Kit Carson Nursing & Rehabilitation Center

Inspectors wroteBased on interview and record review the facility failed to ensure an allegation of resident-to-resident sexual abuse and the results of the investigation involving the allegation of resident-to-resident sexual abuse were reported to the State Agency (SA - state agency that helps protect the public's health and safety) within the required timeframes, as required, for 1 of 1 sampled resident (Resident 1) reviewed for abuse reporting. This deficient practice had the potential to delay regulatory oversight of the facility's investigation and corrective actions, placing Resident 1 and other residents in the facility at risk for continued abuse or inadequate protection from harm.

Inspectors wroteBased on interview and record review, the facility failed to ensure a thorough investigation was completed of an allegation of resident-to-resident sexual abuse for 1 of 1 sampled resident (Resident 1) reviewed for abuse by failing to timely interview the primary witnesses and promptly gather essential investigative information. This deficient practice had the potential to compromise the integrity of the investigation, delay appropriate corrective actions, and placed residents at risk for further abuse, neglect, exploitation, or mistreatment.

Inspectors wroteBased on interview and record review, the facility failed to ensure that a physician-ordered psychiatric evaluation (a mental health checkup by a mental health doctor), identified as an intervention in 1 of 1 sampled residents (Resident 1) care plan (a personalized plan for the person's care and treatment) following a resident-to-resident sexual abuse allegation, was implemented, followed up on, or communicated to the ordering physician when not completed. This deficient practice had the potential to delay Resident 1's psychosocial assessment (a check of a person's emotional and social health), identification of trauma-related needs (support needed after a traumatic experience), and implementation of appropriate intervention following an alleged abuse incident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet the needs of one of two sampled residents (Resident 1) when two medications that were used for breathing and eye irritation were not ordered and available for use. This failure caused Resident 1 to not receive medication as ordered by the doctor and had the potential to affect her breathing and vision.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a person-centered care plan related to antibiotic treatment and monitoring for one of three sampled residents (Resident 1) who was readmitted to the facility with a urinary tract infection (UTI). This deficient practice failed to provide staff with clear guidance regarding the resident's antibiotic therapy, monitoring for effectiveness and adverse reactions, infection management, notification requirements, and necessary interventions to address the resident's medical needs, which placed Resident 1 at risk for unresolved infection, worsening condition, complications, and decline.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 2) was treated with dignity and respect when Resident 2 was observed in bed without a cover over the lower body and was visible from the hallway wearing only an incontinent brief (disposable undergarment designed to absorb urine and stool). This failure had the potential to negatively affect Resident 2's psychosocial well-being (overall emotional and social health).

Inspectors wroteBased on observation, interview, and record review, the facility failed to accommodate the needs of one of three sampled residents (Resident 1) when Resident 1 activated the call light (a device used to request assistance) and staff did not respond in a timely manner. This failure placed Resident 1 at risk for unmet care needs, increased risk for accidents or injury, and had the potential to negatively affect Resident 1's psychosocial well-being (overall emotional and social health).

Inspectors wroteBased on interview and record review, the facility failed to ensure professional standards of care for pharmacy services were met for one of four sampled Residents ( Resident 1) when;Resident 1's anti-anxiety medication order administration times was not followed as written by the physician; andResident 1's medication was administered one hour and forty five minutes after the time it was scheduled. These failures caused Resident 1 psychosocial distress and had the potential to negatively affect her health and well-being.

Inspectors wroteBased on interview and record review, the facility failed to provide quality care and services as per professional standards of practice for one of four sampled residents (Resident 4), when:1a. Facility staff did not assess, notify physician, and treated Resident 4 when she had abdominal pain and did not have a bowel movement for 3 days from 12/14/25 to 12/16/25, from 12/20/25 to 12/22/25, and for 6 days from 12/30/25 to 1/4/26 and had multiple bowel movements of foul odor,b. Licensed Nurses did not completely assess, address, and notify physician of Resident 4's change in condition of abdominal tenderness, increased weakness, and progressive decline in ADL (Activities of Daily Living) when Resident 4 was no longer able to shower herself on 2/5/26, dress herself on 2/6/26 and transfer herself on 2/7/26,c. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure sufficient nursing staff were available to meet resident needs on the evening shift of 2/21/26 for one of three sampled residents (Resident 2) when two certified nursing assistants (CNA) scheduled for the shift were unavailable, one having called off (CNA 8), and the second (CNA 9) leaving early without returning. No replacement staff were secured, and the facility was unable to produce accurate assignment documentation for the shift. This failure resulted in Resident 2, who was dependent on staff for toileting and always incontinent (no control of bowel and/or bladder), being left in a soiled condition for approximately two hours after activating the call light. This placed Resident 2 at risk for skin breakdown, infection, and loss of dignity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that foods available were consistent with the physician-ordered diet for 1 of 1 sampled resident (Resident 1) who was prescribed a pureed diet (food that is blended until smooth, like mashed potatoes), mildly thick liquids (nectar-thick liquids - drinks that are slightly thicker than water to make swallowing safer) and a consistent carbohydrate (CCHO - a meal plan where the amount of carbohydrates is kept about the same at each meal) diet when a jar of peanut butter and jelly was available for consumption at Resident 1's bedside. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure medications were administered in accordance with professional standards of practice for one of four sampled residents (Resident 2), when a prescribed anticoagulant (medication used to prevent blood clots) was administered outside the facility's acceptable time frame due to staff's inability to locate the medication. This failure had the potential to result in adverse clinical outcomes, including blood clot formation for Resident 2.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure appropriate monitoring and safe administration of a blood pressure medication for one of four sampled resident (Resident1) when staff administered metoprolol (medication used to treat high blood pressure) despite low blood pressure readings, did not obtain physician parameters for when to hold the medication, and did not develop a care plan addressing hypertension(high blood pressure) and the risks associated with the medication. This failure placed Resident 1 at risk for symptomatic hypotension 9low blood pressure) and resulted in a change in condition requiring hospitalization due to very low blood pressure.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement one of three sampled residents' (Resident 3's) care plan when Resident 3 experienced two episodes of brief loss of consciousness (LOC - fainting or passing out) on 3/17/26 and his care plan interventions to monitor V/S (vital signs-blood pressure, heart rate, breathing, and temperature) and O2 sats (oxygen saturation - oxygen levels in the blood), to place him in a supine position with legs elevated (laid flat with legs raised to help blood flow to the brain), nursing assessment, and physician notification after the first episode of LOC were not implemented. This failure resulted in another episode of brief LOC and placed Resident 3 at risk for falls, serious injury, worsening condition, and delayed medical intervention.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement appropriate infection prevention and control practices for two of three sampled residents (Resident 1 and Resident 2) when soiled towels were left on the floor of the shared bathroom used by Resident 1 and Resident 2 for two days, creating a potential source of contamination. This failure had the potential to spread infection to Resident 1 and Resident 2 and cause health problems for residents in the facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide quality of care (each resident must receive the necessary care and services to attain or maintain the highest practicable physical well-being) in accordance with professional standards of practice for one of three sampled residents (Resident 1) when,1. The facility staff did not implement in a timely manner the Wound (tissue injury) Doctor's (WD) verbal recommendation on [DATE] to transfer Resident 1 to an acute care hospital for a higher level of care to treat a worsening venous ulcer wound (shallow, slow-healing, or chronic [long term] wounds) on Resident 1's right leg and/or initiate in a timely manner a verbal order on [DATE] from the Medical Director (MD) to arrange a consultation with a vascular surgeon (a highly trained specialist who diagnoses and manages diseases affecting arteries and veins); [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician (Medical Director, MD) took an effective role in overseeing, supervising, and assessing one of three sampled residents (Resident 1's) medical care when the MD did not assess Resident 1's right leg venous stasis ulcer (a slow-healing, open sore on the lower leg or ankle caused by poor blood circulation) after a change in condition was identified on [DATE], follow the Wound Doctor's (WD) recommendation on [DATE] that Resident 1 should be transferred to an acute care hospital for a higher level of care, or follow up in a timely manner on his own verbal order given on [DATE] for Resident 1 to be seen by a vascular surgeon (a doctor who specializes in treating diseases of the blood vessels throughout the entire body). [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to notify the physician of a significant change in condition for one of four sampled residents (Resident 1) when,1. The facility did not notify Resident 1's physician after Resident 1 had consistent moderate to severe hip pain and decreased mobility following a fall on 1/31/26. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to review and revise the person-centered comprehensive care plans (a detailed document outlining a person's healthcare needs, goals, and the specific care and support they will receive, including how, when and by whom) for two of three sampled residents (Resident 2 and Resident 3) when,1. Resident 2's fall risk care plan was not reviewed and/or revised until 3/27/26 (5 days after Resident 2 fell on 3/21/26).2. Resident 3's fall risk care plan was not reviewed and/or revised after Resident 3 fell on 3/25/26. These failures placed Resident 2 and Resident 3 at risk for not receiving the individualized and person-centered care they required to help reduce fall occurrences and mitigate the potential for injury if a fall did occur.

Inspectors wroteBased on interview and record review, the facility failed to provide care and treatment in accordance with professional standards of practice for one of four sampled residents (Resident 2) when,1. The facility did not monitor Resident 2's fasting blood glucose (FSBS, measures the amount of sugar [glucose] in the blood, which serves as the body's main energy source) results before Resident 2 ate breakfast for 11 out of 13 days or ensure Resident 2 did not need further treatment to maintain safe blood glucose levels. This failure placed Resident 2 at risk for experiencing further health complications related to possible fluctuations in blood sugar (hyperglycemic [high blood sugar with can cause confusion and blurred vision] and/or hypoglycemic [low blood sugar which can cause rapid heartbeat, confusion, dizziness, headache and/or loss of consciousness]).

Inspectors wroteBased on interview and record review, the facility failed to maintain a complete and accurate medical record for two of three sampled residents (Resident 2 and Resident 3) when,1. The facility's Interdisciplinary Team (IDT - a group of experts from different fields [like doctors, nurses, and social workers] who work together collaboratively to achieve a common goal, such as comprehensive patient care) failed to complete the Post Fall Follow-Up Report, after Resident 2 fell on 3/21/26 and 3/23/26;2. [...]

Inspectors wroteBased on interview, and record review, the facility failed to develop a care plan for one of three sampled residents (Resident 1) when Resident 1's care needs for fall awareness and fall prevention were not addressed on re-admission. This failure placed Resident 1 at risk for injuring herself in another fall within the facility.

Inspectors wroteBased on interview and record review the facility failed to ensure residents right to privacy were maintained when two residents (Resident 3 and Resident 4) and their rooms were photographed by staff members (Certified nursing assistant (CNA) 3 and CNA 4), using their personal phones, without Resident 3 and Resident 4's knowledge and/or consent. This failure had the potential to negatively affect Resident 3 and Resident 4's psychosocial well-being.a. A review of Resident 4's electronic health record (EHR) indicated Resident 4 was no longer at the facility. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of six residents (Resident 1) with an indwelling catheter (catheter; a thin, flexible tube inserted into the bladder to drain urine) received catheter care and services when:1. Resident 1's suprapubic catheter (a temporary or permanent drainage route for urine, through a small incision in the abdominal wall, from the bladder directly into a collection bag) was not changed as ordered by the physician;2. Resident 1's suprapubic catheter was not consistently monitored following suprapubic catheter changes; and3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the results of the most recent federal recertification survey were readily accessible to residents, family members, and legal representatives of residents, for a census of 75, when the facility's most recent survey results were not available. This failure violated the residents' right to the examination of the most recent survey results and prevented the residents and family members from accessing the facility's last survey results within in the facility. During the Resident Council Meeting on 8/12/2025 at 10:44 AM, when asked if they knew where to find the most recent survey results, the residents who were in attendance responded that they were not aware of where to find the results of the survey and they were also not aware that survey results were available for the residents to read. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety when:1. Food items with inconsistent labeling and dating practices were found in the reach-in refrigerators;2. A box of bacon was found to be passed the use by date but was not discarded in the reach-in refrigerator;3. An opened box of Italian sausage which read keep frozen was found in the reach-in refrigerator;4. Two cartons of health shakes (nutritional supplement provides extra calories and protein), and a tray with cartons of health shakes was found in the reach-in and walk-in refrigerators which did not have a date to identify when they were pulled from the freezer and when they were supposed to be used by; 5. Produce items were found not to be fresh in the walk-in refrigerator;6. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to practice appropriate infection prevention and control measures for a census of 75, when:1. The facility did not complete and document a facility-wide assessment of potential Legionella (bacteria that can cause a severe lung infection called Legionnaire's disease) growth areas and did not implement adequate control measures and monitoring protocols.2. Resident 52's urinary catheter bag (a thin flexible tube used to empty the bladder and collect urine in a drainage bag) was touching the floor.3. Nebulizer face mask and tubing (equipment used with a nebulizer machine that delivers liquid medication to the lungs as a fine mist) for Resident 1 and Resident 86 were unlabeled. There was no documentation when Resident 1's nebulizer face mask/tubing was last changed. [...]

Inspectors wroteBased on observation, and interview, the facility failed to maintain their resident call light system (system/device used by residents to call staff for assistance) when the call light system did not directly alert staff at Station 1 or a centralized staff work area for 47 of 47 residents. This failure resulted in the residents waiting longer periods of time for assistance and put their physical and emotional needs at risk for being unmet.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure that three of twenty-six sampled Residents (Resident 5, Resident 11 and Resident 37) were free from the use of chemical restraints (use of medication to restrict a person's freedom or movement) when:1. A gradual dose reduction (GDR: stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued) was not attempted for Resident 5 and Resident 11's antipsychotic medications (a class of medications used to treat a variety of mental health disorders),2. The use of the antipsychotic medication for Resident 5, Resident 11, and Resident 37 did not have an appropriate clinical indication, and3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an environment free of accidents or hazards for 2 of 26 residents (Resident 62 and Resident 46) when: 1. Resident 62's Smoking assessment was not updated and Resident 62 was left smoking and unsupervised; and,2. An oxygen in use sign was not posted at Resident 46's room entrance. These failures had the potential to place Resident 62, Resident 87, Resident 46 and other residents in the facility with a census of 75 residents, at risk of accidental burns and injuries.1. During a concurrent observation and interview on 8/11/2025 at 9:02 AM with Resident 62, Resident 62 stated she smokes cigarettes at scheduled times that were posted on her wall for 10 minutes each time. Resident 62 was observed to have a pack of cigarettes and 2 lighters on the table. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure safe monitoring and assessment of blood pressure (BP-the force of your blood pushing against the walls of your arteries as your heart pumps blood and was measured as two numbers: systolic [when the heart beats] and diastolic [when the heart rests between beats]) and heart rate (HR-frequency of your heart beats per minute) for a medication used to treat low (hypotension) BP for 1 of 26 sampled residents (Resident 3) when Resident 3's physician prescribed hold parameters (a set of numbers that guide the nursing staff when to not give (hold) a medication) for Midodrine (a medication used to treat low blood pressure) was not followed 7 times between 7/1/25 and 8/14/25. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure medications were stored safely, securely, and properly destroyed (discarding unused or expired medication) in two of three medication carts (a mobile cart containing medication used for administration of medication to residents) for a census of 75 when:1. Two prescription medications (drugs that require a written order from a licensed healthcare professional) of the same brand were found in a basket of over the counter (OTC -medications available without a prescription) medications that were loose in individual blister packs (a form of tamper-evident packaging where a medication is protected by sealed foil) and contained no resident label, expiration date, or indications for use; and,2. An opened multi-use bottle of cough syrup was not labeled with the date opened (date the medication was first opened); [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the menu, spreadsheet and recipe were followed for the therapeutic diets (the modifications of regular diet, tailored to fit the nutritional needs of the particular person. It could be part of a treatment or medical condition and is normally prescribed by a physician) served during the lunch meals on 8/11/25 and 8/12/25 when:1. Resident 71 with CCHO (Consistent Carbohydrate Diet or Controlled Carbohydrate Diet, this dietary approach focuses on maintaining a consistent intake of carbohydrates throughout the day), 2g Na diet (a low sodium diet, usually to manage high blood pressure and/or heart disease), received a ketchup package instead of no ketchup with meal; and,2. [...]

Inspectors wroteBased on interview, and record review, the facility failed to provide education regarding the benefits and potential side effects of the COVID-19 vaccine, for three of five sampled residents (Resident 9, Resident 25, and Resident 51) when all three residents' clinical record did not contain documented evidence that education regarding the risk and benefits of the COVID-19 vaccine were provided. This failure had the potential for the residents and resident's responsible parties to not be fully informed about the risks and benefits, and potential side-effects of the COVID-19 vaccination prior to receiving or declining the vaccination.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 out of 26 sampled residents (Resident 86) with urinary catheters (a thin flexible tube used to empty the bladder and collect urine in a drainage bag) were treated with dignity and their privacy was protected, when Resident 86's urinary catheter bag (a drainage bag attached to a catheter tube that is inside the bladder to collect urine) was exposed and was not placed in a dignity bag (a bag used to the cover and hold the catheter drainage/collection bag so it is not visible). This failure had the potential to negatively effect Resident 86's self-esteem and self-worth. During an observation on 8/11/2025 at 9:16 AM, Resident 86's urinary catheter bag was seen hanging on the side of the bed without a dignity bag. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that one of twenty-eight sampled residents (Resident 11) end of life wishes, and emergent treatment desires were accurate when Resident 11's POLST (Physician Orders for Life Sustaining Treatment: a medical order signed by both a patient and physician that specifies the types of medical treatment a patient wishes to receive toward the end of life) form and electronic medical record code status (the type of emergent treatment a person would or would not receive if their heart or breathing were to stop) had contradictory code status choices marked. This failure resulted in conflicting code status information for Resident 11 and placed Resident 11 at risk for having emergency treatment wishes not honored. [...]

Inspectors wroteBased on observation, interview, and record review, for 1 out of 26 sampled residents (Resident 42), the facility failed to ensure: the use of physical restraint was medically indicated;a care plan was developed for the use of restraint;an informed consent was obtained for the use of restraint. This failure resulted in Resident 42 not being able to move freely and potentially exposed Resident 42 to physical and psychological impact related to restraint.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 of 26 sampled residents (Resident 46) received treatment and care in accordance with professional standards of practice when the care plan for oxygen use for Resident 46, was not developed. This failure had the potential to result in worsening respiratory function, and/or other serious medical complications. Review of Resident 46's admission RECORD, indicated Resident 46 was admitted to the facility in 2023 with diagnoses including chronic combined systolic congestive and diastolic congestive heart failure (the heart struggles to both effectively eject blood and receive blood leading to a range of symptoms such as shortness of breath, fatigue, swelling in legs and ankles, etc.). [...]

Inspectors wroteBased on interview and record review the facility failed to provide services that meet professional standards of practice for two of twenty-eight sampled residents (Resident 5 and Resident 11) when Quarterly Abnormal Involuntary Movement Scale (AIMS - a 12-item assessment tool used to evaluate and monitor the severity of involuntary movements in individuals taking an antipsychotic medication [a class of medications use to treat a variety of mental health disorder]) were not completed for Resident 5 and Resident 11. This failure had the potential for Resident 5 and Resident 11 to experience side effects related to the use of antipsychotic medications to go unrecognized and untreated.1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate hydration (process of providing fluid to the body) for two of 26 sampled residents (Resident 7 and Resident 41), per facility policy and according to each resident's comprehensive plan of care (Care plan- a document detailing an individual's health needs, goals, and the steps needed to achieve those goals) when:1. Resident 7 did not have fluids available to drink at the bedside; and,2. Resident 41 did not have fluids available to drink at the bedside. These failures resulted in Resident 7 having dry mucous membranes (soft tissue that make up the inside the mouth, gums, tongue and lips), chapped lips, and dry and peeling skin on his left leg; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the provision of routine and emergency medications were provided and/or documented for two of the 26 sampled residents (Resident 66 and Resident 78), based on standards of practice and regulatory requirements when:1. Resident 66 did not receive a physician ordered, as needed (PRN), medication called Ipratropium-Albuterol (inhaled medication used to open the airways and make breathing easier) due to medication unavailability from the pharmacy; and, 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure special dietary requirements were implemented for two residents (Resident 53 and Resident 65) during the lunch meal observation on 8/11/25 when Resident 53 did not receive milk with lunch and Resident 65 received corn with lunch which was a documented dislike. This deficient practice had the potential to result in meal dissatisfaction and decreased meal intake that may lead to further complications or Resident 53 and Resident 56's medical status and nutritional status and/or weight loss of both residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide specialized eating utensils for Resident 14 and Resident 32 for the lunch meal on 8/12/25. This deficient practice may lead to Resident 14 and Resident 32 consuming their meal improperly, cause a lack of self-independence during eating and could be a dignity issue, and may cause weight loss.

Inspectors wroteBased on interview, and record review, the facility failed to provide education regarding the benefits and potential side effects for the Pneumococcal (a serious bacterial infection that can cause respiratory illness) vaccine for one out of five sampled residents (Resident 23) when Resident 23's clinical record did not contain documented evidence that education for the pneumococcal vaccine was provided. This deficient practice violated Resident 23's right to make an informed choice to receive or not receive the pneumococcal vaccine.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an environment free of accidents or hazards for two of three sampled residents (Resident 2 and Resident 3) when: 1. Resident 2 ' s and Resident 3 ' s Wander Guard devices (a monitoring device used to alert staff of a resident leaving the premises) were not checked for placement and functionality each shift (3 shifts in a 24 hour period) each day; and, 2. Resident 2 ' s and Resident 3 ' s Elopement (an act or instance when a cognitively impaired person leaves a safe area or premises unsupervised and undetected) Risk Assessments were not completed quarterly; and, 3. Resident 3 exited the facility on 6/4/25 and was missing for an unknown period of time before staff found her in the street on 6/4/25; and, 4. Resident 3 was not reassessed for Elopement Risk after she exited the facility on 6/4/25; and, 5. [...]

Inspectors wroteBased on interview and record review the facility failed to use appropriate and safe transfer methods according to resident's care needs for one of three sampled residents (Resident 2) when, Certified Nursing Assistant (CNA) 2 transferred Resident 2 from the shower chair (a waterproof chair on wheels used to transport residents to and from the shower room) to her bed using a bear-hug (a transfer technique where a caregiver wraps their arms around the individual under the armpits, like a bear hug, to assist in standing and moving them) and one person assist. This failure resulted in a fracture of Resident 2's right seventh rib, and had the potential to cause increased pain, decreased mobility, skin breakdown, and other negative health outcomes for Resident 2.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe environment and the supervision needed to ensure one of 24 sampled residents (Resident 39) was protected from physical abuse when another resident (Resident 79), who had a history of severe mental illness and violent behaviors, entered Resident 39's room and struck him in the face multiple times. This failure resulted in Resident 39 sustaining facial bruising and redness, a cut lower lip, overall head pain, and feelings of fearfulness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a Dietary Supervisor (DS) was onsite on a full time basis (while the DS was employed by the facility on full-time basis, the DS was onsite for less than the minimum required 35 hours per week) to carry out the functions of the day-to-day operation of food and nutrition services, and the facility failed to ensure the Registered Dietitian (RD) provided frequently scheduled consultation to the DS to include overseeing food safety and sanitation, food preparation, meal services, and food storage for 81 residents who received food from the kitchen. The lack of consistent oversight by qualified staff had the potential to result in lapses in the delivery of food and nutrition services, meal distribution accuracy, and safe food handling and sanitation.

Inspectors wroteBased on observations, interview and record review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety when: 1. Several various sizes of tray line pans and serving utensils were stacked and stored wet. 2. A significant amount of food items that was outdated and/or with incorrect and inconsistent label were found in the reach-in refrigerators. 3. Stale and expired produce food items were found available for use in the walk-in refrigerator, 4. The ice machines located in nursing station one and two were not cleaned and sanitized according to the manufactures guidelines; 5. Two refrigerators for residents' brought in food located in nursing station one and two had: -unlabeled food items; -outdated food items; -no temperatures monitoring. 6. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a clean environment for the residents and visitors. One out of three garbage disposal bins located outside by the kitchen had trash inside and was not securely closed with the dumpster lid. This failure had the potential for an unsafe environment for the residents and visitors due to possible pest infestation and spread of diseases in the facility.

Inspectors wroteBased on interview and record review, the facility failed to honor resident's right to participate in care conference (a quarterly and annually meeting that takes place between health care professionals and the resident and/or family to discuss and plan individualized resident care and allow the resident and/or their family to voice opinions, and concerns for the care given) meetings for five of twenty four sampled residents (Resident 70, Resident 61, Resident 29, Resident 37, and Resident 77) when Resident 29, Resident 61, Resident 70 Resident 37, and Resident 77' s quarterly and comprehensive care conference meetings were not held. This failure resulted in not providing the benefit to the residents and families of participating in the planning of their individualized care needs and to voice their care concerns.

Inspectors wroteBased on interview and record review, the facility failed to ensure six of 24 sampled residents (Resident 10, Resident 21, Resident 61, Resident 70, Resident 75, and Resident 239) end of life wishes and emergent treatment desires were accurate and/or available to facility staff when: 1. Resident 70's POLST (Physician Orders for Life Sustaining Treatment: a medical order signed by both a patient and physician that specifies the types of medical treatment a patient wishes to receive toward the end of life) and documented code status (the type of emergent treatment a person would or would not receive if their heart or breathing were to stop) did not match; and, 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services which met professional standards of quality for a census of 81 when: 1. The Station 1 glucometer (a device used to measure how much glucose is in the blood) quality control test (QC, a test that verifies that the device or product meets specific quality standards) logbook was not consistently completed for all active glucometer devices stored in the medication carts at Station 1; and, 2. Resident 21's bedside table was left with a medication cup containing multiple pills. These failures had the potential to result in inaccurate resident blood glucose tests, a wrong medication dose due to the inaccurate test, medication errors, and for Resident 21 to experience a reduction in medication effectiveness due to missed doses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe pharmaceutical services for a census of 81 when: 1. Disposition [destruction] of non-controlled (non-narcotic) prescription medications were not documented. 2. The emergency kit (or E-kit, a box containing emergency medications for faster and easy access when needed) in the refrigerator at nurses Station 1 had been opened and left unsealed with no documentation of the medication that was removed, and the E-kit stored in a cabinet at Station 1 was left opened/unsealed for six days. 3. Prescription drug delivery manifests (receipts) were not consistently signed or reviewed upon delivery by licensed staff. 4. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure monitoring of Vital Signs (VS, including blood pressure (BP) and heart rate/pulse) and VS parameters (a set of VS numbers which doctors use to hold the drug to prevent adverse effects) ordered by a physician for use of high-risk medications (medications that pose significant side effects if not used and monitored safely) were followed for three out of 24 sampled residents (Resident 21, Resident 77 and Resident 13) when: 1. Resident 21's blood pressure (BP) medications were not held according to the VS parameters set by the physician for three different medications on 9/2/24 and 9/7/24. 2. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure safe use and monitoring of psychotropic medications (or mind-alerting medications) for three residents (Resident 21, Resident 37, Resident 58) prescribed psychotropic medications in a sample of 24 when; 1. Non-Pharmacological nursing interventions (Referring to therapies that do not involve drugs, a science-based and non-drug approach that can have a measurable impact on health and quality of life; includes validation therapy, meaningful activities, and /or structured care based on resident's background or interests) were not documented for Resident 21 and Resident 37 with psychotropic medication use. 2. Resident 21's behavior monitoring for use of mind-altering drugs was non-specific and the behaviors did not pose a danger to self or others. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe medication and medical supply storage in the medication cart, treatment cart, refrigerator, and the medication room for a census of 81 when: 1. Station 1's medication refrigerator had heavy frost where insulin (drug used to treat blood sugar disease) and vaccines (use for immunization against serious diseases) were stored, and the refrigerator temperature was not documented twice a day in the medication room. 2. Glucometer (a device used to measure blood sugar) control solution (a product used to calibrate the glucometer for accurate function) and test strips (test strips are used to measure blood sugar levels by soaking blood on the tip of it) bottles were expired (manufacturer beyond use date) and not dated when first opened in the medication room at Station 1. 3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two food service personnel were able to safely and effectively carry out the functions of the food and nutrition services when: 1. Dietary Aide (DA) 1 was unable to verbalize the process of manual dishwashing using a two-compartment sink, and, 2. [NAME] (CK) 2 did not thaw meat using a correct procedure. These failures had the potential to place 81 out of 81 residents who received food from the kitchen at risk for food-borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the menu was followed for residents on a therapeutic diet for the lunch meal on 9/10/24 when: 1. Sixteen residents (Residents 4, Resident 6, Resident 8, Resident 9, Resident 11, Resident 17, Resident 21, Resident 24, Resident 30, Resident 38, Resident 59, Resident 66, Resident 74, Resident 77,Resident 82, and Resident 83) with CCHO (consistent carbohydrate) diet (a diet to treat diabetic disease or control blood sugar) received the diet gelatin without whipped topping instead of with whipped topping. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow safe infection prevention practices for a census of 81 when: 1. A glucometer was used without being cleaned and disinfected between residents during medication pass observation. 2. Nine hand sanitizer bottles were in active use while expired. These failures had the potential to result in the spread of germs, infection, and the need for additional medical interventions (medications and/or treatments).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a homelike environment was provided for 1 of 24 sampled residents (Resident 63), when Resident 63 could not store her personal belongings in her assigned closet space. This deficient practice did not ensure a homelike environment that encouraged the use of personal belongings to the extent possible.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a comprehensive person-centered care plan was developed for one of twenty-four sampled residents (Resident 58), when an indwelling catheter (urinary catheter: a hollow flexible tube that is inserted into the bladder to drain urine) care plan was not developed for Resident 58. This failure had the potential for Resident 58's catheter care needs not being met which could lead to infections and complications.

Inspectors wroteBased on interview and record review, the facility failed to ensure necessary care and services were provided for one of twenty-four sampled residents (Resident 239) when Resident 239 did not receive a shower as scheduled at least twice a week. This failure resulted in Resident 239 not receiving showers and had the potential for poor hygiene, poor skin integrity, and low self-esteem for Resident 239.

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure access to bilateral hearing aids and to assist in arranging for audiologist (ear doctor) referral consult services for one of twenty-four sampled residents (Resident 44). This failure had the potential to impair Resident 44's ability to understand and communicate needs effectively.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of six residents (Resident 58) who entered the facility with an indwelling catheter (urinary catheter: a hollow flexible tube that is inserted into the bladder to drain urine) was assessed for catheterization necessity when Resident 58's record did not indicate the clinical condition for use of the indwelling catheter. This failure had the potential of unnecessary indwelling catheter use which could lead to urinary tract infections (UTI) and further complications for Resident 58.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure respiratory care was provided in accordance with professional standards of practice for 3 of 14 residents (Resident 52, Resident 5, and Resident 43) receiving oxygen therapy when: 1. Resident 52 and Resident 5's oxygen flow rate was not followed as prescribed by the doctor; and 2. Resident 43's oxygen tubing and humidifier (a device for keeping the atmosphere moist in a room) were not dated. These failures had the potential to result in negative health impacts such as ineffective oxygen therapy and respiratory distress for Resident 52, Resident 5, and Resident 43.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure safe medication administration practices when the medication error rate was more than 5% (% or percentage- number or ratio that expressed as a fraction of 100) for a census of 81 residents. Medication administration observations were conducted over multiple days, at varied times, in random locations throughout the facility. The facility had a total of two errors out of 38 opportunities which resulted in a facility wide medication error rate of 5.26 % in two out of 12 residents (Resident 45 and Resident 52) during medication administration observation. These failures resulted in unsafe medications use, medication errors, and not following the doctor's orders.

Inspectors wroteBased on interview and record review, the facility quality assessment and assurance (QAA) committee failed to meet quarterly with all required members for a census of 81, when: 1. Four of six required committee members including the Medical Director (MD), the Director of Nursing (DON), the Infection Preventionist (IP) and the Administrator (ADM), owner, a board member or other individual in leadership role did not attend quarterly Quality Assurance Performance Improvement (QAPI: a data driven and proactive approach to improve the quality of life, quality of care and services delivered in nursing facilities) meeting on 6/28/2024, and 2. The DON and the IP did not attend quarterly QAPI meeting on 4/26/24. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure adequate supervision was provided to 1 of 3 sampled residents (Resident 1), when Resident 1 did not receive 1:1 supervision (a staff member assigned to watch one resident) on 12/12/23 as indicated in her fall care plan. As a result, Resident 1 fell and got a skin tear.

Inspectors wroteBased on observation, interview and record review, the facility failed to protect and keep secure when not in use, confidential resident health data and records for a census of 75. This failure had the potential to expose and disclose personal and confidential health information to unauthorized individuals.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure accurate accountability and effective storage of controlled medications (those with high potential for abuse or addiction), and availability of routine and emergency drugs when: 1. Random controlled medication use audits for 5 out of 6 residents (Residents 18, 21, 22, 35, and 52) did not reconcile. The medications were signed out of the Controlled Drug Record (CDR, an inventory sheet that keeps record of the usage of controlled medications) but not documented on the Medication Administration Record (MAR) to indicate they were given to the residents; 2. Three out of 13 emergency kits (E-kit, a kit containing medications and supplies for immediate use during a medical emergency) were not replaced in accordance with the facility policy and procedures (P&P); and 3. [...]

Inspectors wroteBased on observation, interview and record review, the facility had a 16.6% error rate when 5 medication errors out of 30 opportunities were observed during a medication pass for 5 out of 11 Residents (Residents 1, 18, 27, 48 and 54). These failures resulted in medications not given in accordance with the physician's orders and/or manufacturer specifications which resulted in residents not receiving the full therapeutic effect of the medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: 1. Opened biologicals, multi-dose inhalers and insulin (medication to lower blood sugar level) were dated with an open and discard dates to ensure they were not used beyond the discard dates and expired medications were not available for resident use and, 2. Medication carts were kept securely locked when left unattended. The deficient practices had a potential for residents to receive medications with unsafe or reduced potency from being used past their discard date, and diversion or misuse of medications from not being securely stored in medication carts.

Inspectors wroteBased on observation, interview and review of the policies and procedures, the facility failed to maintain the kitchen in a sanitary condition when: 1. Accumulated dust was built up on the electric wires, sprinkler pipes, and water pipelines in the kitchen, 2. Undated open food items were available for use in the refrigerator, and 3. The kitchen appliances were not maintained in a safe operating condition. These failures had the increased risk for food borne illness for a census of 75.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two residents (Resident 11 and Resident 36) were assisted with Activities of Daily Living (ADLs) when staff did not perform nail care for a census of 75. These failures resulted in fingernails that were long with blackish substance underneath them, and had the potential for Resident 11 and Resident 36 to sustain injury and/or acquire an infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure infection control practice was maintained when: 1. Hand hygiene was not performed in accordance with facility policy and procedure (P&P) during medication administration between Resident 27 and 54 and 2. A nasal cannula (a plastic tubing to deliver oxygen from the concentrator to the patient via nostrils) placed on the floor was reused for Resident 13. These failures had the potential to result in cross contamination between Resident 27 and Resident 54 and Resident 13 being exposed to dust and dirt that could lead to respiratory illnesses or aggravate the existing lung disease.