Hollywood Premier Healthcare Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to review, update, and/or revise a care plan for smoking interventions for one of three sampled residents (Resident 1) by failing to: -Ensure to update the smoking care plan with appropriate interventions and alternative interventions. On 5/10/2026 at 9:30 AM, Resident 1 was involved in a verbal and physical incident with Resident 2 and Resident 3 in the smoking patio at the facility. This failure resulted in Resident 1 not to follow the facility's smoking rules and had the potential not to address Resident 1's needs.

Inspectors wroteBased on observation and interview, the facility failed to maintain a sanitary and comfortable environment for two of four sampled residents (Residents 1 and 2). This deficient practice resulted in unclean resident room floors, presence of food debris, and conditions that could contribute to pest infestation, supporting the complainant's concern. During a review of Resident 1's admission Record, indicated Resident 1 was admitted to the facility on [DATE] with diagnosis of end stage renal disease (ESRD- Condition in which the kidneys cease functioning on a permanent basis leading to the need for regular course of long-term dialysis or kidney transplant to maintain life) and hemiplegia (loss of ability to move one side of the body). [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure one of two sampled residents (Resident 1) diagnosed with dementia (a group of symptoms related to loss of memory, judgment, language, complex motor skills, and other intellectual function) received the necessary care and services for dementia, by failing to: Ensure Resident 1's dementia diagnosis was indicated in Resident 1's Wander/Elopement (when a resident leaves/escapes from a facility without a physician's order and without the staff knowing) Risk Evaluation, dated 4/6/2026. This deficient practice resulted in an inaccurate elopement risk assessment and Resident 1 eloping from the facility on 4/11/2026.

Inspectors wroteBased on observations, interview, and record reviews, the facility failed to ensure a resident and/or responsible party were informed in advance and signed consent of the risks and benefits of a psychotropic medication (drug that affects behavior, mood, thoughts, or perception) for one of four sampled residents, Resident 1. This deficient practice violated Resident 1's right to make an informed decision about the use of psychotropic medication Depakote (a mood stabilizing medication).

Inspectors wroteBased on interview and record review, the facility failed to ensure to provide adequate supervision for one of four sampled residents (Resident 1) to prevent a resident-to-resident altercation (negative and aggressive physical or verbal interactions). On 2/1/2026 at approximately 7:55 AM, Resident 1, who required a one-on-one supervision (assignment of a dedicated staff member), stepped inside Resident 2's room and Resident 2 pushed Resident 1 out of her (Resident 2's) room. This failure caused Resident 2 to push Resident 1 and had the potential for Resident 1 and Resident 2 to sustain physical injuries.

Inspectors wroteBased on interview and record review, the facility failed to notify the resident representative of a significant change in behavior and safety risk for one of four sampled residents (Resident 2) who attempted to leave the facility on 10/5/2025 stating his daughter needed him. This failure had the potential to place the resident at risk for elopement and compromised the ability of the resident representative to participate in care planning and safety interventions. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnosis of dementia (progressive impaired ability to think, remember or make decisions that interferes with doing everyday activities). Resident 2 was listed as his own responsible party in the admission Record. [...]

Inspectors wroteBased on interview and record review the facility failed to notify the physician when the resident had a change of condition for one of three sampled residents (Resident 1). For Resident 1, the facility failed to notify the primary physician on 8/23/25 when Resident 1 had a seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), irregular heart rate and desaturation (when blood oxygen level drops below the normal range). This deficient practice had the potential for Resident 1 to have worsening conditions without appropriate intervention. [...]

Inspectors wroteBased on interview and record review the facility failed to obtain blood sugar level by fingerstick according to accepted professional standards of practice for one of two sampled residents (Resident 2). For Resident 2, who had diagnoses that included diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), the facility failed to obtain blood sugar level when Resident 2 had nothing to eat from 3 p.m. to 9:30 p.m. on 8/30/25. This deficient practice had the potential for Resident 2 to suffer from either hypoglycemia (blood sugar level drop below normal) or hyperglycemia (abnormally high blood sugar) and for the facility not giving Resident 2 proper intervention. During a review of the admission Record indicated the facility admitted Resident 2 on 8/25/25 with diagnoses including DM and dysphagia (difficulty swallowing). [...]

Inspectors wroteBased on interview and record review the facility failed to provide laboratory services for one of three sampled residents (Resident 1). For Resident 1, the facility failed to follow the physician order to obtain blood sample for comprehensive metabolic panel (CMP, series of 14 blood tests that provide information about a person's current metabolism) on 8/15/25. This deficient practice resulted in Resident 1 not provided laboratory services that would help determine the medical and diagnostic needs of Resident 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) was free from sexual abuse (non-consensual sexual contact of any type or sexual harassment) from Resident 2 who had a history of inappropriate sexual behavior of walking around the facility with his genitals (sexual organs) out and masturbating (stimulate own genitals for sexual pleasure) excessively (extremely) while residing in the facility. On 9/6/2025 at approximately 3:55 AM to 4 AM, Certified Nursing Assistant 1 (CNA1) heard grunting (mumbling)/moaning from Resident 1's room (who was nonverbal). CNA1 observed Resident 2 on top of Resident 1 who was in a supine (lying face up) position between Resident 1's legs naked from the waist down on Resident 1's bed. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement its policies and procedures to prohibit and prevent sexual abuse (non-consensual sexual contact of any type or sexual harassment), for one of four sampled residents (Resident 1) by failing to: -Ensure to closely monitor Resident 2 who had a history of inappropriate sexual behavior of walking around the facility with his genitals (sexual organs) out and masturbating (stimulate own genitals for sexual pleasure) excessively (extremely) while residing in the facility. -Ensure Resident 1 was free from sexual abuse from Resident 2. -Ensure to conduct an interdisciplinary team meeting (IDT, a collaborative group of diverse health care professionals from different fields who work together) to address Resident 2's inappropriate sexual behavior of walking around with his genitals out and masturbating. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to: 1. Implement the plan of correction (POC - a formal document that explains step-by-step how an organization will fix a problem and ensure it does not happen again) as indicated on the CMS 2567 statement of deficiency signed and dated 10/6/2025 to prevent and protect the residents from resident-to-resident sexual abuse (any unwanted sexual contact of any type, behavior, or act forced upon a person without their freely given consent). 2. Ensure a third-party consulting agency (an outside business [not affiliated with the facility] hired to give expert advice or perform a specialized service) not affiliated with the facility, provided sexual abuse prevention training to the facility staff by the POC completion date (the specific date by which the facility will correct the deficiencies) of 10/9/2025. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to review/revise the care plans for two of two sampled residents (Resident 5 and Resident 27) by failing to: 1. Ensure to review/revise Resident 5's care plan when Resident 5's Foley catheter (a flexible tube inserted into the bladder to drain urine) was discontinued. 2. Ensure to review/revise Resident 27's care plan for smoking. This failure had the potential to result in a delay in care and interventions for Resident 5 and Resident 27.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain safe resident smoking practices for two of three sampled residents (Resident 27 and Resident 79) investigated under the smoking care area by failing to: 1. Ensure Resident 27 did not to store smoking materials (cigarettes) in his room without supervision. 2. Ensure to provide Resident 79 with a smoking apron, ash tray, and an appropriate place to discard his used unlit cigarette butt (the end of a cigarette) while Resident 79 smoked outside the patio on 8/12/2025 at 9:37 AM. These failures had the potential for Resident 27 and Resident 79 to sustain injuries such as cigarette burns.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide appropriate assistance to residents using special eating equipment for two of four sampled residents by:1. Failing to place the plate guard (a crescent shaped dining aid designed to help prevent food from falling off the edge of a plate while eating) in the correct position for Residents 28 and 73.2. Failing to provide the correct assistive eating device for Resident 73. These failures had the potential to cause inadequate nutrition, weight loss, loss of dignity and confidence for Residents 28 and 73.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store food with a food label and/or date in one of four food storage areas. This failure had the potential to result in a foodborne illness (illness caused by the ingestion of contaminated food or beverages) for the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection control (a set of practices and procedures used to prevent the spread of infections, particularly in healthcare settings) practices for three of six sampled residents (Resident 2, Resident 70 and Resident 85), and for laundry services by failing to: - Ensure Certified Nursing Assistant 1 (CNA 1) washed/sanitized (clean it well enough to reduce germs to a safe, healthy level) her (CNA1) hands before and after she (CNA1) assisted Resident 2 on 8/11/2025 at 9:52 AM. -Ensure Resident 70's mattress and bed linen were not in direct contact with the facility's floor. [...]

Inspectors wroteBased on interview and record review, the facility failed to obtain an informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) for antipsychotic medication (medication that affects brain activity and is used to treat mental health disorders) administration for one of two sampled residents (Resident 11) by failing to: -Ensure to complete an informed consent form (a formal conversation and a signed document that acknowledges the resident's understanding and agreement to the medication treatment plan) for the following medications: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure to provide an advanced directive (a legal document indicating resident preference on end-of-life treatment decisions) to the Responsible Party (RP, an individual who is responsible for handling a resident's finances and medical care) for one of three sampled residents (Resident 70). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident 's environment promoted and enhanced their quality of life when her bed mattress was placed directly on the floor for one of one sampled resident (Resident 70). This failure had the potential to result in Resident 70 acquiring a healthcare-associated infection (infections acquired during healthcare delivery and are not present at the time of admission), experiencing physical safety hazards and psychological harm; and affected the quality of care provided to Resident 70.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a care plan for one of 19 sampled residents (Resident 34) for fall prevention to address the resident's preference of raising his bed to the bed's maximum height. This deficient practice had the potential for Resident 34 to fall and sustain an injury.

Inspectors wroteBased on interview and record review, the facility failed to provide appropriate treatment to prevent a urinary tract infection (UTI, an infection in the bladder/urinary tract) for one of 19 sampled residents (Resident 5), when there was missing documentation of a post void residual (PVR, the amount of urine remaining in the bladder after urination) every six hours as ordered by the physician. This failure had the potential to result in Resident 5 developing a UTI.

Inspectors wroteBased on interview and record review, the facility failed to ensure that one of four sampled residents (Resident 50) received her 6AM dose of hydrocodone-acetaminophen (a pain medication to treat moderate to severe pain) on 8/11/2025. This failure had the potential to result in Resident 50 experiencing unrelieved pain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication bubble packs for three of 87 sampled residents (Resident 26, Resident 59, and Resident 69) were labeled with expiration dates. This failure had the potential to result in the administration of expired or deteriorated medications to the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 19 sampled resident (Resident 34) had the call light (a device used by a patient to signal his or her need for assistance) within reach. This failure had the potential for Resident 34 not to be able to call for assistance and had the potential not to meet Resident 34's needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 35 residents` rooms (room [ROOM NUMBER]) did not accommodate more than four residents. This failure had the potential to result in inadequate space to provide safe nursing care and privacy for Resident 17, Resident 19, Resident 55, and Resident 64.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the resident's right to be free from physical abuse (deliberate, aggressive, or violent behavior with the intention to cause harm) for one of three sampled residents (Resident 2), who was subjected to Resident 1's physical attack, who had diagnoses of schizophrenia (a serious mental disorder in which people interpret reality abnormally, may result in delusions and behavior that impairs daily functioning, may have grandiose delusions [strong beliefs of things that are untrue]). The facility failed to: -Implement the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Prog, reviewed 1/31/2024, which indicated the facility shall uphold the resident's right to be free from physical abuse. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one sampled resident (Resident 3) had a signed informed consent for psychotropic medications (drugs that affect the brain and nervous system, altering mood, behavior, and cognitive function). This failure had the potential for lack of education regarding the use of a psychotropic medication for Resident 3.

Inspectors wroteBased on interview and record review, the facility failed to allow one of two sampled residents (Resident 2) to return to the facility following hospitalization at the General Acute Care Hospital (GACH). Resident 2, who had a bipolar disorder (associated with mood swings), was deemed medically stable to return to the facility but remained at the GACH for over three weeks. This deficient practice placed Resident 2 at risk for discharge from the facility against her needs or wants and a potential for psychosocial harm of not returning to primary residence at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a clean, sanitary, and accident-free environment in two of two shower rooms, Shower room A and Shower room B. This deficient practice had the potential for residents to be exposed to dirt, spread of disease - causing organisms, and accidents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the residents receive adequate supervision and assistance based on the residents ' individual needs to prevent accidental injuries for one of five sampled residents (Resident 2) by failing to ensure Certified Nursing Assistant 3 (CNA 3) was awake and alert while in Resident 2's room. This deficient practice had the potential for resident to experience unavoidable accidents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the residents were served the food preferences listed on the lunch meal ticket (physician ordered diet with resident food preferences) and received substitute meal options of similar nutritive value when one of four sampled residents (Resident 1)'s food preferences were not honored when Resident 1 verbalized, she does not like Mocha Mix (liquid non-dairy creamers). This deficient practice had the potential to result in decreased meal satisfaction, decreased nutritive value for the meal and weight loss.

Inspectors wroteBased on interview and record review, the facility failed to provide and document preparation and orientation to ensure a safe and orderly facility-initiated discharge for one of two sampled residents (Resident 1). Resident 1 and/or Family Member 1 (FM 1) were not involved in the post-discharge planning process. There was no post discharge plan developed for 24 hours prior to Resident 1's discharge and the post discharge plan was not reviewed with Resident 1 and FM 1. This deficient practice had a potential for Resident 1 to have an unsafe facility-initiated discharge.

Inspectors wroteBased on interview and record review the facility failed to ensure resident ' s belongings were protected from loss for one of three sampled residents (Resident 1). For Resident 1 who reported on 8/17/24 that her money in the amount of 40 dollars ($) was missing, the facility failed to search and investigate Resident 1 ' s claim that Resident 1 lost $40. This deficient practice resulted in Resident 1 not given her right to keep her possessions safely while at the facility.

Inspectors wroteBased on interview and record review the facility failed to follow physician order for one of three sampled residents (Resident 1). For Resident 1, the facility failed to follow the physician order to monitor Resident 1 for sedation when Resident 1 was administered methocarbamol tablet (muscle relaxant) 500 milligrams (mg. metric unit of measurement, used for medication dosage and/or amount) orally three times a day and gabapentin (medication used to treat seizure or nerve pain) 300 mg. orally three times a day. These deficient practices had the potential to cause respiratory distress (slow and ineffective breathing) for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1), who had a diagnosis of congestive heart failure (the heart's inability to pump blood throughout the body efficiently), received treatment and care in accordance with professional standards of practice. Resident 1 did not have blood pressure parameters for the blood pressure medications administered. This deficient practice had the potential to jeopardize the safety and well-being of the resident.

Inspectors wroteBased on observation, interview, and record review the facility failed to revise the care plan (a document outlining a detailed approach to care customized to an individual resident's need) for two of six sampled residents (Resident 33 and Resident 83) as evidenced by: 1. Failing to update the tube feeding (TF, a form of nutrition that is delivered into the digestive system as a liquid) care plan for Resident 33 to reflect current physician orders. 2. Failing to update the antibiotic (medicines that help stop infections caused by bacteria) care plan for Resident 83 to reflect current physician orders. These deficient practices had the potential for Resident 33 and Resident 83 to not have their needs met and receive inadequate care.

Inspectors wroteBased on interview and record review, the facility failed to maintain a yearly staff competency and mandated reporting elder and dependent adult abuse training for two of five sampled staff members. This deficient practice had the potential for residents to not receive the appropriate level of care needed affecting quality of care and potentially leading to resident harm.

Inspectors wroteBased on interview and record review, the facility failed to identify, address, and/or obtain necessary services for the behavioral health care needs for one of three sampled residents (Resident 9) . This deficient practice had the potential to lead to the inadequate care of Resident 9.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure secure storage of controlled medications (a term used to describe prescription medications with high abuse potential) and non-controlled medications for one of six sampled residents (Resident 77) during medication administration. 2. Ensure proper labeling of insulin (a medication used to treat high blood sugar), per facility's policies and procedures (P&P) titled, Medication Labeling and Storage and manufacturer's requirements, affecting one resident (Resident 66) in one of two inspected medication carts (Middle Medication Cart). [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to observe proper food storage and handling when: 1. A package of cookies was found left opened and undated on a shelf in the kitchen's pantry. 2. The [NAME] (Cook 1) went to rinse a towel in the sink and the cook did not wash his hands prior to serving prepared food during the facility's lunch tray line. These failures had the potential to result in residents acquiring food borne illnesses.

Inspectors wrote2. A review of Resident 85's admission Record indicated the facility admitted the resident on 7/5/2024 with diagnoses including lack of coordination, unsteadiness on feet, and fatty liver (a condition in which fat builds up in your liver). A review of Resident 85's Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 7/12/2024, indicated the resident was cognitively intact (has the ability to think, understand, and reason). The MDS indicated Resident 85 required partial/moderate assistance for eating, oral hygiene, and upper body dressing. The MDS indicated Resident 85 required substantial/maximal assistance for lower body dressing, putting on/taking off footwear, and personal hygiene. The MDS indicated Resident 85 was dependent on assistance for toileting hygiene, and showering/bathing self. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain a safe and home like environment for one of two sampled residents (Residents 14) by not maintaining and repairing a damaged residents' floor surface. This failure had the potential for unsafe resident`s environment and placed the resident and staff at risk for fall hazard resulting in injury.

Inspectors wroteBased on interview and record review, the facility failed to create a care plan for Diflucan (Fluconazole, a medication that treats and prevents fungal infections) for one of six sampled residents (Resident 83). This deficient practice had the potential for Resident 83 to not have their needs met and receive inadequate care.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide services that promote the prevention of pressure ulcer injury (injury to the skin caused by pressure) for one of two sampled residents (Resident 190) as evidenced by failing to make sure the low air loss mattress (LALM-mattress designed to treat and prevent pressure ulcers) setting was correct. This deficient practice had the potential for worsening of pressure ulcer and harm to Resident 190.

Inspectors wroteBased on observation, interview, and record review, the facility failed to clarify the strength and dose on a physician order for docusate sodium (a medication used to relieve difficulty passing stool and to treat constipation [a term used to describe difficulty passing stool]) liquid, for one of six sampled residents (Resident 1.) This failure had the potential to result in Resident 1 receiving inadequate or excessive dosage of docusate sodium and increased risk for adverse consequences such as constipation or diarrhea due to not receiving medication per physician orders.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the Dietary staff had the appropriate competencies and skills when: 1. Dietary Aide (DA 1) failed to verbalize and follow the manufacturer's guidelines of QT-40 test paper (a type of test strip) when checking the Quaternary Ammonium Compounds (Quats, a group of chemicals used to disinfect surfaces and equipment) sanitizer concentration. This failure had a potential to result in potential cross-contamination (a transfer of bacteria from one object to another), unsanitized food preparation areas and bacterial growth to food that could lead to food borne illness (an illness caused by contaminated food and beverages) for the 88 residents who received food from the kitchen.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain sanitary environment and prevent infestation of flies in and around a waste segregation and disposal area by leaving a trash bin open and overfilled with food leftovers and waste materials. This failure had the potential to affect residents in the facility, flies infecting and causing disease outbreaks.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 35 residents` rooms did not accommodate more than four residents. This deficient practice had the potential to result in inadequate space to provide safe nursing care and privacy for the residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were informed in advance of the risks and benefits of psychoactive medication (a drug that changes brain function and results in alterations in perception, mood, consciousness, or behavior) and hypnotic medication (drugs that induce or prolong sleep in patients with sleep disorder) for one of three sampled residents (Resident 1). This deficient practice violated the resident ' s right to make an informed decision regarding the use of psychoactive medications.

Inspectors wroteBased on interview and record review, the facility failed to initiate a Zyprexa care plan (antipsychotic medication [a class of psychotropic medication used to manage psychosis [including delusions, hallucinations, paranoia, or disordered thought]) for one of three sampled resident (Resident 1). This deficient practice resulted in a failure to meet the resident ' s psychosocial needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide direct supervision of residents when smoking in the facility's smoking patio as indicated in the facility's policy and procedure (P&P) titled, Smoking Policy - Residents dated August 2022, for three of three sampled residents (Residents 1, 2 and 3). As a result, on 6/20/2024 Resident 1 hit Resident 2 on the chin and also hit Resident 3 on the forehead while unsupervised in the smoking patio.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the resident's right to be free from physical abuse (intentional bodily injury) for one sampled resident (Resident 1) by failing to ensure Resident 2's whereabouts every hour per the Physician's Order. This deficient practice resulted in Resident 1 being subjected to physical abuse after Resident 2 poked Resident 1 with a grabbing stick, resulting in Resident 1 having pain to the right knee.

Inspectors wroteBased on interviews and record reviews the facility failed to follow physician orders for laboratory (labs) services for one out of three residents (Resident 1) receiving two anticonvulsant medications Keppra (levetiracetam) and Depakote (is made by combining valproic acid and sodium valproate). This deficient practice of failing to monitor Resident 1 ' s labs placed Resident 1 at risk for medication related adverse reactions.

Inspectors wroteBased on interview and record review, the facility failed to ensure the consultant pharmacist (CP) completed a thorough review of one of three sampled residents (Resident 1) medical records from 12/29/2022 to 5/22/2024. By failing to identify and report to physician when laboratory (labs) tests ordered for medication management, were not done. This deficient practice increased the risk that medication therapy for Resident 1 not being optimized for the best possible health outcomes and could have led to a negative impact on the resident ' s overall physical, mental, and psychosocial well-being.

Inspectors wroteBased on interview and record review the facility failed to implement it's policy and procedures (P & P) on abuse for two of four sampled residents (Resident 1 and Resident 2). The facility failed to report to the state survey agency (SSA) and the appropriate agencies as indicated in the facility Abuse Policy when on: 1. 5/8/24, Resident 1 and Resident 2 were verbally aggressive to one another, calling each other derogatory names and racial slur. 2. 5/9/24, Resident 1 threw a shower sponge on Resident 2 and the shower sponge hit Resident 2 ' s leg. Resident 2 called the police and wanted to press charges against Resident 1. 3. 5/14/24, Resident 1 alleged that Resident 2 wanted to kill and rape Resident 1. These deficient practices resulted in delay of investigation to ensure Resident 1, and Resident 2 felt safe while in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure one sampled resident (Resident 1) had a comprehensive care plan that was updated and revised with effective interventions to prevent resident harm. Resident 1 refused padded side rails and laboratory tests, but there was no appropriate response from facility. This deficient practice caused an increased risk in harm to Resident 1.

Inspectors wroteBased on interview and record review the facility failed to ensure care plan for conferences were held on a regular basis for one of three sampled residents (Resident 1). For Resident 1 the facility failed to: 1. Ensure the care plan meetings were held on a regular basis and as needed. 2. Ensure the care plan were updated after the meeting that would include the discharge goal and discharge preferences of Resident 1 and his Responsible Party (RP). These deficient practices had the potential to fail to meet the needs and preferences of Resident 1 and his RP.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident received treatment and care in accordance with professional standards of practice for one of five sampled residents, Resident 1 by failing to: 1. Implement facility 's policy and procedures (P&P) titled, Death of a Resident, Documenting when Resident 1 expired on [DATE]. 2. Report the unusual occurrence as required by federal or state regulations which affect the health, safety, or welfare of residents, employees or visitors. This deficient practice placed Resident 1 in incomplete assessment and documentation required per facility's P&P upon death and resulted in delay of onsite inspection by the State Agency to ensure resident's death was thoroughly investigated.

Inspectors wroteBased on observation, interview and record review, the facility failed to revise the care plan (written guide that organizes information about the resident's care) for one of three sampled residents (Resident 1) who was a moderate risk for elopement, after the resident eloped (departs the health care facility unsupervised and undetected) from the facility on 10/12/2023. This deficient practice had the potential to place Resident 1 at further risk for elopement and injury related to elopement.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Resident 4 who was admitted with pressure injury stage 2 (PI -when the skin breaks open, wears away, or forms an ulcer, which is usually tender and painful) does not worsen to stage 3 (full-thickness skin loss potentially extending into the subcutaneous tissue layer) for 1 of two sampled resident (Residents 4). This deficient practice had the potential for Resident 4 not to receive appropriate care and treatment for the pressure injury (sores (ulcers) that happen on areas of the skin that are under pressure).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the medication error rate was less than five percent for two of four sampled residents who did not receive their scheduled medications (Lexapro 10 milligrams (mg) - used to treat depression and generalized anxiety disorder) and Folic Acid (used to or prevent anemia (making red blood cells) and Renvela (medication to lower high blood phosphorus (phosphate) levels in patients who are on dialysis) that were not available in the facility at the time of medication administration. This failure of not administering resident 56's and 41's medications resulted to three medication errors out of twenty-nine (29) opportunities resulted to medication administration error rate of (10.3) percent (%), that exceeded the 5% threshold.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow the menu as written for residents who were on regular and mechanical soft diets. The residents received less Corn bread stuffing than what was written on menu. This deficient practice had the potential to result in weight loss in 61 residents due to inadequate calorie intake.

Inspectors wroteBased on observation, staff interviews, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: 1. Food contact surfaces and food preparation counters were not sanitized with adequate amount of sanitizer per manufacture guidelines. Sanitizers and disinfectants are used on food contact surfaces to prevent foodborne illness. Sanitizers are used to reduce microorganisms to safe levels determined by public health codes and regulations. 2. Large amount of ice buildup inside the walk-in freezer door, vinyl strip air curtains (air curtains are devices used to separate two spaces from each other, particularly at an exterior entrance. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that staff was not standing and bending over when assisting the resident with meal during lunch time in a manner that will promote or enhance the resident's dignity and respect for one of one sampled resident (Resident 8). This deficient practice had the potential to cause psychosocial harm to the residents and violates Residents' right to be treated with dignity.

Inspectors wroteBased on observation and interview, the facility failed to provide a safe, clean, and comfortable home like environment for two of three sampled residents, (Residents 32 & 75). This deficient practice had the potential for Residents 32 and 75 leaving in unsanitary environment which had the potential resulting to poor quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a plan of care for pressure injury stage 2 (PI -when the skin breaks open, wears away, or forms an ulcer, which is usually tender and painful) was developed, implemented and revised when the resident stage 2 PI was reclassified as stage 3 (full-thickness skin loss potentially extending into the subcutaneous tissue layer) with measurable objectives, timeframe, and nursing interventions to meet the residents' needs for one of two sampled resident (Residents 4). This deficient practice had the potential for Resident 4 not to receive appropriate care and treatment for the pressure injury (sores (ulcers) that happen on areas of the skin that are under pressure).

Inspectors wroteBased on interview and record review, the facility failed to review and revise the psychotropic medication (medication that affects behavior, mood, thoughts, or perception) care plan for one sampled resident (Resident 47). This deficient practice had the potential to cause inadequate care and harm to Resident 47.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident's medication Lexapro (a medication used to treat depressive disorder) 10 milligrams (mg) and folic acid (vitamin) 1 milligram (mg) were refilled in a timely manner for one of 21 sampled residents (Resident 56). This deficient practice had the potential for the resident missing and not receiving the medications as scheduled and could resulted to ineffective therapeutic level of the medication in Resident 4's blood stream thereby not treatment the resident's anxiety and anemia (low red blood cell in the body)

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide showers according to pre-determined schedule for one of 25 sampled residents (Resident 51), who required assistance with activities of daily living (ADL). This deficient practice resulted in Resident 51 not receiving a shower and had the potential to negatively impact Resident 51s self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide supervision to prevent injury and harm when Residents 18 &73 were smoking in the patio for two of four sampled residents. This deficient practice had the potential of placing Residents 18 & 78 at risk for injuries and harm related to unsupervised smoking.

Inspectors wroteBased on observation, interview and record review, the facility failed to prepare the formula (milk) and feeding tubing (cannula) with date, time, and staff's initials four hours before the administration for two of two sampled residents (Resident 4 and Resident 33). This deficient practice had the potential for the residents to develop tube feeding associated complications such as infection, diarrhea, and this could lead to serious illness, hospitalization, and death.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain adequate staffing for licensed nurse of 3.5 Direct Care Service Hours Per Patient (Resident) day (DHPPD) and certified nursing attendant (CNA) staff of 2.4 DHPPD. This deficient practice resulted in call lights not being answered in a timely manner, late administration of medications and had the potential of affecting the quality of life and treatment for 77 residents residing the facility, including two of two sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure a complete Daily Nursing Staffing (posting information that contains the calculation of the number of hours worked by staff for resident care) was posted daily. This deficient practice resulted in the total number of staff and the actual hours worked by the staff not to be readily accessible to residents and visitors. On 1/4/2021, at 11:00 a. m., during an interview and record review with the Director of Nursing (DON) stated, the Staff Developer was responsible for posting the nursing staffing breakdown with their actual working hours, but currently not in the facility. DON stated not posting the daily staffing hours, resident and visitors would not know how is providing care to their love ones. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the practitioner had documentation and rationale for the extension of the 14 days administration for as need psychotropic medication (medication that affects behavior, mood, thoughts, or perception) of Xanax (medication used to treat anxiety, a disorder that causes intense, excessive, and persistent worry and fear about everyday situations) for one sampled resident (Resident 54). This deficient practice had the potential to cause Resident 54 to receive a medication more than necessary leading to serious illness, hospitalization, or death.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure three staff members properly donned (put on) or doffed (took off) Personal Protective Equipment (PPE, specialized clothing or equipment worn by health care workers for their protection and to help prevent the spread of germs between patients) before entering or exiting a resident's room in the yellow zone (area of the facility where residents who are suspected of having Coronavirus [COVID-19, a virus that causes respiratory illness that can spread from person to person] reside). This deficient practice had the potential to expose residents, staff, and the community to COVID-19.

Inspectors wroteBased on interview and record review, the facility failed to employ a full-time designated Infection Preventionist (IP). This deficient practice had the potential to lead to the spread of infection and Coronavirus disease (COVID-19, a virus that causes respiratory illness that can spread from person to person) between residents, staff, and the community.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the walk-in freezer was maintained in a good operating condition. The walk-in freezer had ice buildup inside the walk-in freezer vinyl strip air curtains, ceiling, floor, and boxes of food. There was ice buildup on the door and the parameters of the door. The gasket was loose not allowing for the freezer door to close shut (gasket-a flexible elastic strip attached to the outer edge of a freezer door. Gasket is designed to form an air-tight seal that serves as a barrier between the cool air inside the appliance and the warmer external environment). The reach in freezer was operational in a manner that had the potential to affect food quality and or increase the potential of growth of microorganism that could cause food borne illness. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide one of three sampled residents (Resident 52) access to call light. Resident 52 did not have a call light in her room. This deficient practice caused Resident 52 not being able to obtain staff assistance during times of need or emergencies which could lead to harm to Resident 52.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of 34 resident's rooms did not accommodate more than four residents. This deficient practice had the potential to result in inadequate space to provide safe nursing care and privacy for the resident.