Lampstand Nursing and Rehabilitation

Inspectors wroteBased on interview and record review, the facility failed to notify the resident and resident's representative(s) of the discharge, reasons for the move, and right to appeal in writing and in a language and manner they understand and send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman for 1 (Resident #1) of 5 residents reviewed for discharge planning. The facility failed to notify Resident #1's RP of Resident #1's discharge, reasons for the move, and right to appeal in writing, in a language and manner they understand, as soon as practicable before the discharging Resident #1 on 04/23/2026 to another facility. The facility failed to send a copy of the notice of Resident #1's discharge to the facility's Ombudsman as soon as practicable before discharging Resident #1 on 04/23/2026 to another facility. [...]

Inspectors wroteBased on interviews and record review the facility failed to immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is a significant change in the resident's physical status for one (Resident #1) of seven residents reviewed for resident rights. The facility failed to ensure ADON A notified the resident's responsible party/medical power of attorney within a reasonable time when Resident #1 fell out of bed on 06/12/2026. This failure could place residents at risk of not having their responsible party/medical power of attorney notified of changes, which could result in a delay in timely intervention and a decline in condition.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that the resident environment remained as free of accidents and hazards as was possible and that each resident received adequate supervision and assistance devices to prevent accidents for 1 of 5 residents (Resident #1) reviewed for accidents hazards and supervision. The facility failed to ensure that Resident #1's bed was in low position, and his alternating air mattress was with the correct settings when Resident #1 experienced an unwitnessed fall on 06/05/2026 at 07:34 PM. This failure could place residents at risk for falls with the possibility of injury, including fractures.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for one of three residents (Resident #1) reviewed for catheter care. The facility failed to ensure Resident #1's urinary drainage bag was found hanging from the bed frame with the bottom of the bag touching the floor/floor mat on two occasions on 06/09/2026. This failure could place residents with indwelling catheters (a tube that is inserted through the urethra to the bladder to drain urine) at risk of developing infections.

Inspectors wroteBased on interview, and record review, the facility failed to ensure residents could exercise their rights without interference for 1 of 10 residents (Resident #1) reviewed for resident rights. The facility failed to prevent staff from obscuring the view of an authorized electronic monitoring device in Resident #1's bedroom on 05/28/2026. This failure placed residents at risk of abuse, neglect, or maltreatment not being identified.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to properly store, prepare, and distribute food in accordance with professional standards for 1 of 1 kitchen observed for food service safety.1. The facility failed to properly store, label and date all food items located in the walk-in refrigerator on 04/08/2026 and 04/10/2026.2. The facility failed to ensure the dry food pantry was clean and free of accumulated black residue on the wall and shelves. These failures could have placed residents at risk for food contamination and foodborne illness. Based on observations, interviews, and record reviews, the facility failed to properly store, prepare, and distribute food in accordance with professional standards for 1 of 1 kitchen observed for food service safety.1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe and sanitary environment to prevent the development and transmission of communicable diseases and infections for 3 of 7 residents (Resident #26, Resident #37, and Resident #76) reviewed for infection control. RN Treatment Nurse C did not change contaminated gloves prior to Resident #26's repositioning; contact with clean supplies; and she did not wash her hands after removing gloves post perineal care. RN B did not sanitize her hands between changing gloves while performing indwelling catheter care on Resident #37. ADON LVN F did not sanitize the over-the-bed table prior to setting supplies on it and turned her back to a sterile field multiple times while performing tracheostomy care on Resident #76. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 (Resident #26) of 7 residents reviewed for resident rights. The facility failed to encourage and assist Resident #26 with dressing in his preferred personal clothing which was available on-site rather than hospital type gowns during the day. This failure could place residents at risk for diminished quality of life, loss of dignity, and a decrease sense of self-worth.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for 1 of 15 residents (Resident #10) reviewed for resident rights. The facility failed to ensure Resident #10's bathroom was free from dirt on the floor. This failure could place residents at risk of infection and diminished quality of life.

Inspectors wroteBased on interviews and record reviews the facility failed to ensure comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 2 ( Resident #22 and Resident #52) out of 8 residents reviewed for care plans. The facility failed to update the comprehensive care plan to reflect Resident #22 and Resident #52 received in room activity programs. This failure could have placed residents at risk for not having their needs identified and met.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for two of eight residents (Resident # 22 and Resident #52) reviewed for ADL care. The facility failed to ensure Resident #22 and Resident #52's nails were cleaned and did not have any on 04/08/2026 and 04/09/2026. This failure could place residents at risk of not receiving services or care, diminished quality of life , and decreased self-esteem.

Inspectors wroteBased on interview and record review, the facility failed to provide an ongoing activity program to support residents in their choice of activities, both facility sponsored group and individual activities, and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for 2 (Residents #22, and #52 of 6 residents reviewed for activities. The facility failed to provide activities for Resident #22 and Resident #52 to meet their psycho-social and mental needs for the months of January, February , March and April 2026. This failure could place residents at risks of boredom, depression, behavior, diminished quality of life and decreased cognitive function.

Inspectors wroteBased on observation, interviews, and record reviews the facility failed to ensure the resident environment remained as free of accident hazards as is possible for one of three housekeeping carts (Housekeeping Cart #1) reviewed for hazards. The facility failed to ensure Housekeeping Cart #1, with chemicals inside the compartments, was locked when unsupervised. This failure could place residents at risk for injuries, illness, and hospitalization.

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure that a resident who is incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 ( Resident #16) of three residents reviewed for catheter care. The facility failed to have the appropriate size foley catheter ( a medical device used to drain urine from the bladder) in the facility when Resident #16 was complaining of pain from his catheter on 04/08/2026. This failure could place residents at risk for infection, sepsis( a serious condition in which the body responds improperly to an infection, causing organ damage) and hospitalization.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide appropriate treatment and services to prevent complications of enteral feeding for one (Resident #33) of two residents reviewed for enteral feeding (a tube is inserted directly through the abdomen to the stomach to provide nourishment). The facility failed to ensure RN D attended to a flow error alarm on a feeding pump for 45 minutes for Resident #33 on 04/08/2026. This failure could place residents at risk of malnutrition, pain, and/or significant changes in condition.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 1 of 4 medication carts ( Medication Cart #1) reviewed for medication storage. The facility failed to ensure Medication Cart #1 was locked and medications were secure and not accessible to other staff, residents or visitors. This failure could place residents at risk of having unauthorized access to prescriptions, biologicals, and over-the-counter medications.

Inspectors wroteBased on observations, interviews, and reviews, the facility failed to provide food that was prepared in a form designed to meet individual needs and by methods that conserve nutritive value and flavor for 4 residents who ate pureed diets from 1 of 1 kitchen reviewed for food and nutrition services. The facility failed to ensure that the lunch meal on 04/09/2026 was served at the correct temperature and was palatable. The facility failed to ensure [NAME] A refrained from adding an unmeasured amount of liquid to fish sticks, pureed meal during lunch service on 4/10/2026. This failure could affect residents at risk for diminished or altered nutritional status and potential weight loss. Email received from the Administrator on 04/09/2026 at 8:23 revealed 4 residents at the facility received a pureed diet. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain medical records in accordance with accepted professional standards and practices that are completely and accurately documented for 1 (Resident #26) of 7 residents reviewed for medical records. The facility failed to maintain complete and accurate documentation of provided incontinent care for Resident #26. This deficient practice could place residents at risk for not receiving proper care due to incomplete and inaccurate records.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 4 (Resident #1) residents reviewed for measurable objectives and timeframes. The facility failed to enter dates into the Care Plan when Resident #1 sustained bruises, and no goal or interventions for the resident's diagnosis of schizophrenia (a mental health disorder). This failure could result in inadequate care due to incomplete and inaccurate care plans.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 (Resident #1) of 5 residents observed for pharmacy services. The facility failed to assure Resident #1 was aware of the medications that he was administering. This failure could affect residents receiving medications by placing them at risk for medication errors.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide the care and supervision to prevent accidents for 1 of 7 (Resident #1) residents reviewed for accidents and hazards. The facility failed to ensure that Resident #1 was repositioned with two-person assist and left in an unsafe position when CNA A walked away from the bedside on 9/15/2025. The noncompliance was identified as Past Noncompliance (PNC). The IJ template was provided to the facility on [DATE] at 1:25PM. The IJ began on 9/12/2025 and ended 9/15/2025. The facility corrected the noncompliance before the survey began on 10/08/2025. This failure placed residents at risk for accidents, falls, fractures, and diminished quality of life. Findings Include: Record Review of Resident #1's Facesheet dated 10/08/2025 revealed a 37 y/o male, admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interviews, and record reviews the facility failed to ensure residents were free from significant medication errors for 1 of 7 (Resident #1) residents reviewed for pharmacy services. The facility failed to ensure that Resident #1 was provided pharmacy services to ensure that he did not have a preventable seizure on 9/14/2025 at 8:10AM. The noncompliance was identified as Past Noncompliance (PNC). The IJ template was provided to the facility on [DATE] at 1:25PM. The IJ began on 9/12/2025 at 11:22PM and ended 9/15/2025. The facility corrected the noncompliance before the survey began on 10/08/2025. This failure placed residents at risk for seizures, hospitalization and death. Findings Include: Record Review of Resident #1's Facesheet dated 10/08/2025 revealed a 37 y/o male, admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure the legal surrogate so designated may exercise the resident's rights to the extent provided by state law for 1 of 7 (Resident #1) residents reviewed for resident rights. The facility failed to ensure that LVN F did not care for Resident #1 on 10/08/2025 and 10/09/2025 after the RP told him to leave the room and not care for Resident #1 after 10/08/2025 at 7:32AM. This failure couple place residents whose rights are exercised through a legal representative at risk of not having their rights exercised. Findings Include: Record Review of Resident #1's Facesheet printed on 10/08/2025 revealed a 37 y/o male, admitted to the facility on [DATE]. Diagnoses included unspecified convulsions, schizophrenia, weakness, and personal history of traumatic brain injury (TBI). [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access, for 1 Resident (Resident #1) of four residents reviewed for medication storage, in that: A bottle of Nystatin Topical Powder was found on 04/24/25 at 12:55 pm left unattended and unsecured at Resident #1's bedside. This deficient practice placed residents at risk for unauthorized access, drug diversion, or ingestion of medications leading to harm.

Inspectors wroteBased on interviews, observations, and record reviews, the facility failed to provide a notice of residents' rights to the residents during the residents' stay for three out of four halls. Information of residents' rights was posted only on Hallway 4 and not accessible for viewing by all facility residents. Resident rights were not included in residents' admission packets since November 2023. These failures placed residents at risk of a decreased quality of life, decreased awareness or their rights, and decreased execution of their resident rights.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for sanitation. 1. The facility failed to properly label food and dispose of store perishable foods in the dry storage pantry and walk in fridge. 2. The facility failed to ensure the ice machine was properly cleaned. These failures could place residents who were served from the kitchen at risk for consuming hazardous expired food and developing foodborne illnesses. Findings Included: Observation on 02/10/25 at 9:30 am revealed a 50-pound bag of yellow onions sitting in water on the floor in the dry storage room. Observation on 02/10/25 at 9:38 am revealed cold eggs sitting on the stove top in a pan with a spatula in the pan. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections, for two of two medication aides (MA A and MA B) observed for infection control practices during medication pass. A) MA A failed to sanitize the blood pressure cuff during medication pass after using it on Resident #46 then using it on Resident #45. B) MA B failed to sanitize the blood pressure cuff during medication pass after using it on Resident #133 then using it on Resident #28. This failure could place residents who require assistance with medication administration at risk for healthcare associated cross-contamination and infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain all mechanical and electrical equipment in safe operating condition in 1 of 1 kitchen, in that: The coffee brewing system was not heating. The left side of the double oven was not heating. One well on the steam table was not heating The mobile heated delivery cart was not maintaining a proper temperature. This deficient practice could place residents at risk of decreased resident's quality of life who receive meals from the kitchen and could result in foodborne illness for residents who received meals from the kitchen.

Inspectors wroteBased on interview and record review, the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service in 1(DA B) of- 8 1 kitchen staff in that: DA B had not received training from facility management staff, mandatory online training, or obtained a food handlers certificate before working in the kitchen. This could leave the resident's at risk of consuming improperly handled food and a contracting a foodborne illness

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute food in accordance with professional standards for food service safety for one of one kitchen reviewed for kitchen sanitation. The facility failed to ensure [NAME] C properly used proper hand hygiene during food preparation. This failure could place residents who ate food from the kitchen at risk for foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident's right to a safe, clean, comfortable, and homelike environment for 1 (Resident #1) of 4 residents reviewed for environment. The facility failed to ensure Resident #1's room was free of odor and soiled sheets. This failure placed residents at risk of living in an uncomfortable environment leading to a diminished quality of life.

Inspectors wroteBased on interview and record review , the facility did not ensure prompt efforts were made to document a resident grievance for one (Resident #2) of four residents reviewed for grievance resolutions. The facility failed to promptly document grievances regarding answering call lights and begin an investigation. This failure placed resident at risk of not having their grievances resolved.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain functional abilities for 1 (Resident #3) out of 7 residents reviewed for ADLs. The facility failed to ensure Resident #3 was placed in a safe and comfortable position while eating. This failure placed the resident at risk of discomfort and choking/aspiration.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident #3) out of five residents reviewed for infection control. 1. The facility failed to ensure staff wore PPE while providing care for Resident #3. 2. The facility failed to ensure staff followed the facility policy and tied back long hair to minimize cross contamination. These failures placed the residents at risk of cross contamination and infection.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure residents received services in the facility with reasonable accommodations of each resident's needs for 1 of 8 residents (Resident #1) reviewed for resident rights in that: The facility failed to ensure Resident #1's call light was within reach on 08/14/24. This failure could affect residents who needed assistance with activities of daily living and could result in needs not being met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide and document an effective discharge planning process that focused on the resident's discharge goals, the preparation of the residents to be active partners and effectively transition them to post discharge care, and the reduction of factors leading to preventable readmissions for 1 of 6 (Resident #1) of residents reviewed for safe discharge. On 4/26/2024 the facility discharged Resident #1 from the facility pending a hearing for an appeal. The facility transported Resident #1 and all of his belongings to RP1's home. There was no one at the home who was able to accept Resident #1, the facility left the resident sitting outside of the home that was located on a busy street. Resident #1 was considered blind, was moderately cognitively impaired, was at risk for elopement with a previous history of elopement. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to review and revise care plans for 1 (Resident #1) of 5 residents reviewed for care plan revision. The facility failed to complete a quarterly review and revision of Resident #1's care plan by 03/29/24. Resident #1's last care plan was reviewed, revised, and completed on 12/29/23. This failure could place residents at risk of not having their individual care needs met in a timely manner or a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in the facility's only kitchen reviewed for kitchen sanitation. The facility failed to discard of food products that were past the use by date or in accordance with facility policy. The facility failed to properly label left over food held in the walk-in refrigerator. The facility failed to ensure that their three-door refrigerator was operating at a temperature of 41 degrees Fahrenheit or less and that temperatures were properly logged. The facility failed to remove dented cans from the dry storage area to prevent service to residents. The facility failed to clean the industrial can opener. The facility failed to clean up a liquid spill in the kitchen. [...]

Inspectors wroteBased on interviews and record review the facility failed to enter baseline care plans for three of three Residents (Resident #136, Resident #138 and Resident #141) admitted within the last month and reviewed for new admissions to the facility. The facility failed to follow its policy which reflected residents must have a baseline care plan on admission and it must be presented to the resident. This failure put residents at risk for not being provided assistance as needed.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for 3 of 22 residents (Resident #8, Resident #33, Resident #57 ) reviewed for ADL's. A) The facility failed to ensure assistance was provided for showering/bathing and personal hygiene for Resident #8. B) The facility failed to provide nail care for Resident #33. C) The facility failed to provide nail care for Resident #57. These failures could lead to a reduction in quality of life by creating isolating behaviors due to embarrassment, loss of self-esteem, and dignity and could contribute to health-related issues from lack of hygiene. Findings Included: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure two of four residents reviewed with limited range of motion (Resident #33 and Resident #51), received appropriate treatment and services to prevent a decline in range of motion. A) The facility failed to ensure Resident #33 had interventions in place for her hand contractures to prevent further decline of her hand, associated pain and pressure areas. B) The facility failed to ensure Resident #51 had interventions in place for her left-hand contracture (A permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen and a decrease in ROM) and left knee contracture to prevent further decline of the range of motion in her left hand and left knee. [...]

Inspectors wroteBased on observations and record review, the facility failed to accommodate the needs and preferences for two of twenty residents (Residents #33 and #74) reviewed for accommodation of needs, in that: The facility failed to ensure that Residents #33 and #74 had their call lights in reach. This deficient practice could place residents at risk for not receiving timely care and nursing interventions.

Inspectors wroteBased on interview and record review the facility failed to recognize the residents right to formulate an advance directive for one of three residents (Resident #138) reviewed for DNR status. The facility failed to enter a life code status for Residents #138 in his chart until pointed out by the surveyor on second day of survey. This failure could place residents at risk of not having their end of life wishes met.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for 1 of 1 resident (Resident #74) reviewed for physical environment, in that: The facility failed to maintain a clean commode free from feces. These failures could affect resident by placing him at risk for diminished quality of life due to the lack of a well-kept environment, infection, and illness.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents received care, consistent with professional standards of care to prevent development or worsening of diabetic ulcers for one of five (Resident #1) residents reviewed for diabetic ulcers. The facility failed to ensure Resident #1 received her physician ordered diabetic ulcer preventative measures routinely. This failure could place residents at risk for worsening pressure ulcers leading to discomfort, pain, and potential infections.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents received care, consistent with professional standards of care to prevent development or worsening of pressure ulcers for one of one (Resident #32) reviewed for pressure ulcers. The facility failed to ensure Resident #32 received her physician ordered pressure ulcer preventative measures routinely. This failure could place residents at risk for worsening pressure ulcers leading to discomfort, pain, and potential infections.

Inspectors wroteBased on observation, interviews and record reviews the facility failed to ensure the resident environment remains free of accident hazards as possible. The facility failed to ensure a needle was disposed of safely when a blood draw needle was found in a Resident #48's room with blood in tubing. This failure put residents in danger of accidental injury and exposure to blood borne illness.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents who are incontinent of bladder receive appropriate treatment and services to prevent urinary tract infections for two of four residents reviewed for catheters (Resident #22, and Resident #138). A) The facility failed to ensure Resident #22's received care to prevent urinary tract infections when they stored his catheter bag on the floor. B) The facility failed to ensure Resident #138 received care to prevent urinary tract infections when they stored his catheter bag on the floor. These failures could place residents with foley catheters at risk for urinary tract infections and change of condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respiratory care was provided consistent with professional standards of practice for 2 of 6 Residents (Resident #22 and #59) reviewed for respiratory care. A) The facility failed to ensure Resident 22's oxygen tubing was changed weekly and his oxygen concentrator filter was clean and in place. B)The facility failed to ensure Resident #59's oxygen tubing and nasal canula were dated and changed. The facility further failed to ensure Resident #59 was comfortable by receiving humidified air to prevent dried nasal passages. This failure could place residents who use respiratory equipment at risk for respiratory infections.

Inspectors wroteBased on observation and interviews the facility failure to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles. The facility failed to ensure safe medication administration when an observation during medication pass on [DATE] revealed five loose pills were found within the medication cart's drawers and greatly increased the chances for accident administration to the wrong resident. This failure put residents at risk for accidental ingestion of medication that was not prescribed to them and subsequent side effects.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide reasonable accommodation of one of one (Resident #31) resident reviewed with needs and preferences to assist the resident in maintaining and/or achieving independent functioning, dignity, and well-being to the extent possible in accordance with the resident's own needs and preferences. The staff did not accommodate Resident #31's dietary preferences. This failure could affect residents who have told the facility their food preferences and rely on the facility to not serve them food that they have told them they dislike to the detriment to their dignity and quality of life .

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe functional environment for room [ROOM NUMBER], 200 hall, Resident #22, staff, and the public. A large crack in the floor was observed from the outside wall in room [ROOM NUMBER](Resident #22's room) which extended all the way through the room and across 200 hallway. Ants were noted building a mound from the crack under Resident #22's bed. This failure could place residents at risk for an unsafe environment.

Inspectors wroteBased on interview and record review the facility failed to obtain timely laboratory services to meet the needs of 1 of 4 residents reviewed for laboratory services. (Resident #3) The facility failed to obtain laboratory values as ordered on [DATE]. Resident #3's laboratory blood draw specimen became useless after an extended time and was not redrawn. Resident #3 was hospitalized on [DATE] with diagnoses including sepsis. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 5:10 p.m. While the IJ was removed on [DATE] at 1:45 p.m., the facility remained out of compliance at actual harm with a scope identified as isolated, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk for a delay in identifying or diagnosing medical issues. Findings Include: [...]