in food preparation;3. A plastic container used to store food-contact utensils was dirty;4. Water pitchers and lids were stored with visible water droplets and were stacked and stored while still wet;5. A dented canned food item was stored in the canned goods storage area for use;6. A refrigerator located in the nurses' break room that stored resident food items had a temperature reading of 50 degrees Fahrenheit (F; a unit of temperature measurement); and7. A food delivery service driver was in the kitchen without a hair net. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to practice appropriate infection prevention and control measures for a census of 89 residents when:1. A staff member was observed delivering a meal tray inside a contact precaution (used to prevent the spread of germs through touch by requiring gloves and gown) room without wearing gown and gloves despite precaution signage posted outside the room;2. Hand hygiene (washing hands or using hand sanitizer) was not performed in-between resident care for Resident 105, Resident 9, Resident 106, and Resident 89;3. The glucometer (a portable device that measured blood sugar levels by analyzing a small drop of blood on a test strip) cleaning and sanitization process was not completed; and 4. Dirty coffee cups were stored on the coffee cart with clean pitchers of coffee, water, and juice. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents right to privacy and dignity was maintained for 2 of 28 sampled residents (Resident 89 and Resident 94) when: 1. Resident 89's indwelling urinary catheter (a thin, hollow tube inserted through the urethra into the bladder to collect and drain urine) bag (a clear bag that collects urine from the catheter) lacked a dignity bag cover (a discreet, protective sleeve or pouch designed to hold and hide urinary drainage bags allowing for more confidence when moving in public); and, 2. A staff member entered Resident 94's room without knocking and requesting permission prior to entry. These failures placed Resident 89 and Resident 94 at risk of compromised privacy, dignity, feelings of embarrassment, loss of privacy and psychosocial harm.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure self-administration of medication was appropriate for 1 of 28 sampled residents (Resident 14), when two bottles labeled Refresh Tears Lubricant Eye Drops were observed on Resident 14's bedside table and Resident 14 was using it without a doctor's order, without self-medication administration assessment and was not incorporated into Resident 14's care plan. This deficient practice had the potential to result in inappropriate medication use, contamination of the medication, and lack of clinical oversight of Resident 14's treatment.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that one of two sampled residents (Resident 55) Minimum Data Set (MDS -a federally mandated resident assessment tool) was accurately coded when Resident 55's MDS indicated that Resident 55 had no dental issues when Resident 55 was in fact missing all upper teeth, had no upper denture and the bottom teeth were in various stages of decay. This failure had the potential to affect Resident 55's plan of care due to inaccurate coding of the MDS.

Inspectors wroteBased on interview, and record review, the facility failed to develop and implement a comprehensive care plan for 1 of 28 sampled residents (Resident 34), when a comprehensive care plan was not developed for Resident 34's cardiovascular (relating to or affecting the heart and blood vessels) medical condition requiring 5 blood pressure medications. This failure had the potential to place Resident 34 at risk for not receiving effective and person-centered care.

Inspectors wroteBased on observation, interview and record review the facility failed to revise and review the person-centered comprehensive care plans (a detailed document outlining a person's healthcare needs, goals, and the specific care and support they will receive, including how, when and by whom) for two of 28 sampled residents (Resident 10 and Resident 55) when,1. Resident 10's comprehensive care plan continued to reflect hospice services were active in providing care after Resident 10 had been discharged from services on 8/27/25,2. Resident 55's comprehensive care plan concerning the need for dentures and the pending authorization from the [Dental Service Provider] had not been revised since 11/4/24. These failures placed Resident 10 and Resident 55 at risk of not receiving the individualized and person-centered care that they required.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of twenty-eight sampled residents (Resident 5 and Resident 6) received care in accordance with professional standards of practice (guidelines and criteria established by professional organizations designed to ensure safe competent and ethical care for residents in all practice settings) when:Intake and output was not documented daily in the medical record per physician order in February 2026 for Resident 5,The indwelling urinary catheter (a tube inserted into the bladder to drain urine) placement, functioning and care was not documented daily in February 2026 per physician orders for Resident 5, andIntake and output was not documented daily in the medical record per physician orders in January 2026 and February 2026 for Resident 6. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that there was sufficient, qualified nursing staff available to at all times to provide nursing and related services to meet the residents' needs safely and in a manner that promotes the residents' rights, as well as physical, mental and psychosocial well-being when three of twenty-eight sampled residents (Resident 77, Resident 35, and Resident 8) call lights (a button or cord in a hospital or nursing home room that allows a patient to call for help) were not answered in a timely manner to provide requested care. This failure had the potential to place Resident 77, Resident 35 and Resident 8 at risk for injury and psychosocial distress due to extended wait periods.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe pharmaceutical services for a census of 89 residents when:1. The emergency kit (or Ekit, an emergency supply of prescription medications) content was not resupplied in timely manner for an injectable medication called Zyprexa (or olanzapine, a mood stabilizer or mental health drug) for over 5 days in the facility's Automated Dispensing Machine (or ADM, electronic control of drug use and dispensing);2. Resident 18's TPN (Total Parenteral Nutrition, intravenous (IV) form of nutrition given through the vein) product was labeled by the provider pharmacy with two different beyond use dates (or BUD, expiration date, the date after which not to be used) on each side of the bags; and3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe medication storage practices in the medication carts, medication refrigerators, and medication rooms for a census of 89 residents when:1. The east station medication room stored unlabeled IV (intravenous; medication given through a vein) fluid bags, un-returned resident medication stored in an unclean cabinet, and injectable drugs were stored in a wet, soiled plastic zip lock bag inside the refrigerator;2. The east station medication cart 2 contained unopened eye drop marked to be refrigerated when not opened;3. The west medication room IV cart had opened, undated vials of injectable medication called lidocaine (a numbing agent) along with unlabeled IV fluid bags;4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure routine dental care was followed up on for one of twenty-eight sampled residents (Resident 55) when, dental services for Resident 55's dentures were not followed up on since 8/25/24. This failure placed Resident 55 at risk for decreased meal intake, continued decay of remaining teeth, and psychosocial distress over the lack of dentures and poor oral health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a complete and accurate medical record for 3 of 28 sampled residents (Resident 10, Resident 5, and Resident 66) when:1. Resident 10's Interdisciplinary (IDT - a group of different health professionals (like doctors, nurses, therapists, and social workers) who work together, sharing information and decisions to provide comprehensive care for a patient) Care Conference Notes and care plan (a structured, individualized document that outlines the medical and supportive services a patient needs to address their specific health conditions and goals) indicated Resident 10 was receiving hospice services (specialized, holistic care for individuals with terminal illnesses (typically 6 months or less to live) who have stopped curative treatment) even though Resident 10 had been discharged from hospice on 8/27/25.2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that complete and accurate nurse staffing information was posted in a readily accessible location for residents and visitors. This deficient practice had the potential to prevent residents, families, and the public from accessing accurate information regarding daily nurse staffing levels, which is required to promote transparency and awareness of the staffing resources available to meet resident care needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident's right to return to the facility was protected for one of three sampled residents (Resident 1), when Resident 1 was transferred to the hospital and was not allowed to return to the facility on [DATE]. This failure placed Resident 1 at risk for psychosocial harm (mental and emotional suffering) due to separation from the resident's home and familiar environment.

Inspectors wroteBased on interview and record review, the facility failed to protect one of five sampled residents (Resident 4) from physical abuse when, Resident 3 with a history of aggressive behavior, hit Resident 4 in the face with a water pitcher on 10/9/25. This deficient practice resulted in Resident 4 being sent to the emergency room with a facial contusion (bruise), facial lacerations (a torn, ragged wound or cut through the skin, typically caused by blunt force trauma or a sharp object) to the upper lip and right eyebrow which required stitches (threads used to sew up wounds to hold the skin together for healing), and pain. This deficient practice had the potential to affect Resident 4's psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe and comfortable homelike environment to three of five sampled residents (Resident 1, Resident 2, and Resident 3) when: Resident 2 stated she did not feel safe at the facility after an altercation with Resident 4; and Resident 1 and Resident 3 stated they were both scared of Resident 4. These failures removed Resident 1, Resident 2 and Resident 3's right to a dignified homelike environment, with the potential to result in psychosocial harm.

Inspectors wroteBased on interview and record review, the facility failed to develop or revise a comprehensive care plan (a guide that healthcare workers used to ensure Resident 1 received tailored care to his/her individual needs and goals) for one of three sampled residents (Resident 1), when a care plan was not developed for the use of methadone (a powerful pain reducing medication that could cause headaches, dizziness, nausea, impaired coordination, unconsciousness or death) for Resident 1. This failure placed Resident 1 at risk for not receiving specific and individualized care related to the use of a strong pain medication (methadone).

Inspectors wroteBased on interview and record review, the facility failed to provide an effective pain management plan when non-pharmacological pain interventions (interventions that did not involve the use of medications to treat pain such as heat therapy, cold therapy, and repositioning) were not implemented for three out of three sampled residents (Resident 1, Resident 2, and Resident 3). These failures had the potential to place Resident 1, Resident 2, and Resident 3 at increased risk of experiencing adverse side effects (undesired harmful effects as a result of taking medication for pain such as drug to drug interactions, constipation, respiratory depression) of pain medication and/or the use of unnecessary medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services which met professional standards of quality for diabetic (inability to regulate sugar levels in the body) residents in a census of 87 when the quality control solution (QC, used to verify the product meets specific standards) for the East Unit's glucometer (used to measure a resident's blood sugar) was expired. This failure had the potential to cause an inaccurate blood sugar test which could have resulted in diabetic residents receiving the wrong dose of a blood sugar reducing medication called insulin endangering their health and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were labeled, stored, and disposed of according to standards of practice for a census of 87 when: 1. Expired (no longer usable) medications were stored in a medication cart; 2. Opened, unlabeled vials of tuberculin purified protein derivative (PPD, used in the testing of staff and residents for the presence of tuberculosis infection) were stored in a medication room refrigerator; 3. Staff clothing (pants) was stored in a treatment cart with medications and resident care equipment; 4. Expired liquid narcotic medication (a drug that in moderate doses relieves pain and induces sleep but in excessive doses can cause coma) and an expired vial of tuberculin PPD were stored in a medication room refrigerator; and 5. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure qualified staff oversight of the facility's food and nutrition services according to federal and state requirements for a census of 87, when the Interim Certified Dietary Manager (ICDM) was not certified, and the Registered Dietician (RD) worked at the facility less than 35 hours per week. This failure had the potential to affect food safety for 87 residents eating facility prepared food.

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 87 residents who ate facility prepared meals when: 1. Spoiled produce food items were located in the walk-in refrigerator; 2. Staff personal items were kept in the refrigerator and kitchen preparation area; 3. Several various sizes of metal pans were stacked and stored wet; 4. The ice machine was not cleaned and sanitized properly per manufacturer's guidance; and, 5. Resident freezer temperatures were not being monitored. These failures had the potential to put residents eating facility prepared meals at risk for foodborne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to practice appropriate infection prevention and control measures for a census of 87, when: 1. Resident 30 did not have Enhanced Barrier Precautions ([EBP] an approach to the use of personal protective equipment (PPE; items such as gloves, gowns, and facemasks) to reduce transmission of Multidrug-Resistant Organisms [MDROs are bacteria that are resistant to three or more classes of antimicrobial drugs] between residents in skilled nursing facilities) signage and PPE (clothing and equipment that is worn or used in order to provide protection against hazardous substances or environments) outside the room; 2. Dirty coffee cups were placed on a coffee cart alongside clean cups; and 3. [NAME] pants were stored alongside medications and equipment in a respiratory treatment cart. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident (Resident 26) in a sample of 24 was treated with dignity and respect when staff stood over Resident 26 while assisting with breakfast on 11/19/24. This failure had the potential to negatively impact Resident 26's psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 of 24 sampled residents (Resident 31) needs were accommodated when Resident 31 did not have a working call light (a device used by residents to call for assistance). This failure increased the risk for psychosocial and/or physical harm if Resident 31 was unable to contact staff for her needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain residents' right to privacy of personal information, when resident meal tickets were discarded in the facility kitchen garbage bin for a census of 87. This failure increased the risk of unauthorized access of residents' personal and medical records.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe, clean, and comfortable living environment for 2 of 24 sampled residents (Resident 340 and Resident 31), when Resident 340's and Resident 31's floor vents (provides cold and warm air) were full of dust and debris. This failure had the potential to negatively impact Resident 340's and Resident 31's homelike environment and their health.

Inspectors wroteBased on interview and record review, the facility failed to accurately complete, and ensure the completion of, a Pre-admission Screening and Resident Review (PASRR, a required assessment for individuals with mental illness, intellectual or developmental disabilities, or related conditions, so that a determination of need, appropriate setting, and a set of recommendations for services to be included in the individual's plan of care is provided) for two of twenty-four sampled residents (Resident 60 and Resident 72), when, 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure 1 of 24 sampled residents (Resident 6) received treatment in accordance with quality care when, Resident 6 had left knee swelling, and exhibited signs of pain via facial grimacing and screaming during care provided to her by staff and, a. Nursing staff did not adequately assess Resident 6's source of pain and provide pain management based on Resident 6's level of pain; and, b. There was a delay in obtaining an x-ray result of Resident 6's left knee, ordered to provide information as to the source of Resident 6's pain. These failures had the potential for Resident 6 to experience prolonged pain and suffering and may have resulted in a delay of treatment and other complications related to her fractured femur (thigh bone) and dislocated left knee.

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident on fluid restriction (Resident 7), out of 24 sampled residents, physician was notified when Resident 7's fluid intake exceeded the restricted amount specified by the physician. This failure had the potential to result in a decline in Resident 7's health and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assist one of twenty-four sampled residents (Resident 72) with a referral to receive outside dental services when: 1. Resident 72 requested new dentures during a dental exam on 4/11/24; and, 2. Resident 72 was unable to tolerate dental services provided within the facility on 7/26/24, 8/27/24, and 9/6/24. This failure had the potential to delay Resident 72 from receiving dental services and obtaining dentures and could have led to complications related to dental and nutritional needs for Resident 72.

Inspectors wroteBased on interview and record review, the facility failed to provide education to a resident about Pneumococcal (a serious bacterial infection that can cause respiratory illness) vaccines for one of five sampled residents (Resident 23) prior to administration. This deficient practice violated Resident 23's right to make an informed choice to receive or not receive the pneumococcal vaccine.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a functioning call light system (system/device used by residents to call staff for assistance) was in place for two of twenty-four sampled residents (Resident 31 and Resident 45) when, Resident 31 and Resident 45's call lights were not working and an alterantive means to call for assistance was not provided to the residents. This failure had the potential to result in Resident 45 and Resident 31 being unable to call staff for help when needed and their needs not being met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide staff education regarding autism (a brain and developmental disorder that affects how people interact with others, communicate, learn, and behave) to ensure quality care was delivered for one of one residents (Resident 72) with a diagnosis of autism. This failure resulted in facility staff being untrained in caring for a resident with autism and Resident 72 not receiving specialized care and services which recognized the signs of autism and incorporated a system of responding to his behavioral health needs, which had the potential to result in escalating behaviors for Resident 72 and psychosocial distress.

Inspectors wroteBased on interview, and record review, the facility failed to provide notice of a facility-initiated discharge to the appropriate parties and provide all the required information on the 30-Day Notice of Transfer or Discharge, (a document given by the facility to the resident indicating an upcoming transfer or discharge from the current facility to another facility/home) that was given to Resident 1 when: 1. The facility did not inform the Office of the State Long-Term Care (LTC) Ombudsman (a government appointed person who actively supports the rights of the residents) on the same day the facility served Resident 1 with a 30-Day Notice of Transfer or Discharge form, 2. The location that Resident 1 was transferred to was not listed on the 30-Day Notice of Transfer or Discharge form; and, 3. [...]

Inspectors wrote4. Review of Resident 16's admission Record indicated Resident 16 was admitted to the facility in October 2023, with multiple medical diagnoses that included benign prostatic hyperplasia (a condition in men in which the prostate gland is enlarged). During an observation on 11/7/23, at 9:56 a.m., in Resident 16's room, Resident 16 was observed to be sitting at the edge of his bed and was noted with an indwelling urinary catheter. Review of Resident 16's care plan failed to show a urinary catheter care plan was developed upon admission. During an interview on 11/8/23, at 3:23 p.m., with LN 14, LN 14 confirmed Resident 16 did not have a urinary catheter care plan. During a concurrent interview and record review on 11/9/23, at 10:51 a.m., with the DON, the DON confirmed Resident 16 did not have a urinary catheter care plan. The DON stated there should be a care plan in place. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure 1 of 21 sampled residents (Resident 10) received a required mental health evaluation for an identified mental disorder. This failure had the potential for Resident 10 's access to specialized treatment, care, and services for an identified mental disorder to be denied.

Inspectors wroteBased on interview and record review the facility failed to ensure an accurate psychiatric (mental health) diagnosis was documented in the medical records for 1 out of 21 sampled residents (Resident 13) based on standards of practice. This failure could result in inaccurate treatment, care and monitoring of Resident 13's psychotropic medication (medications that affect mood or behavior).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 of 21 sampled residents (Resident 4) was assisted in gaining access to hearing services when Resident 4's physician order to be evaluated by an audiologist (a person with specialized training in the science and medicine of hearing and balance) was not acted upon. This failure had the potential for Resident 4 to not effectively communicate and express her needs and negatively impact Resident 4's quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide preventative care and treatment consistent with professional standards of care for one of six sampled residents with pressure injuries (Resident 63) when Resident 63's pressure injury (PI- an injury to skin and underlying tissue resulting from prolonged pressure) plan of care of the right knee PI was not followed. This failure had the potential for Resident 63's right knee pressure injury to worsen and develop complications.

Inspectors wroteBased on observation, interview, record review, the facility failed to ensure 1 of 21 sampled residents (Resident 16) who was admitted to the facility with an indwelling urinary catheter (foley catheter, tube inserted into the bladder to drain urine) had a physician order for the catheter. This deficient practice had the potential for Resident 16 to have an increase in recurrent UTI's and could cause actual harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide treatment and care in accordance with professional standards of practice for 2 of 4 sampled residents with a 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) line (Resident 79, and Resident 80) when: 1. Resident 79's PICC line dressing was not changed at least weekly; and 2. Resident 80's PICC line dressing was not changed at least weekly. These failures had the potential to increase the risk of developing an infection for Resident 79 and Resident 80.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure timely availability of medications for three of twenty-one sampled residents (Resident 29, Resident 40, and Resident 68) when: 1. Resident 29's zonisamide (medication used to prevent and control seizures) 50 mg (milligram, unit of measure) dose was not available for administration on 11/6/23. 2. Resident 40's neomycin/polymyxin B/hydrocortisone otic solution (medication used to treat ear infections) was not available for administration on 11/6/23. 3. Resident 68's lorazepam (medication used to treat anxiety) was not available for administration on 11/6/23. These failures had the potential to cause Resident 29 an increased risk of seizures, Resident 40's infection to worsen and Resident 68 to experience symptoms of anxiety and distress.

Inspectors wroteBased on interview, and record review, the facility failed to ensure safe use and monitoring of blood thinner (medication with high risk of bleeding) and cardiac (heart) medications for 1 out of 21 sampled residents (Resident 49) based on standards of practice on safe use of high-risk (drugs with heightened risk of causing significant patient harm due to side effect profile) medications when: 1. Resident 49 was on four different blood thinning medications without daily side effect monitoring; and, 2. Resident 49 was on duplicate cardiac medications known as beta blockers (beta blocker medications are a class of drugs that cause the same additive effect on the heart) for the same indication with additive effect on heartbeat and blood pressure. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication administration error rate was less than 5 percent (%, a number or ratio indicating parts per hundred) when 7 medication errors occurred out of 33 opportunities during medication administration observation for 4 out of 17 residents (Resident 23, Resident 29, Resident 40, and Resident 68). As a result of these failures, the facility's medication administration error rate was 21% which could contribute to unsafe medication use and not following the doctor's orders.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe medication storage practices for a census of 80 when: 1. Unlabeled prescription medications were stored in the East Hall treatment cart, 2. An expired bottle of vitamin B6 (vitamin supplement) was stored in a [NAME] Hall medication cart, 3. Expired normal saline (saltwater solution) syringes were stored in the East Hall emergency supply cart and expired normal saline vials were stored in the [NAME] Hall intravenous (IV, administered in the vein) emergency supply cart; and, 4. Unpackaged, unlabeled IV fluid bags and IV fluid bags labeled with the names of discharged residents were stored in the [NAME] Hall emergency IV supply cart. These failures had the potential for the use of medications that were expired and the possibility for a medication to be used for the wrong resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe food production when: 1. Multiple food items were found undated and were not labeled with an open date and/or use by date in the refrigerator, freezer, and the dry storage area (foods that do not require to be kept cold), 2. Multiple expired food products were not removed from the kitchen and were available for use, 3. Cleaned, ready to use water pitchers with lids were placed on an unsanitary wooden shelf; and, 4. A clear pitcher containing orange colored liquid was leaking onto the shelf and the liquid was dripping onto the bottom shelf that contained a tray with food ready to be served. These failures had the potential to expose 78 residents of a census of 80 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 effectively coordinate nursing care with the hospice (specialized health care that focuses on the providing care to terminally ill residents) agency for 1 of 13 sampled residents (Resident 68) receiving hospice care when Resident 68 did not receive their scheduled anti-anxiety medicine. This failure resulted in Resident 68 not receiving five scheduled doses of Lorazepam (anti-anxiety medication) resulting in Resident 68 experiencing distress, agitation, and anxiety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control practices with a census of 80 when: 1. Resident 13 was on transmission based precautions (TBP, precautions implemented based upon means of transmission to prevent or control infections) and no TBP signage on the use of personal protective equipment (PPE), and an isolation cart (cart containing supplies such as gown, gloves, mask, and/or face shield) were not placed outside of Resident 13's room, 2. Facility failed to follow safe infection control practices for cleaning and disinfecting shared glucometers (a device used to measure blood sugar) in-between resident care for Resident 80 and Resident 50; and, 3. Facility failed to prevent contamination of multi-dose medication containers when oral syringes were returned to storage after resident use for Resident 41 and Resident 63. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure appropriate use of an antibiotic medication (used to treat bacterial infections) within the antibiotic stewardship program, for one of seven residents (Resident 291) when Resident 291's antibiotic order did not have a stop date. This failure increased Resident 291's risk for an infection with bacterial organisms resistive to certain antibiotics (MDRO; multidrug-resistant organisms, germs that are resistant to many antibiotics) in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 of 21 sampled residents (Resident 68) had a functioning call light (visual cue that a resident needs assistance) at the bedside. This failure had the potential for Resident 68's needs not being met in a timely manner and placed Resident 68 at risk for injury (falls) related to getting out of bed to find assistance.

Inspectors wroteBased on interview, and record review, the facility failed to provide recent education to their staff regarding Post Traumatic Stress Disorder (PTSD - a mental health condition triggered by a terrifying event, causing flashbacks, nightmares, and severe anxiety) to ensure quality of care was delivered for one resident with a diagnosis of PTSD (Resident 18), with a census of 80 residents. This failure resulted in Resident 18 not receiving specialized nursing care that recognized the signs of trauma and incorporated a system of responding to trauma, which had the potential to result in re-traumatization for Resident 18.

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident 1), in a sample of 3, received quality care in accordance with professional standards of practice when the facility did not initiate and monitor essential laboratory values based on alerts of drug interactions for medications Resident 1 was receiving. This failure was a factor in Resident 1's transfer to the hospital with acute kidney failure, hyperkalemia (high blood potassium-a mineral that is needed by all tissues in the body), and dehydration, and had the potential to negatively impact Resident 1's health and well-being.