Holiday Manor Care Center

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for three of 19 (Resident 12, 1, and 79) sampled residents when the facility failed to: a. Develop and implement a care plan addressing Resident 12's visual impairment. b. Develop and implement a care plan for Resident 1 to address the risks associated with the use of Seroquel (a medication used to treat certain mental/mood disorders) which carries a Black Box Warning (is the most stringent safety warning the FDA can require from a drug manufacturer. As the name implies, a box warning is a bold, black-bordered notice at the top of a drug's label or informational package insert. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure the kitchen's ice machine was free from a black particle on the inside of the ice machine which had the potential to affect 87 of 88 residents receiving ice from the kitchen's ice machines. 2. Ensure three cutting boards were free from cracks and scratches. 3. Ensure two oven mitts did not have black spots on them. These failures had the potential to result in harmful bacteria growth and cross contamination (a transfer of harmful bacteria from one place to another or one object to another) that could lead to foodborne illness (illness caused by food contaminated with bacteria, viruses, and other toxins).

Inspectors wroteBased on interview and record review, the facility failed to notify the physician for two of 19 sampled residents (Resident 79 and Resident 41) when:1. Resident 79's blood sugar was greater than 200 milligrams per deciliter (mg/dL, a unit of measure for blood sugars, normal reference range 80 - 130 mg/dL) as indicated in the physician's order. This deficient practice placed Resident 79 at risk of becoming hyperglycemic (occurs when a resident has too much sugar [glucose] in their blood, often because their body has too little insulin or cannot use it properly) which can lead to diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) complications, such as nerve damage, eye disease and kidney damage. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain privacy of confidential information for one of four sampled residents (Resident 2), when Licensed Vocational Nurse 1 (LVN 1) left the resident's electronic health record (EHR- a digital version of a patient's paper chart) open and unattended. This deficient practice violated Resident 2's right to privacy and confidentiality of medical records.

Inspectors wroteBased on interview, and record review, the facility failed to update and revise a resident`s care plan by failing to: a. Update and revise a care plan after a resident's physician discontinued the resident's dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) treatment for one of one resident (Resident 83) reviewed under the dialysis care area. This deficient practice had the potential to result in Resident 83's inadequate care and monitoring due to the care plan not reflecting the resident's current dialysis treatment and related care needs. b. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide books of interest to a resident to support the resident's activity preferences as identified in the Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 9/7/2025, for one of three residents (Resident 82) investigated under the care area of Activities. This deficient practice had the potential to result in the resident's activity preferences not being honored, leading to reduced quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet the needs of residents during review of one of two medication carts (Med Cart 1) affecting Resident 41 by failing to: 1. Ensure Licensed Vocational Nurse 3 (LVN) 3 administer medications within the required one hour timeframe. 2. Ensure LVN 3 did not document medications in the electronic Medication Administration Record (eMAR) as administered when medications have not been given. 3. Ensure LVN 3 document medication refusal in the eMAR and notify the physician of the refusal. 4. Ensure LVN 3 store medications in the medication cart in accordance with the facility policy. These failures placed the resident at risk for avoidable harm and significant clinical complications due to improper medication administration, documentation, and storage practices.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free of significant medication errors for one of one of resident (Resident 30) reviewed under the care area of insulin by failing to clarify and carry out the physician's order to change Resident 30's insulin administration regimen from twice daily to once daily, resulting in the resident not receiving prescribed insulin from 4/3/2026 through 5/20/2026. This deficient practice had the potential to result in uncontrolled blood glucose levels, including hyperglycemia and its associated complications such as nerve damage, kidney damage and diabetic ketoacidosis (DKA-life threatening medical emergency when people with diabetes do not have insulin. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure an expired Lantus Insulin (a long-acting man-made-insulin used to control high blood sugar in people with diabetes mellitus [DM- a disorder characterized by difficulty in blood sugar control and poor wound healing]) pen for Resident 30 was removed from one of two medication carts (Med Cart 2) inspected during inspection of medication carts. This deficient practice had the potential for the Lantus Insulin to be used beyond the use by date which could affect the efficacy and render the insulin non-effective in the management of Resident 30's diabetes.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain complete and accurate clinical records for two of 19 sampled residents (Resident 23 and Resident 41) by: a. Failing to accurately document insulin (a natural hormone [are chemicals which circulate in the blood stream] that turns food into energy and manages your blood sugar level) injection site administrations. The deficit practice resulted in incomplete and inaccurate clinical records that did not reflect the resident's actual treatment and failed to meet accepted documentation standards. b. Failing to ensure Licensed Vocational Nurse 3 (LVN 3) did not document medications in the electronic Medication Administration Record (eMAR) as administered when medications have not been given. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement its antibiotic stewardship program (set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use) by failing to conduct infection surveillance for a resident who was prescribed a long-term (being prescribed for more than seven to ten days) antibiotic for one (Residents 4) of three residents sampled for antibiotic usage. This deficient practice had the potential for Resident 4 to develop antibiotic resistance from unnecessary or inappropriate antibiotic use for future infections.

Inspectors wroteBased on interview and record review, the facility failed to notify a physician for one of three sampled residents (Resident 1) regarding the following:1. Resident 1's elevated blood sugar (BS) levels greater than 200 milligrams per deciliter (mg/dl - unit of measurement) per the physician orders.2. Resident 1's refusal to undergo a complete blood count (CBC - an essential blood test that measures the cells circulating in the blood, including the red blood cells [oxygen transport], white blood cells [infection fighting], and platelets [clotting], used to evaluate overall health and diagnose medical conditions) for anemia (a condition in which the body lacks sufficient healthy red blood cells) on 4/6/2026. These deficient practices may result in worsening symptoms, increased risk of hospitalization or complications and a decline in the resident's overall health status. [...]

Inspectors wroteBased on interview and record review, the facility licensed nurses failed to accurately assess and complete fall risk evaluations for two of three sampled residents (Resident 1 and Resident 2). These deficient practices had the potential to place the residents at increased risk for injury related to falls.a. [...]

Inspectors wroteBased on interview and record review, the facility's licensed nurses failed to follow physician orders for one of three sampled residents (Resident 1) to check blood sugar (BS) two times a day for diabetes mellitus (DM - a disorder characterized by difficulty in BS control and poor wound healing) before breakfast and before dinner, and to notify the physician when BS levels exceed 200 milligrams per deciliter (mg/dl - unit of measurement). These deficient practices had the potential to result in medication errors and negatively affect the delivery of care and services to Resident 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's call light (a device used by a resident to signal his/her need for assistance from staff) was within reach for one of three sampled residents (Resident 1). This deficient practice had the potential to delay staff response and result in unmet resident needs. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that the Physician Progress Notes (records documenting the physician's assessment, evaluation, and management of resident care) were maintained as required for one of three sampled residents (Resident 1). This deficient practice had the potential to result in inconsistent care coordination due to incomplete documentation and placed Resident 1 at risk for poor continuity of care and unmet care needs. [...]

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure a copy of the resident's Advance Directive (a legal document indicating resident preference on end-of-life treatment decisions) was readily available in the resident's medical record for one (Resident 49) out of six sampled residents investigated for Advance Directives. 2. Ensure two of six sampled residents (Resident 20 and Resident 291) were provided written information concerning the right to refuse or accept medical or surgical treatments and formulate an Advanced Directive upon admission. These deficient practices had the potential to create confusion, which could lead to conflict with the resident's wishes regarding his/her health care.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive person-centered care plan (a document that summarizes a resident's needs, goals, and care/treatment) by failing to: 1. Develop a care plan addressing a resident's diagnosis of post-traumatic stress disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event) for one of one sampled resident (Resident 49) investigated for trauma-informed care. 2. Develop a care plan addressing a resident's restorative nursing assistant (RNA - an ongoing program that focuses on helping individuals, especially those in long-term care, maintain and improve their functional abilities and independence, often following rehabilitation) therapy for one of two sampled residents (Resident 47) investigated under the care area of position and mobility. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure licensed nurses attempted nonpharmacological interventions (treatments or therapies that do not involve the use of medications) prior to administering as needed (PRN) morphine sulfate (a drug used to treat moderate to severe pain) to one of one sampled resident (Resident 17) investigated under the care area of pain management. This deficient practice had the potential to place the resident at increased risk of experiencing adverse side effects (undesired harmful effect resulting from a medication or other intervention).

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure licensed nurses attempted nonpharmacological interventions (treatments or therapies that do not involve the use of medications) prior to administering as needed (PRN) lorazepam (used to treat anxiety disorder [a mental health condition characterized by persistent and excessive worry or fear that interferes with daily life]) for one of two sampled residents (Resident 29). 2 Ensure the physician's order for a resident's PRN lorazepam had a stop date (the date on which a specific medication or treatment order, as written by a physician, is scheduled to be discontinued unless the physician extends or modifies the order) for one of five sampled residents (Resident 17). [...]

Inspectors wrote2. During a review of Resident 61's admission Record (face sheet), the admission record indicated that the facility originally admitted the resident on 5/13/2022, and readmitted on [DATE], with diagnoses including Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), dementia (a progressive state of decline in mental abilities), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). [...]

Inspectors wroteBased on interview, and record review, the facility failed to develop a complete and accurate baseline care plan (a document that summarizes a resident's needs, goals, and care/treatment) within 48 hours of a resident's admission to the facility for one of two sampled residents (Resident 21) by failing to complete oxygen use, pain, safety risks, and skin risk sections in the resident's baseline care plan. This deficient practice had the potential of Resident 21 to not receive appropriate care and treatments.

Inspectors wroteBased on interview, and record review, the facility failed to update and revise a resident's care plan (a document that summarizes a resident's needs, goals, and care/treatment) after the resident's change of condition (a sudden, clinically important deviation from a resident's baseline in physical, cognitive, behavioral, or functional domains) on 2/17/2025, for one of two sampled residents (Resident 18). This deficient practice had the potential to result in Resident 18 receiving inadequate care and supervision at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the low air loss mattress (LALM - a specialty bed that alternates pressure to help heal and prevent pressure ulcers [an injury that breaks down the skin and underlying tissue when an area of skin is placed under pressure]) was set correctly for one of one sampled resident (Resident 291). This deficient practice had the potential to place Resident 291 at risk for discomfort and development of pressure ulcers/injuries.

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of one sampled resident (Resident 13) received treatment and services to prevent decrease in range of motion (ROM- full movement potential of a joint) by failing to follow Resident 13`s physician order for Restorative Nursing Assistant (RNA- nursing aide program that helps residents to maintain their function and joint mobility) exercise program. This deficient practice had the potential to place the resident at risk for further decline in range of motion (ROM- full movement potential of a joint) decline.

Inspectors wroteBased on interview and record review, the facility failed to ensure Fall Risk Evaluations were completed accurately for one of three sampled residents (Resident 16). This deficient practice placed the resident at risk of not receiving appropriate care and services after a fall incident and had the potential to place the resident at an increased risk for falls.

Inspectors wroteBased on interview and record review, the facility failed to provide trauma-informed care (an approach to delivering care that involves understanding, recognizing and responding to the effects of all types of trauma) to a resident with a diagnosis of post-traumatic stress disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event) by failing to complete a timely trauma-informed care assessment and conduct an interdisciplinary team (IDT- a group of health care professionals with various areas of expertise who work together toward the goals of the residents' care plan) meeting to address the resident's specific needs for one of one sampled resident (Resident 49) investigated under the care area of trauma-informed care. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow its policy and procedure titled, Social Assessment, for one of two sampled residents (Resident 18) by failing to conduct a social service assessment within 14 days of the resident's admission to the facility. This deficient practice had the potential for the resident not to attain the highest practicable physical, mental, and psychosocial well-being and delay in the delivery of care and services.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure licensed nurses documented on the Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) after administering as needed (PRN) tramadol (medication used for moderate to severe pain) for one of two sampled residents (Resident 29). 2. Ensure licensed nurses documented on the MAR after administering PRN oxycodone (medication used to treat moderate to severe pain) for one of two sampled residents (Resident 8). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were free from any significant medication errors for one of five sampled residents (Resident 34) by failing to administer clozapine (medication used to treat schizophrenia [mental disorder in which people interpret reality abnormally]) as ordered. This deficient practice had the potential for the medication to not be effective or cause adverse reaction (undesired harmful effect resulting from a medication or other intervention) to Resident 34.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store unopened insulin (hormone that lowers the level of glucose [sugar] in the blood) pens (a medical device used to inject insulin subcutaneously [SQ - administering medication where a short needle is used to inject a medication into the tissue layer between the skin and the muscle]) inside the refrigerator for two of two sampled residents (Resident 80 and 391). This deficient practice had the potential for the insulin to lose efficacy and can result in uncontrolled blood glucose.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow safe food handling practices when Dietary Aide 1 (DA 1) was wearing an uncovered, dangling bracelet in the kitchen. This deficient practice had the potential to place 89 out of 90 residents who receive food from the facility's kitchen at risk for foodborne illnesses (refers to illness caused by the ingestion of contaminated food or beverages).

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Implement its policy titled, Enhanced Barrier Precautions (EBP - a set of infection control practices that use personal protective equipment [PPE - equipment worn to reduce exposure to hazards in the workplace] to reduce the spread of multidrug-resistant organisms [MDROs - microorganisms that are resistant to multiple classes of antibiotics and antifungals] in nursing homes) by failing to ensure one of one sampled resident (Resident 57) who had a colostomy bag (a medical device that collects stool from a surgical opening in the abdomen) was placed on EBP. This deficient practice had the potential to transmit infectious microorganisms to staff and other residents in the facility. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was free of unnecessary psychotropic drugs (medications capable of affecting the mind, emotions, and behavior) for one of three sampled residents (Resident 1) by failing to summarize a resident's monthly behavior and side effects summary. This deficient practice had the potential to result in the resident receiving unnecessary psychotropic drugs potentially increasing Resident 1's risk of adverse reactions (undesired harmful effect resulting from a medication or other intervention).

Inspectors wroteBased on interview and record review, the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one of three sampled residents (Resident 1), by failing to document on a resident's Activities of Daily Living (ADL - activities related to personal care) Flow Sheet. This deficient practice resulted in incomplete resident medical care information for Resident 1 and had the potential to result in confusion with the care and services for Resident 1 which could place the resident at risk for not receiving appropriate care.

Inspectors wroteBased on interview and record review, the facility failed to notify the physician and the resident's family regarding a skin discoloration on a resident's coccyx (tailbone) for one of three sampled residents (Resident 1). This deficient practice had the potential to negatively affect the delivery of care and services to Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure a neurological assessment (evaluation of a person's nervous system [includes the brain, spinal cord, and a complex network of nerves]) was completed after an unwitnessed fall for one of three sampled residents (Resident 4). This deficient practice had the potential to result in confusion in the care and services for Resident 4, which could place the resident at risk of not receiving appropriate care due to incomplete resident medical care information.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure no more than two layers of linen were used with the use of a low air loss mattress (LALM - a specialty bed that alternates pressure to help heal and prevent pressure injuries [an injury that breaks down the skin and underlying tissue when an area of skin is placed under pressure]) for two of three sampled residents (Resident 2 and Resident 3). 2. Ensure the LALM was set to the correct setting as ordered for two of three sampled residents (Resident 2 and Resident 3). These deficient practices had the potential to increase the residents' risk of skin breakdown.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staffing information of the actual hours worked by licensed and unlicensed nursing staffing directly responsible for resident care per shift was posted daily for two of two days on 12/17/2024 and on 12/18/2024. This deficient practice had the potential to keep residents and visitors unaware of the total number of staff and the actual hours worked by staff in the facility.

Inspectors wroteBased on interview and record review, the facility failed to obtain a physician's order prior to applying zinc oxide (treats or prevents skin irritation like cuts, burns, or incontinent [loss of bowel or bladder control] brief rash) cream for one of three sampled residents (Resident 1). This deficient practice had the potential to negatively affect the delivery of care and services.

Inspectors wroteBased on interview and record review, the facility failed to promptly notify the physician of the results of a Stat (without delay, immediately) X-ray (a type of medical imaging that uses radiation to take pictures of the inside of your body) for one of three sampled residents (Resident 1). This deficient practice resulted in the delay of necessary care and services for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to implement its policy and procedure for ensuring the reporting of a reasonable suspicion of a crime in accordance with Section 1150B of the Act by failing to report to the State Survey Agency (SSA) an allegation of sexual abuse (any sexual activity that occurs without consent [permission]) within two (2) hours of the incident for one of four sampled residents (Resident 1). This deficient practice resulted in a delay of an onsite inspection by the SSA to ensure the safety of the other residents and had the potential to result in unidentified abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control practices by: 1. Failing to store a mouthpiece (used to inhale a mist of liquid medicine that is created by a handheld nebulizer [HHN - a small, portable device that turns liquid medication into a mist that can be inhaled into the lungs]) and tubing of HHN in a bag when not used for one of five sampled residents (Resident 5). 2. Failing to report more than two suspected cases of scabies (a contagious skin condition characterized by a rash [an area of the skin that has changes in texture or color and may look inflamed or irritated] and intense itching) for two of five sampled residents (Resident 2 and Resident 3). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to notify two of five sampled residents (Resident 2 and Resident 3) physician, when on 9/24/2024, Resident 2 and Resident 3 had changes in their skin condition. Resident 2 had dry flaky skin on both hands, itchiness, crust on both palms and Resident 3 had dry flaky skin on the right palm and itchiness. This deficient practice resulted in a delay of medical care and treatment which could have resulted in a negative impact to Resident 2 ' s and Resident 3 ' s well-being.

Inspectors wroteBased on interview and record review, the facility (Skilled Nursing Facility 1 [SNF 1]) failed to protect the resident ' s right to be free from neglect (the failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress) for one of three sampled residents (Resident 1), when the facility discharged Resident 1, who exhibited behaviors that made Resident 1 a danger to himself (Resident 1) and others, and who was admitted to SNF 1, a locked facility (facility that cares for residents that utilize secured perimeter fences or locked exit doors) to SNF 2, a non-locked facility (a facility that does not have secured or locked units) on [DATE] without providing safe and orderly discharge services by: 1. [...]

Inspectors wroteBased on interview and record review, the facility (Skilled Nursing Facility 1 [SNF 1]) failed to ensure a safe and orderly discharge was provided to one of three sampled residents (Resident 1), who exhibited behaviors that made Resident 1 a danger to himself (Resident 1) and others, and who was admitted to SNF 1, a locked facility (facility that cares for residents that utilize secured perimeter fences or locked exit doors) to Skilled Nursing Facility 2 (SNF 2), a non-locked facility (a facility that does not have secured or locked units) on [DATE] by: 1. Failing to ensure Registered Nurse 2 (RN 2) obtained a physician order from Medical Doctor 1 (MD 1- Resident 1 ' s attending physician) to discharge Resident 1 to SNF 2 on [DATE]. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the needed care and services that were resident centered for one of three sampled residents (Resident 1) when on 6/15/2024, Licensed Vocational Nurse 2 (LVN 2) did not endorse (to inform) to Licensed Vocational Nurse 1 (LVN 1) or Registered Nurse Supervisor 1 (RNS 1) that Resident 1 had sustained a fall. This deficient practice placed Resident 1 at risk for a delay in needed care and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled resident (Resident 1) was provided with activities of daily living (ADL). This deficient practice resulted in a delay in delivering the necessary care and services to Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician was notified of medication refusals for approximately three months for one of five sampled residents (Resident 87) investigated for unnecessary medications. This deficient practice had the potential to result in the adverse effects (undesired harmful effect resulting from a medication or other intervention) of hypertension (high blood pressure [the force of the blood pushing on the blood vessel walls is too high]), have increased depression (feelings of sadness), and to have increased cholesterol (a waxy, fat-like substance that in high amounts in the body can cause heart disease) levels in the body.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were provided a comfortable and homelike environment for seven of 17 sampled residents (Resident 194, 3, 10, 47, 52, 62, and 79) by failing to provide communal dining. This deficient practice had the potential to result in decreased social interactions, decreased psychosocial wellbeing, and weight loss in residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident's orthostatic blood pressure (taking a blood pressure [BP- the pressure of circulating blood against the walls of blood vessels] lying down, sitting up, and standing up) was taken correctly for one of five sampled residents (Resident 87) investigated for unnecessary medications. This deficient practice had the potential to place Resident 87 at risk for developing symptoms of orthostatic hypotension (a form of low blood pressure [the force of the blood pushing on the blood vessel walls is too low] that happens when standing after sitting or lying down which can cause dizziness or lightheadedness and possibly fainting).

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 one of two sampled residents (Resident 17) investigated during the Medication Storage and Labeling task by failing to: 1. Ensure Licensed Vocational Nurse 1 (LVN 1) administered Resident 17's Ambien (medication used to aid sleep), gabapentin (a medication used to treat nerve pain), and simvastatin (a medication used to treat hyperlipidemia (high cholesterol [a waxy substance that can build up in the blood resulting in stroke or heart issues]) per the physician's orders on 3/14/2024. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Medication Regimen Review (MRR, a monthly thorough evaluation by the consulting pharmacist of a resident's medication regimen, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) was acted upon for four of five sampled residents (Resident 19, 87, 57, and 7) investigated for unnecessary medications by: 1. Failing to conduct an MRR for Resident 19 and 87. 2. Ensure the physician's response to the pharmacy recommendations were carried out for a gradual dose reduction (GDR, tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose) of mirtazapine for resident 57. 3. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents were treated with respect and dignity by failing to ensure the certified nursing assistant sat at eye level while providing feeding assistance for one of four sampled residents (Resident 59) investigated under the Dining Observation Task. This deficient practice had the potential to affect a resident's self-worth and self- esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's call light device (device used by residents that when pressed informs facility staff that assistance is being requested) was within reach for two of two sampled residents (Resident 13 and Resident 44). This deficient practice had the potential to delay the provision of services and residents' needs not being met.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a form where licensed nurses can summarize a person's health conditions, specific care needs, and current treatments) for medication refusal for approximately three months for one of five sampled residents (Resident 87) investigated for unnecessary medications. This deficient practice had the potential to negatively affect the delivery of care and services to Resident 87.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medication and biologicals were stored with currently accepted professional standards for one of two medication carts (Medication Cart 1) investigated during the Medication Storage and Labeling task by failing to: 1. Ensure two opened bottles of glucometer (medical device for determining the approximate concentration of glucose [sugar] in the blood) control solution (solutions used to test the glucometer for proper function) were labeled with the open date. 2. Ensure Medication Cart 1 refrigerated emergency medication kit (e-kit- basic emergency medical kit that includes common emergency drugs) was secured after opening and there was documentation indicating what was removed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain accurate clinical records in accordance with accepted professional standards and practices by failing to: 1. Ensure Licensed Vocational Nurse 1 (LVN 1) did not willfully falsify entries in Resident 17's Medication Administration Record (MAR-a flow sheet where nursing documents medications provided to a resident daily) for one of two sampled residents (Resident 17) investigated for medication storage and labeling by documenting the administration of Ambien (a medication used to aid sleep), gabapentin (a medication used to treat nerve pain), and simvastatin (a medication used to treat hyperlipidemia (high cholesterol [a waxy substance that can build up in the blood resulting in stroke or heart issues]) on 3/14/2024. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that both the top and bottom small dryers (Dryer Unit 2) inside the laundry room were maintained in good working condition when the thermometer (tool that measures temperature) for each dryer was observed not working on 3/22/2024. This deficient practice had the potential to lead to contamination of resident clothes and may cause a spread of infection.

Inspectors wroteBased on interview and record review, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Social Security Act by failing to report an allegation of abuse that occurred on 2/27/2024 for two of two sampled residents (Resident 1 and Resident 2) within two hours of being made aware of the allegation to the State Survey Agency (SSA). This deficient practice had the potential to result in unidentified abuse in the facility and placed residents at risk from further abuse.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) by: 1. Resident 2 for one of five sampled residents (Resident 1), when on 11/1/2023, Resident 2 punched Resident 1 in the stomach. 2. Resident 4 for one of five sampled residents (Resident 3), when on 11/11/2023, Resident 4 punched Resident 3 in the face. These deficient practices resulted in Resident 1 being subjected to physical abuse by Resident 2 while under the care of the facility, and Resident 3 being subjected to physical abuse by Resident 4 while under the care of the facility. Resident 3 sustained a bloody nose (bleeding from inside the nostrils caused by the physical impact of being hit on the nose). [...]

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) for one of five sampled residents (Resident 1) on 9/23/2023 when Resident 2 hit and scratched Resident 1 on the face. This deficient practice resulted in Resident 1 being subjected to physical abuse by Resident 2 while under the care of the facility. Resident 1 sustained a skin tear (a wound that happens when the layers of skin separate or peel back) on the left cheek of his face and redness (red discoloration to the skin) on right cheek of his face, left cheek of his face, and left lower jaw. [...]