Highland Pines Nursing Home

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure an accurate MDS assessment was completed for 2 of 22 residents reviewed for MDS accuracy. (Resident #12 and Resident #60) The facility failed to accurately code Resident #12's falls within the last 30 days on the admission MDS assessment. The facility failed to ensure Resident #60's Annual MDS assessment accurately reflected her positive PASRR status for mental illness. This failure could place residents at risk of not receiving needed care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all Pre-admission Screening and Resident Review (PASRR) Level I residents with mental illness were provided with a PASRR Evaluation assessment prior to admission for 1 of 5 residents (Residents #60) reviewed for PASRR care and services. The facility failed to ensure Resident #60 had a PASRR evaluation (Level II) completed prior to re-admission from an in-patient psychiatric facility. This failure could place residents at risk of not receiving care and services to meet their needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure the baseline care plan that included the instructions for resident care needed to provide effective and person-centered care was completed and provided to the resident and/or their representative for 2 of 5 residents reviewed for new admissions (Resident #103 and #105). The facility failed to ensure the baseline care plan that included the instructions for resident care needed to provide effective and person-centered care was provided to the resident and/or their representative for Resident #103 and Resident #105. This failure could place residents at risk of not receiving care and services to meet their needs.

Inspectors wroteBased on interviews and record reviews, the facility failed to implement a comprehensive person-centered care plan for each resident to ensure the comprehensive care plan described the services and interventions to be used to attain and maintain the residents' practicable physical, mental, and psychosocial well-being for 2 (Resident#17 and Resident #31) of 18 residents reviewed for care plans. The facility failed to implement a person-centered care plan for a laceration, received in the facility prior to the initiation of the comprehensive care plan on 01/05/2026, requiring sutures with interventions for Resident #17, to meet medical, nursing, mental and psychosocial needs. The facility did not ensure that Resident #31's care plan had specific triggers for a trauma related problem. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 2 medication storage rooms. (Storage room [ROOM NUMBER])The facility failed to ensure Resident #95's expired Gabapentin was removed from Storage room [ROOM NUMBER]. These failures could place residents at risk for not receiving the therapeutic benefit of medications or adverse reactions to medications and inaccurate drug administration.

Inspectors wroteBased on observation, interview and record review, the facility failed to store all drugs and biologicals in locked compartments for 1 of 4 medication carts (Medication Cart #1) reviewed for pharmacy services. The facility failed to ensure Medication Aide Cart #1 for the 200 short hall was locked when unattended. This failure could place residents at risk of having unauthorized access to medications or lead to harm or drug diversions.

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. 1. A sack of flour was not stored six inches off the floor. 2. Raisin bread, sliced cheese, and tortillas were not labeled or dated. These failures could place residents at risk for food borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 residents (Resident #106) reviewed for infection control practices. The facility failed to ensure LVN A and CNA B utilized enhanced barrier precautions while pulling Resident #106 up in bed on 01/12/2026. This failure could place residents and staff at risk for cross contamination and the spread of infection.

Inspectors wroteBased on observation, interviews and record review the facility failed to ensure residents were free from abuse for 1 of 8 residents (Resident #1) reviewed for resident abuse. The facility did not ensure Resident # 1 was free from abuse on 2/20/25 when he was slapped on the top of his hand. The noncompliance was identified as PNC. The noncompliance began on 2/20/25 and ended on 2/20/25. The facility had corrected the noncompliance before the investigation began. This failure could place residents at risk of physical harm, mental anguish, or emotional distress.

Inspectors wroteBased on interviews and record review, the facility failed to ensure residents were free from abuse for 3 of 6 residents (Resident #21, Resident #50, and Resident #74) reviewed for abuse. The facility failed to ensure Resident #21 did not feel abused during bathing by CNA P in September and October 2024. The facility failed to ensure Resident #50 did not experience abuse by Resident #70 on 10/06/24. The facility failed to ensure Resident # 74 (victim) was free from undesired touching by Resident #77 (alleged perpetrator) on 10/5/2024. These failures could place resident at risk for emotional distress and further abuse.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure residents received care, consistent with professional standards of practice, to prevent pressure ulcers based on the comprehensive assessment for 3 of 6 Residents (Resident #21, Resident #51, and Resident #79) whose records were reviewed for skin integrity. The facility failed to ensure Resident #21, Resident #51, and Resident #79's pressure-relieving mattresses (is designed to distribute the patient's body weight over a broad surface area and help prevent skin breakdown) were on the correct settings. The facility failed to ensure Resident #79 received and/or documented wound care on 10/05/24, 10/06/24, 10/07/24, 10/10/24, 10/11/24, and 10/13/24. These failures could place residents at risk for developing pressure ulcers and could contribute to developing avoidable pressure ulcers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that each resident who was incontinent of bowel/bladder and each resident with an indwelling catheter received appropriate treatment and services to prevent urinary tract infections, for 3 of 7 residents (Resident #52, Resident #79, and Resident #88) reviewed for indwelling urinary catheters. The facility failed to ensure Resident #52, Resident #79, and Resident #88's indwelling catheter (drains urine from your bladder into a bag outside your body) had a catheter securement device to anchor catheter to their legs on 10/14/24, 10/15/24, and 10/16/24. The facility failed to ensure Treatment Nurse M did not place Resident #79's catheter bag on the bed during wound care on 10/15/24. Theses failures could place residents at risk for urinary tract infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals, and preferences for 3 of 5 residents (Resident #25, Resident #16, and Resident #15) reviewed for respiratory care and services. 1. The facility failed to obtain a physician's order for Resident #25's oxygen, prior to surveyor intervention. 2. The facility failed to ensure Resident #25's oxygen concentrator was clean and free of gray/black debris. 3. The facility failed to ensure Resident #15's CPAP mask was stored in bag and oxygen concentrator had a filter on 10/14/24-10/17/24. 4. The facility failed to ensure Resident #16's oxygen concentrator filter was free from gray, fuzzy particles on 10/14/24-10/16/24. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items for 5 of 24 resident personal refrigerators reviewed for food safety (Resident #42, Resident #49, Resident #51, Resident #72, and Resident #81). 1. The facility failed to ensure the refrigerator for Resident #72 was cleaned, clutter free and free from meat with green mold. 2. The facility failed to ensure Resident #42, Resident #49, Resident #51, and Resident #81's refrigerator temperature was checked and logged daily. These failures could place resident at risk for food borne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for 6 of 24 residents reviewed for infection control practices (Resident #'s 2, 7, 37, 39, 91, and 100), 1. The facility failed to ensure CNA C changed her gloves and performed hand hygiene appropriately while providing incontinent care to Resident #2. 2. The facility failed to ensure Resident #7 had enhanced barrier precautions sign posted on door with storage container for PPE on 10/14/2024 for resident with a feeding tube. 3. [...]

Inspectors wroteBased on interviews and record review the facility failed to ensure each resident was informed before or at the time of admission, and periodically during the residents stay, of services available in the facility and of charges for those services, which included charges for services not covered under Medicare/Medicaid or by the facility's per diem rate for 2 of 3 residents (Resident #274, and Resident #275) reviewed for Medicare/Medicaid coverage. The facility failed to ensure Resident #274, and Resident #275 were given a SNF ABN (a document that informs a Medicare beneficiary that Medicare will no longer pay for skilled services) when discharged from skilled services at the facility prior to covered days being exhausted. These failures could place residents at risk for not being aware of changes to provided services.

Inspectors wroteBased on interviews and record review, the facility failed to report the results of all investigations to the Administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation was verified appropriate corrective action must be taken for 1 of 7 residents (Resident #1) reviewed for abuse and neglect. The facility failed to ensure the provider investigation report regarding Resident#1's incident with Resident #26, dated 09/12/24 was turned into the state survey agency (HHSC) within 5 working days of the reported incident for Resident #1. This failure could place residents at risk for abuse and neglect.

Inspectors wroteBased on interviews and record review, the facility failed to ensure assessments accurately reflected the resident's status for 2 of 24 resident reviewed for assessments. (Resident #49 and Resident #88) The facility failed to ensure Resident #49's MDS dated [DATE], was not inaccurately coded for being on an antipsychotic medication (are a class of psychotropic medication primarily used to manage psychosis). The facility failed to ensure Resident #49's MDS dated [DATE], was not inaccurately coded as having a diagnosis of bipolar (is a mental illness that causes extreme shifts in mood, energy, and activity levels) instead of mood disorder. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) Level I assessment accurately reflected the resident's status for 1 of 13 residents (Resident #97) reviewed for PASRR Level I screenings. 1. The facility failed to ensure the accuracy of the PASRR Level 1 screening for Resident #97. This failure could place residents who had a mental illness at risk of not receiving a needed assessment (PASRR Evaluation), individualized care, or specialized services to meet their needs.

Inspectors wroteBased on interviews and record review the facility failed to notify the State Mental Health Authority to inform them of a significant change in mental condition for 1 of 5 (Residents #93) residents reviewed for Preadmissions Screening and Annual Resident Review (PASRR). 1. The facility failed to notify the SMHA to ensure Resident #93 received a new PASRR level 1 screening following identification of his diagnosis of post-traumatic stress disorder on 01/25/24. This failure could affect residents who may have a mental disorder diagnosis by placing them at risk for not receiving the necessary services that may benefit them daily.

Inspectors wroteBased on interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet resident's medical, nursing, mental and psychosocial needs identified in the comprehensive assessment for 1 of 24 residents reviewed for care plans. (Resident #25) The facility failed to ensure that Resident #25's care plan addressed his oxygen use. These failures could place residents at risk for not receiving the necessary care or having important care needs identified.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide the necessary services to maintain personal hygiene for 2 of 5 residents reviewed for ADLs. (Resident #81 and Resident #88) The facility failed ensure Resident #81 was provided timely incontinent care on 10/15/24. The facility failed to ensure Resident #88 did not have yellow substance on his gum line and between his teeth on 10/14/24, 10/15/24, and 10/16/24. The facility failed to ensure Resident #88 was gotten or offered to get out of bed in October 2024. Theses failures could place residents who required assistance from staff for ADLs at risk of not receiving care and services to meet their needs which could result in poor care, feelings of poor self-esteem, lack of dignity and health.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide pharmaceutical services to include procedures that assured the accurate dispensing and administering of all drugs to meet the needs of 1 of 12 residents reviewed for pharmaceutical services. (Resident #72) Facility staff failed to remove Lidocaine patches 5% strength from Resident #72's personal refrigerator. These deficient practices could affect residents and place them at risk of not receiving the therapeutic dosage and drug diversion.

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary medications (is a medication used: In excessive doses (including duplicate therapy); or For excessive duration; or Without adequate monitoring; or Without adequate indication for its use; or In the presence of adverse consequences which indicate the dose should be reduced or discontinued) for 1 of 5 residents (Resident #21) reviewed for unnecessary medications in that: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident's PRN orders for psychotropic drugs were limited to fourteen (14) days for 1 of 24 residents selected for unnecessary medications review. (Resident #59). Resident #59 had a PRN order for Lorazepam, a psychotropic medication, for more than fourteen days without physician documentation re-evaluating the medication to continue it PRN or to become a scheduled medication. This failure could place residents who receive PRN psychotropic medications at risk of receiving unnecessary medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that it was free of medication error rate of 5 percent or greater. The facility had a medication error rate of 14.81%, based on 4 errors out of 27 opportunities, which involved 2 of 5 residents (Resident #39, Resident #90) reviewed for medication administration. 1. The facility failed to administer Resident # 39's [NAME] vitamin B-complex (contains essential vitamins such as B-complex, vitamin C, and folic acid, which help manage or prevent deficiencies common in individuals with compromised renal function.) and administered incorrect dose of Vitamin D3 25 mcg (a nutrient your body needs for building and maintaining healthy bones) on 10/15/2024. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents were free of significant medication errors for 1 of 10 residents (Residents #51) reviewed for pharmacy services. The facility failed to ensure Resident #51 received Acetaminophen-Codeine Oral Tablet 300-60mg (is used to help relieve mild to moderate pain; Tylenol #4 contains 60 mg of Codeine) as scheduled on 10/13/24 (8am and 3pm) and 10/14/24 (8am). This failure could place residents at risk of discomfort and pain.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure drugs and biologicals were stored in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 2 of 38 residents. (Resident #274 and Resident # 54) 1. The facility failed to ensure Santyl and Mupirocin ointment 2% was properly stored and locked in accordance with currently accepted professional standards for Resident # 54. 2. The facility failed to ensure Triamcinolone Acetonide Ointment 1% was properly stored and locked in accordance with currently accepted professional standards on [DATE] for Resident # 274. This failure could place residents at risk for adverse effects and reduced therapeutic effects of medication and supplies.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet each resident's medical, nursing, mental and psychosocial needs for 1 of 5 residents reviewed for care plans. (Resident #1) The facility failed to develop and implement the comprehensive person-centered care plan for Resident #1 by not documenting foley catheter changes. This failure could place residents at risk of not having individual needs met, a decreased quality of life, and cause residents not to receive needed services.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident received adequate supervision to prevent accidents for 1 of 5 residents reviewed for accidents (Resident #14). The facility failed to ensure Resident #14 who was identified as high fall risk, confused, unable to be assessed for ability to sit to stand due to medical condition and safety concerns, and required wheelchair was monitored more closely to prevent falls or injury. This failure could place residents at risk for injury or harm.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure a resident received adequate supervision to prevent accidents for 1 of 7 residents reviewed for accidents (Resident #1). The facility failed to ensure Resident #1 who was identified as confused and a wanderer and had increased confusion was monitored more closely. Resident#1 was found on a high traffic street in a wheelchair in the street, with no sidewalk and a few inches for a holder on 7/27/24. The facility staff did not know the resident had eloped, or exactly how he left the facility. An Immediate Jeopardy (IJ) was identified on 07/31/24. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency) for 1 of 7 residents (Resident #1) reviewed for neglect. Resident #1 was identified as confused and a wanderer and had increased confusion but was not monitored more closely. [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to consult with the resident physician when there was a need to alter treatment for 1 out of 3 residents (Resident #61) reviewed for notification of changes. The facility failed to notify and consult with the physician about the changes in Resident #61's high blood sugar readings. This failure could place residents at the risk of not receiving appropriate medical interventions, which could result in severe illness or hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, sanitary, comfortable, and homelike environment 4 of 35 residents reviewed for environment. (Resident #34, Resident #73, Resident #23, and Resident #267) 1. The facility failed to ensure Resident #34 and Resident #73's portable air conditioning unit/filter was free of gray fuzz and dust-like particles. 2. The facility failed to ensure Resident #34's fan was free of gray fuzz and dust-like particles. 3. The facility failed to ensure Resident #23's bathroom was cleaned daily. 4. The facility failed to ensure Resident #267 did not have enteral feeding (also known as tube feeding, is a way of delivering nutrition directly to your stomach or small intestine) on the floor, IV pole, wall, and mattress. [...]

Inspectors wroteBased on interview, observation, and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet each resident's medical, nursing, mental and psychosocial needs for 2 of 7 residents reviewed for care plans. (Resident #72, Resident #98) The facility failed to implement the care plan intervention to document Resident #72 and Resident #98's meal intake. The facility failed to implement the care plan intervention for Resident #98 to receive his Frozen Nutritional Treats with meals. These failures could place residents at risk of not having individual needs met and cause residents not to receive needed services

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain personal hygiene were provided for 4 of 6 residents reviewed for ADLs (Resident # 79, Resident #98, Resident #66, Resident #90). 1. The facility failed to ensure Resident #79 received her scheduled bed bath. 2. The facility failed to ensure Resident #98 received his schedule bed baths. 3. The facility failed to ensure Resident #98 was offered to get out of bed. 4. The facility failed to ensure Resident #66 was routinely showered/bathed and shaved. 5. The facility failed to ensure Resident #90 was routinely showered/bathed. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who was incontinent of the bladder and had an indwelling urinary catheter received appropriate treatment and services for 3 of 4 resident (Resident #5, #79, and #89) reviewed for incontinence and urinary catheters. The facility failed to ensure Resident #5 had a physician's order for her indwelling urinary catheter with appropriate diagnosis for use. The facility failed to provide timely incontinence care to Resident #79 and Resident #89. These failures could place residents at risk for not receiving appropriate care, infections, skin breakdown and decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that respiratory care was provided consistent with professional standards of practice for 7 of 35 residents reviewed for respiratory care. (Resident #4, Resident #26, Resident #34, Resident #56, Resident #67, Resident #73, and Resident #75). 1. The facility failed to ensure oxygen concentrator filters were free of gray fuzz, hair-like and dust-like particles for Resident #4, Resident #26, Resident #34, and Resident #73. 2. The facility failed to ensure Resident #75's oxygen concentrator was free of gray fuzz and dust-like particles in the slatted vent on the back of the oxygen concentrator. 3. The facility did not ensure oxygen concentrator filters were free from brown like substances for Resident #56 and Resident #67. 4. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 4 of 6 residents (Resident #s 9, 68, 23, 79) reviewed for pharmacy services. ADON K failed to ensure she had a witness when wasting Resident #9's acetaminophen-codeine 300-60mg tablet (controlled medication used for pain). The facility failed to ensure Resident #68's Lorazepam (controlled antianxiety medication) was accurately reconciled. The facility failed to administer Resident #23 and Resident #79's scheduled medication per the facility's policy timeframe. These failures could place the residents at risk of not having medications available for use, not receiving medications, and drug diversion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 6 of 6 residents (Resident #s 5, 81, 32, 23, 79, and 98) and 4 of 4 staff (ADON K, LVN V, CNA A, CNA B) reviewed for infection control. The facility failed to ensure ADON K cleaned the glucometer after using it on a Resident #81. The facility failed to ensure ADON K performed hand hygiene during Resident #81's medication administration. The facility failed to ensure LVN V performed hand hygiene during Resident #5's medication administration. The facility failed to ensure CNA A provided proper incontinent care to Resident #32. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 2 of 3 residents (Resident #98, Resident #267) reviewed for reasonable accommodations. The facility failed to ensure Resident #98 and Resident#267 call lights were within reach. The facility failed to ensure Resident #98, and Resident #267 had been assessed for the appropriate type of call light. These failures could place residents at risk for unmet needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents had a right to personal privacy and confidentiality of medical records for 2 (Resident #81 and Resident #5) of 7 residents reviewed for privacy and confidentiality. ADON K failed to ensure she closed the EMR of Resident #81 before entering his room to obtain a blood sugar check and administer medications. LVN V failed to ensure she closed Resident #5's EMR before entering the supply room and leaving the cart unattended. These failures could place residents at risk for low self-esteem, loss of dignity and decreased quality of life due to medication administration record being accessible to others.

Inspectors wroteBased on interviews and record review, the facility failed to ensure that the comprehensive care plan was reviewed and revised by the interdisciplinary team and the participation of the resident for 1 of 2 residents (Resident #82) reviewed for care plan timing and revision. The facility failed to ensure the IDT were in attendance to Resident #82's care plan meeting. This failure could place residents at risk of not being able to attain or maintain their highest practicable level of physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were offered sufficient fluid intake to maintain proper hydration and health for 3 of 4 resident (Resident #23, Resident #79, Resident #98) reviewed for hydration. The facility failed to ensure Resident #23, and Resident #79 received adequate hydration. The facility failed to ensure Resident #98 received thickened liquid for hydration between meals. The facility failed to implement the care plan intervention for Resident #98 to receive his Frozen Nutritional Treats with meals. These failures could place residents at risk for dehydration, electrolyte imbalance, and infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 1 of 6 medication carts and 3 of 27 residents reviewed in sample (Resident #319, Resident #13 and Resident #81 ). The facility failed to have Resident #319's Arthritis hot pain cream stored and locked in an area not accessible to other staff, residents, or visitors. The facility failed to ensure Resident #13 did not have prescribed and OTC medications at bedside. ADON K failed to ensure the medication cart for hall 300 rooms 316-331 was locked when it was left unattended while giving Resident #81's medication. ADON K and LVN V failed to ensure the medication cart for hall 300 rooms 316-331 was locked when it was left unattended. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure safe and sanitary storage of resident's food items for 2 of 3 residents reviewed for personal food safety. (Resident #16 and Resident #34) The facility did not implement the personal food policy related to personal refrigerators for Resident's #16 and Resident #34. These failures could place the residents at risk for food borne illness.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure all patient care equipment was in safe operating condition for 1 of 1 resident (Resident#14) reviewed safe, functional equipment. The facility failed to ensure Resident #14 had an armrest cushion and secured side panel of her wheelchair. This failure could place residents at risk for skin issues, discomfort, and falls.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their own established smoking policy for 1 of 3 residents (Resident #61) reviewed for smoking. The facility failed to ensure Resident #61 followed the facility's policy on smoking. the did not have a lighter and cigarettes on his bedside table. This failure could place residents at risk of unsafe smoking and injury.