Linden Grove Health Care Center

Inspectors wroteBased on interview and record review the facility failed to protect resident's right to be free from physical abuse for 1 of 4 sample residents (Resident 1) reviewed for Resident-to-Resident altercations. This failure placed residents at risk for abuse, psychosocial harm, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide showers/bathing for 2 of 5 sampled residents (Residents 1 and 2) and implementation of orders for 1 of 3 sampled residents (Resident 3) when reviewed for quality of care. This failure placed residents at risk for unmet needs, poor personal hygiene, and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure 6 of 6 residents (Residents 4, 5, 6, 7, 8, and 9) reviewed for insurance disenrollment were informed of the risks/benefits, options, and alternative changes in their insurance, in ways that were easy for the residents and/or the residents' representative to understand. The facility failed to develop written policies and procedures regarding the process of assisting beneficiaries with changing their health care coverage, including the need to obtain a document signed by the beneficiary or representative that acknowledges that the specific information regarding the impact of a change in coverage was provided to them orally and in writing, and that they understood the information. [...]

Inspectors wroteBased on interview and record review the facility failed to protect resident's right to be free from physical abuse for 2 of 4 sample residents (Residents 1 and 2) reviewed for resident-to-resident altercations. This failure placed residents at risk for abuse, psychosocial harm, and a diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to provide the necessary care and services for 1 of 4 residents (Resident 3) reviewed for quality of care when new skin impairments were not investigated to rule out abuse/neglect, investigation conclusions were not accurate to the identified skin impairment, treatment orders were not implemented at the time of the skin impairment identification and wound team recommendations were not followed. This failure placed residents at risk for unmet care needs, worsening wounds, and a decreased quality of life.

Inspectors wroteBased on interview and record review the facility failed to protect resident's right to be free from physical abuse for 3 of 4 sample residents (Residents 1, 3, and 4) reviewed for resident-to-resident altercations. This failure placed residents at risk for abuse, psychosocial harm, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure sufficient nursing staff and functional call light systems were in place across multiple units and shifts to meet residents' basic care needs, including timely response to call lights and assistance with activities of daily living. This deficient practice was systemic in nature, resulting in delayed responses, unmet care needs, and inadequate supervision for residents, and placed residents at risk for an unsafe environment, avoidable discomfort, incontinence, skin breakdown, delayed medication administration, and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to conduct performance evaluations for 5 of 5 Certified Nursing Assistants (CNA) (Staff D, F, GG, EE, and PP) in the last 12 months. These failures placed the residents at risk of receiving less than optimal care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure foods were palatable, prepared, and served in a manner acceptable to residents across the facility, as evidenced by widespread and ongoing resident complaints regarding food quality, taste, temperature, portion size, and accuracy of meal trays. This deficient practice affected multiple residents over an extended period of time, resulting in residents refusing meals, requesting frequent substitutions, and reporting unmet nutritional needs, placing residents at risk for reduced nutritional intake, avoidable weight loss, delayed medical improvement, and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to maintain a full-time qualified social worker. This failure placed residents at risk of lacking medically related social services and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and appropriate medication practices by leaving medications unattended at the bedside for residents who were not assessed or approved to self-administer medications for 3 of 3 sampled residents (Residents 40, 15, and 114) reviewed for accident hazards. This practice was inconsistent with the residents' interdisciplinary team (IDT) assessment and care plan and placed the residents at risk for adverse medication outcomes.

Inspectors wroteBased on record review and interview, the facility failed to provide written bed hold notice at the time of transfer to the hospital for 4 of 4 sampled residents (Residents 1, 40, 7 and 8) when reviewed for hospitalization and failed to provide written notice of transfer/discharge and recapitulation of their stay for 2 of 4 sampled residents (Residents 40 and 111) when reviewed for discharge. These failures placed the residents at risk for lacking knowledge regarding their right to hold their bed while in the hospital and diminished quality of life. Resident 1 Review of the electronic health record (EHR) showed Resident 1 admitted to the facility on [DATE] with diagnoses of diabetes (when the body doesn't process sugars) and respiratory failure. The resident was able to make needs known. Review of the progress notes showed Resident 1 was transferred to the hospital on [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the minimum data set assessment (MDS) accurately reflected the status for 3 of 27 sampled residents (Residents 10, 8 and 40) reviewed for accuracy of assessments. This failure placed the residents at risk for unmet care and a diminished quality of life. Resident 10 Review of the electronic health record (EHR) showed Resident 10 admitted to the facility on [DATE] with diagnoses to include schizoaffective disorder (mental health condition with mood disorder symptoms), depression (mood disorder), and anxiety (emotion associated with worry, fear or panic). Resident 10 was able to make needs known. During an interview on 01/05/2026 at 11:36 AM, Resident 10 stated they were unable to hear anything in their left ear. [...]

Inspectors wroteBased on interview and record review the facility failed ensure care plans were reviewed and revised for 5 of 22 residents (Residents 12, 8, 2, 37 and 51) reviewed for care plan review. This failure placed the residents at risk for injuries, unmet needs, care not provided as ordered and a diminished quality of life. Resident 12 Resident 12 admitted to the facility on [DATE] with diagnoses to include diabetes (high blood glucose), high blood pressure and muscle weakness. Resident 12 was able to make needs known. Observation and interview on 01/05/2026 at 10:57 AM, showed Resident 12 with a wander guard device on their left wrist. Resident 12 stated they did not know what the device was for. Observations on 01/06/2026 at 4:08 PM, 01/08/2026 at 11:46 AM, 01/09/2026 at 8:28 AM and 2:30 PM and 01/12/2026 at 3:13 PM showed Resident 12 asleep in bed with the wander guard in place. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide the necessary care and services to maintain personal hygiene for 3 of 5 residents (Residents 117, 99 and 17) when reviewed for activities of daily living. This failure placed the residents at risk for unmet needs, decreased sense of self-worth and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide respiratory care consistent with professional standards of practice for 3 of 3 sampled residents (Residents 40, 42 and 51) when reviewed for respiratory care. Failure to obtain and/or follow physician orders for oxygen (O2) therapy, ensure O2 saturation (Sats, the percentage of red blood cells carrying O2 in the blood) was ordered with parameters, care plan, and ensure O2 concentrators (a device used for O2 therapy) filters (used to protect the resident from particulate matter) were cleaned and maintained routinely, placed residents at risk for unmet needs and potential negative outcomes.

Inspectors wroteBased on interview and record review, the facility failed to ensure medications were administered only when necessary and in accordance with provider orders for 4 of 7 sampled residents (Residents 4, 115, 2, and 99) when reviewed for unnecessary medications/pain management. Failure to ensure non-medicated methods of pain relief were used before pain medications and ensuring blood pressure medications were provided per parameters placed residents at risk of using unnecessary medications, avoidable side effects, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident refrigerators were maintained to ensure food was safely stored for 2 of 2 sampled refrigerators (100 and 200 Hall Refrigerators) when reviewed for kitchen. This failure placed residents at risk of foodborne illness, avoidable discomfort, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an infection prevention and control program to prevent the transmission of communicable diseases and infections by completing the analyzation of infection control data, identifying trends, and completing follow-up activities in response to those trends for 3 of 3 months (October, November and December 2025) when reviewed for Infection Control. The facility also failed to implement transmission-based precautions (TBP) for 2 of 4 halls when reviewed for TBP. These failures placed residents and staff at risk for communicable diseases and infections, poor clinical outcomes, and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to administer pneumococcal vaccines for 3 of 7 residents who consented to the vaccine (Residents 5,19 and 35) and failed to provide education on the risks and benefits of vaccines for 3 of 7 residents (Residents 42, 63 and 65) when reviewed for immunizations. These failures placed the residents at risk for communicable diseases and denied the residents the opportunity to make an informed decision regarding receiving immunizations.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was provided risks/benefits and provided consent prior to being administered psychotropic (mind altering) medications for 1 of 5 sampled residents (Resident 114) when reviewed for unnecessary medications. This failure placed the resident at risk of unknown side effects, inability to advocate in their medication regimen, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to reasonably accommodate a resident's expressed preference for grooming services by not assisting the resident with accessing a haircut after onsite salon services were discontinued for 1 of 22 sampled residents (Resident 4) when reviewed for resident rights. This failure placed the resident at risk for lack of dignity and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure that Skilled Nursing Facility (SNF) Advanced Beneficiary Notices (ABN, a notification that provides an estimated cost of continuing services which may no longer be covered by Medicare. Beneficiaries may choose to continue the services but may be financially liable), was provided timely and/or completed as required for 2 of 3 sampled residents (Residents 93 and 23) when reviewed for Beneficiary Notification. This failure placed residents at risk of not upholding their right to make informed choices about further treatment or services as required by the Medicare Program.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a homelike environment to include a mattress for a bed frame for 1 of 22 sampled Residents (Resident 8) reviewed for homelike environment. This failure placed the Resident at risk for decreased mood and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete a follow up assessment for a Wander Guard (device that alarms and restricts movement in and out of doors) for 1 of 3 sampled residents (Resident 13) when reviewed for physical restraints. This failure placed the Resident at risk for unmet needs, decline in mood, and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure psychotropic medications (medications affecting the mind) were prescribed to treat a specific condition for 2 of 5 sampled residents (Residents 13 and 115) when reviewed for unnecessary medications. This failure placed residents at risk for avoidable side effects, chemical restraint, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to implement their written abuse policies by failing to identify potential mental abuse for 1 of 3 sampled residents (Resident 46) when reviewed for abuse. Additionally, the facility failed to conduct and/or obtain reference checks/information from previous or current employers prior to hire for 5 out of 5 sampled staff (Staff D, Staff JJ, Staff C, Staff HH, and Staff H) and to complete timely criminal background checks for 2 out of 5 sampled staff (Staff D and C) when reviewed for abuse and neglect prevention. These failures placed the residents at risk for abuse, mental suffering, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to identify and report an allegation of abuse for 1 of 3 sampled residents (Resident 46) when reviewed for abuse. This failure placed the resident at risk of further abuse, psychological distress, and diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement a comprehensive plan of care for 2 of 22 sampled residents (Residents 8 and 17) when reviewed for care plans. These failures placed the residents at risk for unmet care needs and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a device to prevent pressure ulcers was applied per provider's order for 1 of 3 residents (Resident 114) when reviewed for pressure ulcers. This failure placed residents at risk for avoidable skin injury, pain, decrease in activities of daily living, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide quality of care related to monitoring of resident weights, bowel management/treatments, or edema management/treatment for 4 of 22 sampled resdients (Residents 5, 2, 13, and 99) when reviewed for quality of care. This failure placed residents at risk of unintended weight loss, untreated constipation, discomfort, unmitigated swelling, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to thoroughly investigate the root cause of a fall, ensure new interventions were appropriately developed or timely initiated and analyzed in an effort to prevent future falls, failed to maintain safe food storage in a resident's personal refrigerator, and/or left unsecured chemicals in a resident's bathroom for 2 of 5 sampled residents (Residents 114 and 40) when reviewed for accidents. These failures placed residents at risk of injuries, foodborne illness, negative outcomes, and a diminished quality of life.

Inspectors wroteBased on interview, and record review, the facility failed to ensure residents with significant weight loss were identified, assessed and that interventions were implemented for 1 of 5 sampled residents (Resident 5) when reviewed for nutrition. This failure placed the resident at risk of malnourishment, poor healing, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure enteral nutrition (the delivery of nutrients through a feeding tube directly into stomach or small intestines) was administered in accordance with provider's orders and professional standards of practice for 1 of 2 sampled residents (Resident 8) when reviewed for enteral nutrition. The facility failed to have a system in place which ensured the amount of formula (liquid food product) and water a resident receives was reconciled with the amount they were ordered to receive. This failure placed the Resident at risk for inadequate nutrition, dehydration, and diminished quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to provide pain management that is consistent with professional standards for 2 of 3 residents (Residents 99 and 17) when reviewed for pain management. Failure to administer pain medications per providers ordered parameters placed the residents at risk for uncontrolled pain and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate of less than five percent. A total of two errors were made in twenty-seven opportunities equaling a 7.4% medication error rate during medication administration for 2 of 3 sampled residents (Residents 7 and 52) when reviewed for medication administration. This failure placed the residents at risk of receiving medications that were not effective or less effective and a diminished quality of life. Finings included. Observation on 01/09/2026 at 8:14 AM, showed Staff Y, Licensed Practical Nurse (LPN), administering medications to include vitamin C 500mg to Resident 7. Review of the January 2026 medication administration record (MAR) showed Resident 7 did not have an order for Vitamin C 500mg and had received the wrong medication. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to secure (lock) 1 of 4 treatment Carts (Cart South 2) and 1 of 6 medication Carts (Cart South 3) when reviewed for medication storage. This failure placed residents at risk for medication diversion and misuse, lack of safety, poisoning, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide COVID-19 immunizations for 2 of 7 residents (Residents 26 and 19) reviewed for COVID-19 immunization. This failure placed the residents at an increased risk for complications related to COVID-19 infection that could result in severe illness or death.

Inspectors wroteBased on interview and record review, the facility failed to provide necessary care and monitoring of a Foley catheter (a medical device inserted into the bladder) to prevent the occurrence of an avoidable pressure injury (PI - localized damage to skin and/or underlying soft tissue related to an inserted medical device) for 1 of 3 residents (Resident 1) reviewed for quality of care. Resident 1 experienced harm when they developed an avoidable PI to the skin around the urinary catheter insertion site, with unrelieved pain evidenced by anxiousness, rolling in bed, restlessness, verbalizing pain and discomfort that required transfer to the hospital for evaluation, treatment, and pain management. This failure placed residents at risk of infection, injury and a decreased quality of life. Findings Included. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that 1 of 6 residents (Resident 1) was free from a significant medication error that resulted in opioid overdose and hospitalization in an intensive care unit, requiring administration of Narcan (a life-saving opioid-reversing medication). In addition, the facility failed to ensure correct medication administration documentation for 6 of 6 residents (Residents 1, 2, 3, 4, 5, and 6) reviewed for medication errors. On 08/14/2025 at 2:37 PM, the facility was notified of an Immediate Jeopardy at Code of Federal Regulations (CFR) 483.45(f)(2), F760, Free of any significant medication errors, related to the facility's failure to ensure that a resident (Resident 1) was not subject to significant medication errors. [...]

Inspectors wroteBased on interview and record review, the facility failed to accurately assess, identify, monitor, and adequately supervise residents at risk of elopement for 1 of 3 sample resident (Resident 1) reviewed for accident hazards. Resident 1, who had a cognitive impairment and lacked safety awareness, experienced harm when they exited the facility unsupervised, was subsequently observed by a bystander to fall on a freeway ramp, hit their head, and was transported by Emergency Services (EMS) personnel to a hospital for evaluation. This failure placed residents at risk for potential injury, negative outcome, and decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to have psychotropic medication (medications that affect a person's mental state) consents completed, signed, and in place prior to residents receiving these medications for 3 of 5 sampled residents (Residents 92, 87, and 2) reviewed for unnecessary medication use. This failure placed the resident or their legal representatives at risk for lack of knowledge to make an informed decision regarding the use of the medication, adverse side effects, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain provider's order, assessment and consent for the use of low bed for 3 of 3 sampled residents (Residents 86, 74 and 89) reviewed for use of physical restraints. This failure placed the residents at risk for injury, unmet needs and a diminished quality of life.

Inspectors wroteResident 77 Review of the EHR showed Resident 77 admitted to the facility on [DATE] and was able to make needs known. The quarterly MDS, dated [DATE], showed Resident 77 had diagnoses that included dementia (a group of thinking and social symptoms that interferes with daily functioning), depression, and osteoarthritis (a condition that causes pain, stiffness, and reduced movement in the joints). During an interview on 01/22/2025 at 11:50 AM, Resident 77 stated about five months ago a man creeped into their room, the man had a mental problem, and staff were aware. During a follow-up interview on 01/23/2024 at 10:04 AM, Resident 77 stated about six months ago they heard the door to their room shaking, a white man with white hair kicked the door open, they told the man to get out, and they told staff about it. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an ordered intervention (Low Air Loss Mattress - LALM, a mattress used to redistribute pressure evenly and can help prevent pressure ulcers, also known as bedsores) was being monitored and used as directed in the prevention of pressure ulcers for 3 of 7 residents (Residents 73, 83, and 18) when reviewed for pressure wound related interventions. This failure prevented the facility implementing the plan of care that included the needed intervention (LALM) to promote wound healing and prevent decline.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure there was a registered nurse (RN) working a minimum of eight hours each day for 60 of 92 days when reviewed for staffing. This failure placed the residents at risk for delayed assessments/treatments and a diminished quality of care.

Inspectors wroteResident 48 Review of the quarterly minimum data set assessment (MDS), dated [DATE], showed Resident 48 readmitted on [DATE] with multiple diagnoses to include heart and lung disease, fibromyalgia (a chronic condition characterized by widespread musculoskeletal pain and fatigue), quadriplegia (paralysis or loss of ability to move all four limbs), radiculopathy (a condition whereas one or more nerve roots in the spinal column becomes compressed and irritated), anxiety and depression. The electronic health record (EHR) showed Resident 48 was able to make needs known and was dependent on staff for all activities of daily living. Review of Resident 48's current care plan, multiple dates, showed the resident exhibited or was at risk for alterations in comfort related to chronic pain and musculoskeletal disorder. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that the Quality Assessment and Performance Improvement (QAPI) program self-identified deficiencies and failed to develop/implement effective plans of action to sustain plan of corrections for previous deficiencies. Failure to have an effectively functioning QAPI program that consistently self-identified deficient practices led to repeated deficiencies, and a pattern of deficiencies that placed residents at repeated risk for unmet needs that could negatively impact their safety, quality of life and quality of care.

Inspectors wroteBased on interview and record review, the facility failed to periodically review a resident's advanced directive (AD, a legal document that states your wishes for medical care if you are unable to make decisions for yourself) and obtain and maintain court-appointed guardianship (legal process where a court appoints someone to make decisions for a person who is unable to do so for themselves) documentation for 1 of 2 sampled residents (Resident 77) when reviewed for advanced directive. This failure placed the resident at risk of not having an established decision maker, lack of ability to direct care, and a diminished quality of life.

Inspectors wroteBased on observations and interview, the facility failed to provide a safe, sanitary, and homelike environment for 1 of 4 sampled residents (Resident 62) reviewed for environment. Failure to ensure a wheelchair was in good repair placed the resident at risk for infections, injuries, and diminished quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident was free from neglect when it prevented transfer out of a power wheelchair for three nights, prevented wound care during that time and caused distress related to transfer assistance from staff for 1 of 7 sampled residents (Resident 78) reviewed for abuse/neglect. This failure placed facility residents at risk of not receiving required care and services and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide written notification of the reason for hospital transfer to the resident or responsible party and/or Washington State Long-Term Care Ombudsman program (Ombuds) for 2 of 4 sampled residents (Resident 81 & 13) reviewed for hospitalization. This failure placed the resident at risk for not knowing rights regarding transfer and discharge from the facility, and diminished protection from been inappropriately discharged .

Inspectors wroteBased on interview and record review, the facility failed to provide written bed hold notice at the time of transfer to the hospital for 2 of 4 sampled residents (Residents 81 and 13) reviewed for hospitalization. This failure placed the residents at risk for lacking knowledge regarding their right to hold their bed while in the hospital and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to accurately assess the status for 1 of 5 sampled residents (Resident 41) reviewed for Pre-admission Screening and Resident Review (PASARR, a mental health screening tool). This failure had the potential to place the resident at risk for not receiving the care and services required to meet their needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure Pre-admission Screening and Resident Review (PASARR, a mental health screening tool) assessments were accurately or timely completed for 2 of 7 sampled residents (Residents 92 & 360) reviewed for PASARRs and unnecessary medications. This failure placed the residents at risk for unidentified mental health care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement comprehensive person-centered care plans for 2 of 24 sampled residents (Residents 39 & 84) whose care plans were reviewed. Failure to develop and implement care plans that were individualized, and accurately reflected resident care needs related to impaired vision and smoking status placed residents at risk of unmet care needs and potential negative outcomes.

Inspectors wroteBased on interview and record review, the facility failed conduct timely care planning meetings with residents or responsible party for 2 of 4 sampled residents (Residents 48 & 77) reviewed for care planning. These failures placed residents at risk for unmet needs, care not provided as directed, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet professional standards of practice for diagnosing residents with mental health disorders 1 of 5 sampled residents (Resident 2) reviewed for use of unnecessary medications. This failure placed the resident at risk for unmet needs, complications, and diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a mobility device was available for 1 of 5 sampled residents (Resident 4) when reviewed for mobility. The facility failed to implement a bowel program for 2 of 5 sampled residents (Residents 24 and 108) reviewed for bowel management. These failures placed the residents at risk for unmet needs, worsening condition, and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure risk factors were consistently monitored and addressed to minimize the risk for accident hazards for 2 of 7 residents (Residents 94 and 86) when reviewed for accident hazards. The failures to consistently monitor and ensure a wanderguard devices was functional for Resident 94 and to identify and minimize the risk factors for falls for Resident 86 placed them at risk for potential injury, negative outcomes and decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure the facility's Registered Dietician's (RD) recommendations were administered as ordered to prevent continued weight loss for 1 of 3 sample residents (Resident 73) reviewed for nutrition. This failure placed the residents at risk for unmet nutritional needs and continued weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide respiratory care consistent with provider orders for 1 of 2 sampled residents (Resident 59) reviewed for respiratory care. Failure to follow provider's orders for oxygen (O2) therapy placed residents at risk for unmet needs and potential negative outcomes.

Inspectors wroteBased on interview and record review, the facility failed to provide pain medication per provider's order to ensure a resident was able to participate in physical therapy services for 1 of 5 sampled residents (Resident 24) reviewed for position and mobility. This failure placed residents at risk of decreased mobility, increased pain, unidentified and unmet care needs, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to act on the consultant pharmacist's medication regimen review (MRR) recommendations and/or to have clearly documented rationale for not following the recommendation for 1 of 5 sampled residents (Resident 92) reviewed for unnecessary medication use. This failure placed the resident at risk for experiencing adverse side effects, medical complications, and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to conduct gradual dose reduction (GDR, a trial attempt to discontinue a medication) were free from excessive dosages and durations without adequate monitoring and indications for use, or in the presence of adverse consequences, related to the use of psychoactive (affecting the mind) medications for 1 of 5 sampled residents (Resident 94) and failed to monitor for psychoactive medication side effects for 2 of 5 sampled residents (Residents 87 and 92) when reviewed for unnecessary medication use. The facility's failure to monitor behaviors and side effects and conduct GDR related to use of psychoactive medications placed the residents at risk for adverse side effects, medical complications, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure medications were properly labeled and stored prior to medication administration, in accordance with accepted professional standards, in 1 of 4 medication carts reviewed. This failure placed residents at risk of medication errors and potential adverse events.

Inspectors wroteBased on interview and record review, the facility failed to ensure dressing changes were completed as ordered by the provider for 1 of 3 sample residents (Resident 1) reviewed for quality of care. This failure placed residents at risk of unmet needs, decline in status, and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure consents were obtained for 2 of 5 residents (Residents 1 and 2) reviewed for consents for Wanderguard (a device worn on or close to the resident's body designed to alarm when the resident came within close proximity to an alarmed exit door), and failed to ensure physician orders and consents were obtained for 2 of 5 sampled residents (Residents 3 and 4) reviewed for physical restraints. This failure placed residents at risk for injury, unmet needs, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide eight consecutive hours of direct care supervision by a Registered Nurse (RN) for 9 of 29 days reviewed and failed to meet the State RN staffing requirement of 24-Hour RN coverage for 29 of 29 days reviewed for RN staffing. This failure placed residents at risk for delay in resident assessments, identification of changes in condition, provision of care and services outside the scope of practice of the Licensed Practical Nurse (LPN), and unmet care needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two of four residents (Resident 68 and 85) reviewed for range of motion/mobility, consistently received restorative services (movement of joints to maintain range of motion) to maintain or prevent declines in mobility. This failure resulted in harm to Resident 68 who experienced a decrease in left hip extension and worsening of the left knee contracture (a permanent shortening of muscle and loss of joint mobility). This failure placed residents at risk of decreased motion, mobility and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure sufficient qualified nursing staff were available to provide care and services for all facility residents. The facility had insufficient staff to ensure residents received assistance with Restorative services, Activities of Daily Living (ADL), and call light response in accordance with established clinical standards, care plans, and preferences. These failures placed residents at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection prevention and control program to control and prevent the transmission of a communicable disease by ensuring the proper application of transmission-based precautions (TBP) for 2 of 2 hallways (North and South) and to ensure the proper use and fit of personal protective equipment (PPE) by staff during an outbreak of a respiratory virus. The facility also failed to provide laundry services in a safe and sanitary manner. These failures placed residents, visitors, and staff at risk for a communicable disease, infections, and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to conduct timely care planning meetings with the resident or responsible party for 2 of 24 residents (Residents 38 and 49) reviewed for care planning. This failure placed the residents at risk for unmet needs, not being involved or informed of their plan of care and decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide the services to assist residents with activities of daily living (ADL) for 5 of 24 residents (Residents 88, 4, 12, 26, and 48) reviewed for activities of daily living. Failure to provide showers as scheduled (Residents 88, 4, 12, and 26) and assistance to get out of bed (Resident 48) placed the resident at risk for medical complications, unmet needs, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care which met professional standards for 5 of 24 residents (Residents 14, 38, 71, 59, and 48) when reviewed for quality of care. The facility's failure to consistently monitor and document bowel movements and implement the bowel program when needed (Residents 14, 38, 71, and 59), failure to monitor for adverse side effects (Resident 38), failure to identify and monitor a skin condition (Resident 48) placed the residents at risk for worsening condition, discomfort, and a decreased quality of life. Bowel Program Resident 14 Review of the annual minimum data set (MDS), a required assessment tool, dated 10/08/2023, showed resident was able to make needs known and was diagnosed with chronic pain and constipation. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure freedom from unnecessary medications for 5 of 9 residents (Residents 71, 26, 2, 59, and 38) reviewed for unnecessary medications. Failure to provide nonpharmacological interventions prior to as needed pain medications (Residents 38, 26, 2, and 59) and to monitor for anticoagulation (blood thinning) side effects (Resident 71) placed the residents at risk for unintended side-effects related to the medications, medical complications, and a diminished quality of life. Findings Included . <Anticoagulation> Review of a document titled Anticoagulation - Clinical Protocol revised November 2018 showed, The staff and physician will monitor for possible complications in individuals who are being anticoagulated and will manage related problems. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate monitoring and assessment of medications for mental health for 4 of 5 residents (Residents 81, 5, 12 and 26) when reviewed for unnecessary medications. Lack of meetings to discuss medications (Residents 81 and 5), lack of blood pressure monitoring (Resident 12) and prolonged use of as needed medications (Resident 26) placed residents at risk of receiving unnecessary medications, avoidable side effects, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a safe and sanitary food storage program in 1 of 1 facility kitchen reviewed for food safety. This failure placed residents at risk of foodborne illness and a diminished quality of life.

Inspectors wroteBased on interview, the facility failed to maintain a qualified social worker on a fulltime basis. This placed residents at risk of a lack of medically related social services and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to obtain an informed consent prior to psychotropic (affecting the brain) medication usage for 1 of 5 residents (Resident 12) reviewed for unnecessary medications. This failure had the potential for the resident or their legal representatives to have lack of knowledge to make an informed decision regarding use of these medications.

Inspectors wroteBased on interview and record review, the facility failed to address grievances/concerns raised by the Resident Council group for 3 of 3 months (October 2023, November 2023, and January 2024) when reviewed for Resident Council. Failure for administrative staff to act upon grievances voiced by the Resident Council and failure to report back to the council in writing for a response, rationale and action taken on grievances placed residents at risk for continued concerns, unmet needs, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to obtain or offer assistance in formulating or periodically checking if residents had an advance directive (AD) for 2 of 24 residents (Residents 22 and 65) reviewed for AD. This failure placed the residents at risk to be denied the opportunity to direct their health care if they were to become unable to make decisions or communicate their health care preferences.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide clean sheets and/or reasonable care for personal property for 5 of 5 residents (Residents 12, 13, 35, 68 and 86) when reviewed for safe, clean, and comfortable environment. This failure placed the residents at risk for loss of personal property, a diminished sense of security, possible infections, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to complete a thorough investigation on an allegation neglect for 1 of 5 residents (Resident 68) reviewed for accidents and/or incidents. This failure placed residents at risk for unidentified neglect and continued exposure to neglect.

Inspectors wroteBased on interview and record review, the facility failed to properly notify the Office of State Long-Term Care Ombudsman (SLTCO, an advocacy group for residents in a nursing home) or the resident/resident representative of discharges for 2 of 5 residents (Residents 159 and 22) reviewed for hospitalization. These failures placed residents at risk for being inappropriately discharged , lack of access to an advocate who can inform them of their options and rights, and to ensure that the SLTCO and residnt/ resident representative was aware of facility practices and activities related to transfers and discharges.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) accurately reflected the current status for 2 of 5 residents (Residents 80 and 88) reviewed for PASRRs. This failure had the potential to place residents at risk for inappropriate placement and/or not receiving timely and necessary services to meet mental health care needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to thoroughly investigate a resident fall and plan new interventions to decrease the chance of a fall or reduce injury from a fall for 1 of 1 resident (Resident 81) reviewed for accidents. This failure placed residents at risk for repeated falls, avoidable injury, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide dialysis (a process to remove waste from blood) care consistent with professional standards for one of one resident (Resident 40) reviewed for dialysis. This failure placed the resident at risk for adverse health outcomes, inadequate quality of care and decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure expired medications were removed/disposed of in accordance with professional standards for 1 of 3 medication carts (North Hall medication cart #3) reviewed for Medication Storage. This failure placed residents at risk of receiving expired medications.

Inspectors wroteBased on interview and record review, the facility failed to provide routine dental care for 1 of 3 residents (Resident 19) reviewed for dental. This failure placed residents at risk for difficulty eating, dental pain, unintended weight loss, and a diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to provide assistance and follow up on an appointment for dental care services for 1 of 3 resident (Residents 49) reviewed for dental services. This failure placed the residents at potential risk for continued dental problems and decreased the quality of life.

Inspectors wroteBased on interview and record review, the facility failed to timely refer a resident to hospice services for 1 of 2 residents (Resident 160) reviewed for hospice. This failure placed the resident at risk of not receiving palliative services, unnecessary pain and suffering, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide influenza and pneumococcal vaccines for 2 of 5 residents (Residents 93 and 98) when reviewed for vaccinations. This failure placed the residents at a higher risk for contracting influenza and pneumococcal infections, related complications, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to address safety risk factors and provide the necessary supervision to ensure safety from avoidable accident and injuries for 1 of 3 residents (Resident 1) reviewed for accidents and supervision. This failure resulted in harm when Resident 1 was hit by a moving vehicle while in their wheelchair unsupervised out in the parking lot of the facility. Resident 1 required emergency medical services to transfer to the hospital, sustained a fracture to the left ankle, and experienced severe pain and discomfort.

Inspectors wroteBased on interview and record review, the facility failed to provide the bed-hold notice at the time of transfer to the hospital for 4 of 4 residents (Residents 1, 2, 3 and 4) reviewed for hospitalization. This failure placed the residents at risk for lack of knowledge regarding their right to hold their beds while admitted in the hospital.

Inspectors wroteBased on interview and record review, the facility failed to implement the discharge plan and ensure a safe and orderly discharge for 1 of 3 residents (Resident 2) reviewed for discharge planning process. This failure placed the resident at risk for unmet needs, medical complications, readmission to the hospital or skilled nursing facility and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide the necessary care and services in the management of a surgical wound for 1 of 3 residents (Resident 3) reviewed for wound management. This failure placed the resident at risk for worsening of the wound, infection, medical complications, additional surgery, rehospitalization, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to maintain 8 hours of Registered Nurse (RN) coverage to directly supervise resident care, 24 hours a day, seven days a week for 65 of 91 days (from April 2023 through June 2023) reviewed for RN coverage. This failure placed all residents at risk to not have immediate access to assessments, care and services provided by an RN, a delay in care and treatment, unmet care needs and medical complications.

Inspectors wroteBased on interview and record review, the facility failed to ensure the direct care data for registered nurse (RN) hours were accurately entered into the Payroll Based Journal (PBJ, a system for tracking staffing in nursing homes) for 1 of 1 quarter (Fiscal Year (FY) 2023 3rd quarter, April 2023 through June 2023) reviewed for PBJ reporting. This failure caused the Centers for Medicare and Medicaid Services (CMS) to have inaccurate data related to nursing home staffing levels which had the potential to impact care and services provided to all the residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to properly implement the compliance and ethics program, prevent the submission of data know to be inaccurate and unethical practices for 1of 1 quarter (Fiscal Year Quarter 3, April 2023 through June 2023) reviewed for Payroll Based Journal (PBJ, a system for tracking staffing in nursing homes) reporting. This failure had the potential to negatively impact the nursing staffing levels and the care and services being provided to all the residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive care plan that addressed the use of an indwelling urinary catheter for 1 of 3 residents (Resident 1) reviewed for indwelling catheter care. This failure placed the resident at risk for unmet care needs, medical complications, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide a completed discharge summary that included discharge instructions regarding indwelling urinary catheter (a catheter inserted and kept in the bladder to drain urine) care and follow-up referrals for 1 of 3 residents (Resident 1) reviewed for discharge planning. This failure placed the resident at risk for complications by not receiving the necessary information to ensure continuity of care when discharged to the community.