Longview Hill Nursing and Rehabilitation Center

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure residents received mail delivered to the facility for 3 of 3 confidential residents reviewed for right to communication. The facility failed to ensure residents received their mail unopened and on Saturdays. This failure could place residents at risk of potentially being denied their rights and receiving and opening mail in a timely manner and a diminished quality of life.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure residents with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 3 of 12 residents with limited range of motion (Resident #64, Resident #103 and Resident #53).1. The facility failed to ensure Resident #53 had hand roll on right hand and palm guard splint on left hand for up to 8 hours during the day on 03/16/26, 03/17/26 and 3/18/26.2. Resident #64 had limited range of motion to upper right extremity with no services to prevent further decrease in range of motion.3. The facility failed to ensure Resident #103 had a contracture prevention device in place for the treatment of his left-hand contracture on 03/16/26 and 03/17/26. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure an accurate MDS was completed for 1 of 5 residents (Resident #49) reviewed for PASRR services. The facility did not ensure Resident #49's significant change MDS assessment was accurately coded to reflect his level II PASRR status for intellectual and developmental disabilities. This failure could place residents at risk of not receiving care and services to meet their needs.

Inspectors wroteBased on interviews and records reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 (Resident #20 and Resident #111) of 18 residents reviewed for care plans. 1. The facility failed to ensure Resident #20 had a comprehensive care plan for limited range of motion to her lower extremity.2. The facility failed to ensure Resident # 111 had a comprehensive care plan for limited range of motion to her lower extremity. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an ongoing program of activities based on the comprehensive assessment to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for 1 of 6 residents reviewed for activities. (Resident #108)The facility failed to provide Resident #108 with consistent, scheduled, one-on-one activities. This failure could place residents at risk of not having activities to meet their interests or needs and a decline in their physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 2 of 5 residents (Resident #4 and Resident #14) reviewed for skin integrity. The facility failed to ensure Resident #4 and Resident 14's pressure- redistribution mattress (is designed to distribute the patient's body weight over a broad surface area and help prevent skin breakdown) was on the correct settings. This failure could place residents at risk for developing pressure ulcers and could contribute to developing avoidable pressure ulcers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were offered sufficient fluid intake to maintain proper hydration and health for 1 of 1 resident (Resident #108) reviewed for fluid intake. The facility failed to ensure Resident #108's water pitcher was in reach on 3/16/2026 and 3/17/2026. This failure could place residents at risk of dehydration.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide pharmaceutical services to include procedures that assured the accurate dispensing and administering of all drugs to meet the needs of 1 of 1 residents (Resident #95.)The facility medication aide failed to ensure that Resident #95 took his medication before leaving the room. This deficient practice could affect residents and place them at risk of not receiving the therapeutic dosage and drug diversion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary storage of residents' food items for 1 of 12 resident personal refrigerators reviewed for food safety (Resident #11). The facility failed to ensure the refrigerator and dry storage foods for Resident #11 was inspected for expired food and expired food disposed of. This failure could place residents at risk for food borne illnesses.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain all essential equipment in a safe operating condition, for 1 of 4 refrigerators in a medication room reviewed for food service in that: The facility failed to ensure the refrigerator in medication room on hall 4 was cleaned, defrosted and food stored at an appropriate temperature on 3/17/26. This failure could place residents at risk for food borne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure treatment was provided, consistent with professional standards of practice, to prevent new pressure injuries from developing for 2 of 4 residents reviewed for pressure injuries (ulcers). (Resident #1, Resident #2)1. The facility failed to complete weekly skin assessments for Resident #1 since 01/27/26. 2. The facility failed to complete quarterly Braden Scale Assessments on Resident #1 and Resident #2. There were no quarterly Braden Scale Assessments for Resident #1 since 06/04/25 and for Resident #2 since 02/08/24. These failures could place residents at risk for developing avoidable pressure injuries and the worsening of existing pressure injuries.1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident or the resident's representative had the right to access all records pertaining to the resident, including current clinical records, within 24 hours (excluding weekends and holidays) upon oral or written request, and to obtain copies of such records within two working days upon request for 1 of 4 residents (Resident #1) reviewed for resident rights. The facility did not provide Resident #1's MPOA access to Resident #1's urinalysis (UA) lab results in December 2025 when she verbally requested access. This failure could place residents at risk for delayed medical decision-making, lack of informed consent, and potential harm due to the representative's inability to timely review laboratory results and participate in care planning.

Inspectors wroteBased on interview and record review the facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment were thoroughly investigated for 1 of 2 residents (Resident #1) reviewed for abuse. The facility failed to thoroughly investigate an allegation of abuse reported to the Administrator regarding Resident #1 on 08/25/25. The Administrator did not interview Resident #1, her representative, or the caregiver that verbalized the allegation of abuse. These failures could place residents at risk for abuse, neglect, exploitation, mistreatment, and injuries of unknown source.

Inspectors wroteBased on interview and record review the facility failed to ensure residents were free of any significant medication errors for 1 of 7 residents reviewed for medications. (Resident #1) The facility failed to ensure: 1. Resident #1 was administered his regular evening medication as ordered along with Resident #2's evening medication on the evening of 5/5/2025. [...]

Inspectors wroteBased on record review and interview the facility failed to consult with the physician when there was a significant change in residents' physical status that was life threatening for 2 of 7 residents (Resident #1 and Resident #2) reviewed for change in condition. The facility failed notify Resident #1's physician on 2/5/25 when his PICC continued to be dislodged and he was unable to receive his IV antibiotics. Resident #1 did not receive his IV antibiotic medication from 2/6/25 through 2/7/25 (a total of 6 doses). The facility failed to notify Resident #1's physician of his x-ray results that were ordered on 2/7/25 with results that indicated they were sent back to the facility on 2/7/25. Res #1's MD was notified on 2/10/25 that Res #1's x-ray indicated he had pneumonia, and he was transferred to the hospital. [...]

Inspectors wroteBased on record review and interview the facility failed to provide care and treatment in accordance with professional standards of practice based on the comprehensive assessment for 2 of 7 residents (Resident #1 and Resident #2) reviewed for quality of care. The facility failed to ensure Resident #1 received IV antibiotics when his PICC line was dislodged on 2/5/25. Resident #1 did not receive his IV antibiotic medication from 2/6/25 through 2/7/25 (a total of 6 doses). The facility failed to address Resident #1's chest x-ray that was ordered and sent back to the facility on 2/7/25 until 2/10/25. The facility notified Resident #1's MD on 02/10/25 that Resident #1's x-ray indicated he had pneumonia, and he was transferred to the hospital. Resident #1 was admitted to the hospital on [DATE] with diagnoses of right lobe pneumonia due to ESBL(extended spectrum beta lactamase). [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide pharmaceutical services including procedures that assure the accurate dispensing and administering of all drugs to meet the needs of residents for 5 of 6 residents reviewed for medication administration. (Resident #3, Resident #4, Resident #5, Resident#6, and Resident #7.) Resident #3 had insulin that was past the 28-day labeled precautionary instructions. LVN E was going to administer the mediations. After she noted the insulin was past the 28- days, she had difficulty finding the correct medications. Residents # 4 # 5, and #7 had insulin in the medication cart that was past the 28-day labeled precautionary instructions. Resident #6's insulin had a space on the box for an opened date but there was not a date listed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. The facility failed to ensure: 1. Food items were sealed and dated. 2. Hair restraints were worn appropriately by dietary staff. These failures could place residents at risk for foodborne illness.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop, and implement a comprehensive care plan to meet the medical, nursing, mental and psychosocial needs for 4 of 34 residents (Resident #17, Resident #21, Resident #79, and Resident #110) reviewed for care plans. 1. The facility failed to care plan Resident #17's verbal and other behavioral symptoms, the diagnosis of COPD (is a chronic lung disease that makes it difficult to breathe) and use of an antiplatelet medication (work to make your platelets less sticky and thereby help prevent blood clots from forming in your arteries). 2. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary medications (a medication used in excessive doses and including duplicate therapy or for excessive duration; or without adequate monitoring, or without adequate indications for its use; or in the presence of adverse consequences which indicated the dose should be reduced or discontinued) for 3 of 6 residents reviewed for unnecessary medications. (Resident #66, Resident #71, and Resident #78) The facility failed to ensure Resident #66 did not receive an antibiotic, Cephalexin 250mg BID for an UTI, without appropriate lab work. The facility failed to ensure Resident #71's antibiotic, Macrobid 100mg BID, was discontinued after her urine culture (checks urine for germs (microorganisms) that cause infections) results showed no organism growth. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure each residents' drug regimen was free from unnecessary psychotropic drugs (without adequate behavior monitoring and diagnosis) for 3 (Resident # 17, Resident #23, and Resident #110) of 5 residents whose medications were reviewed. The facility failed to ensure Resident #17's behaviors were documented to justify her Wellbutrin (is a prescription medicine used to treat adults with a certain type of depression called major depressive disorder, and for the prevention of [NAME]-winter seasonal depression (seasonal affective disorder)) dosage increase on 11/22/24. The facility failed to ensure Resident #23 had behavior and side effect monitoring for her prescribed anticonvulsant, Depakote. The facility failed to ensure Resident #110 had side effect monitoring for her prescribed Trazadone. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food that was palatable and served at an appetizing temperature for 7 of 28 residents (Resident's #10, #13, #17, #34, # 60, # 86 and #101) reviewed for palatable food. The facility failed to provide palatable food served at an appetizing temperature or taste to Resident #10, Resident #13, Resident #34, Resident #60, Resident #86 and Resident #101, who complained the food was bland, and did not taste good. This failure could place residents who ate food from the kitchen at risk of weight loss, altered nutritional status, and diminished quality of life.

Inspectors wroteBased on observations, interviews, and record review the facility failed to treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for 2 of 2 residents (Resident #66 and Resident #17) reviewed for resident rights. 1. The facility did not ensure CNA Q and CNA R explained the procedure before initiating the transfer and incontinent care provided on 12/21/2024 to Resident #66. 2. The facility failed to provide scheduled smoke breaks for Resident #17 who resided on the memory care, secured unit. The failure could place residents at risk for diminished quality of life, loss of dignity and self-worth.

Inspectors wroteBased on observation, interviews, and record review the facility failed to ensure residents have the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives and to choose the option he or she prefers for 3 of 17 residents reviewed for the right to be informed. (Resident #68, Resident #79, and Resident #108) 1. The facility failed to ensure Resident #68's Consent for Antipsychotic (used to treat certain mental/mood disorders) or Neuroleptic (also known as Antipsychotic) Medication Treatment HHSC Form 3713 was correctly completed for Abilify (antipsychotic medication used to treat certain mental/mood disorders) as evidenced by there was no clinical indications for use, no dosage or frequency, and no side effects, risks, or benefits listed for the proposed treatment. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, and comfortable homelike environment for 1 of 4 residents (Resident # 21) reviewed for a homelike environment. The facility failed to ensure Resident #21's floors were free of debris, dust, and shreds of papers. The facility failed to ensure Resident #21's dresser was free from a white creamy substance on the top flat surface, side of dresser and front of the dresser. The facility failed to ensure Resident #21's bathroom cabinet was clean from a dried sticky red liquid . The facility failed to ensure Resident #21's personal refrigerator door was free from white splattered dried substances. These failures could place residents at risk for an uncomfortable, unhomelike environment, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the right of the residents to be free from abuse for 1 of 4 residents (Resident #66) reviewed for abuse. The facility failed to keep Resident #66 free from abuse when CNA Q and CNA R roughly provided mechanical lift transfer and incontinent care to her on 12/21/2024. This failure could place residents at risk of abuse, creased resistance to care, increased agitation, skin tears, soreness, and injury

Inspectors wroteBased on interview and record review, the facility failed to notify the resident and the resident's representative of the transfer or discharge and the reasons for the transfer or discharge in writing at least 30 days before the resident is transferred or discharged or as soon as practicable before transfer or discharge when a resident has not resided in the facility for 30 days for 1 of 1 resident (Resident #169) reviewed for transfer and discharge. The facility failed to provide Resident #169's representative with a written 30-day discharge notice with a reason of discharge. This failure could place residents at risk of improper discharge planning and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure assessments accurately reflected the resident status for 1 of 34 residents (Resident #79) reviewed for MDS assessment accuracy. The facility failed to accurately reflect Resident #79 was receiving Quetiapine Fumarate (Seroquel), an antipsychotic medication (used to treat certain mental/mood disorders). These failures could place residents at risk for not receiving care and services to meet their needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) Level I assessment accurately reflected the resident's status for 1 of 6 residents (Resident #39) reviewed for PASRR Level I screenings. Resident #39's PASRR Level 1 screening did not indicate a diagnosis of mental illness, although the diagnoses major depressive disorder were diagnosed on [DATE] . This failure could place residents who had a mental illness at risk of not receiving a needed assessment (PASRR Evaluation), individualized care, or specialized services to meet their needs.

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 receive the necessary services to maintain grooming and personal hygiene for 3 of 28 residents reviewed for ADLs. (Resident #5, Resident #46, and Resident #51) The facility did not ensure Resident #5, Resident # 46, and Resident # 51 did not have chin hair on 01/13/2025 and 01/14/2025. These failures could place residents at risk of not receiving care or services, decreased quality of life, embarrassment, and decreased self-esteem.

Inspectors wroteBased on observations, interview and record review, the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 2 residents reviewed for accidents (Resident #66). The facility failed to ensure a safe environment when CNA Q and CNA R walked away and left Resident #66 unsupervised at bedside during a mechanical lift transfer on 12/21/2024. This failure could place residents at risk of injuries, falls and hospitalizations.

Inspectors wroteBased on interviews and record review, the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrated that this was not possible or resident preferences indicated otherwise for 1 of 9 residents (Resident #23) reviewed for nutrition. The facility failed to follow the dietician's recommendation to increase Resident #23's Med Pass 120ml TID to QID ordered on 11/15/24 and 12/06/24. This failure placed resident at risk for malnutrition and weight loss.

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate administering of all drugs and biologicals, to meet the needs of 1 of 28 residents (Resident #17) reviewed for pharmacy services. The facility failed to ensure Resident #17's Wellbutrin (is a prescription medicine used to treat adults with a certain type of depression called major depressive disorder, and for the prevention of [NAME]-winter seasonal depression (seasonal affective disorder)) SR Oral Tablet Extended Release 200mg was available for administration on 10/13/24, 10/14/24 and 11/04/24. This failure could place residents at risk for inaccurate drug administration.

Inspectors wroteBased on observation, record review and interview the facility failed to store all drugs and biologicals in locked compartments for 1 of 9 med carts and 2 of 36 Residents (Resident #10, Resident # 39) reviewed for medication storage. 1. The facility failed to securely store prescription medication Nystop powder 100,000 units and Venelex 60-gram ointment for Resident #10. 2. The facility failed to keep medication being administered under the direct observation of the person administering medications. Resident #39 had a medication cup, with approximately 10 medications in pill form in it, sitting on his bedside table. 3. The facility failed to ensure CMA J secured the medication cart for Hall 200. These failures could place residents at risk for health complications and not having received the intended therapeutic benefit of their medications and adverse reaction.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items for 1 of 12 resident personal refrigerators reviewed for food safety (Resident #61). The facility failed to ensure the refrigerator for Resident #61 did not contain spoiled milk and the surfaces were clean. This failure could place resident at risk for food borne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and 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 2 of 4 residents (Resident #51 and Resident #66). 1. LVN G failed to use enhanced barrier precautions by donning a gown when performing gastrostomy tube feeding on Resident #51. 2. CNA Q and CNA R failed to change their gloves while performing incontinent care on Resident #66 and touched the resident and clean surfaces with soiled gloves . These failures could place residents at risk of exposure to communicable diseases, cross-contamination, and infections.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident's PRN orders for psychotropic drugs were limited to fourteen (14) days for 2 of 4 residents reviewed for unnecessary medications review. (Residents #1 and #2). 1. Resident #1 had a PRN order for Lorazepam, a psychotropic medication, for more than fourteen days without physician documentation re-evaluating the medication to continue it PRN or to become a scheduled medication. 2. Resident #2 had a PRN order for Lorazepam, a psychotropic medication, for more than fourteen days without physician documentation re-evaluating the medication to continue it PRN or to become a scheduled medication. This failure could place residents who receive PRN psychotropic medications at risk of receiving unnecessary psychotropic medications .

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure menus and nutritional adequacy met the nutritional needs of residents in accordance with established national guidelines for 2 of 2 observed meals reviewed for meal accuracy. The facility failed to ensure there was 7 days' worth of food available from 09/01/2024 through 09/03/2024 to prepare and serve their planned and/or alternate menu on 09/01/2024 through 09/03/2024 for breakfast, lunch, and dinner. This deficient practice could place residents at increased risk for inadequate nutrition.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 1 of 3 (Resident #1) residents reviewed for quality of care. 1. The facility failed to ensure ADON D and LVN E performed a skin assessment on Resident #1, after her family member reported concerns regarding worsening of moisture associated skin damage (inflammation and erosion of the skin, results from prolonged exposure to different sources of moisture such as feces, urine, sweat and other bodily fluids) to her buttocks on 02/23/2024. 2. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to consult with the resident's physician when there was a significant change in the resident's physical and mental status that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications for 1 of 4 (Resident #1) residents reviewed for notification of change. The facility failed to notify Resident #1's NP when she had a worsening of her skin conditions. This failure could result in residents not receiving treatments, supplements, or medications to maintain health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as possible and provided supervision to prevent avoidable accidents for 1 of 4 residents (Resident #2) reviewed for quality of care. The facility failed to ensure Resident #2's call light was answered promptly by LVN A. This failure could place residents at risk of injury from accidents and hazards.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medical record was complete and accurately documented for 1 of 4 residents (Resident #1) reviewed for resident records. The facility failed to ensure LVN A accurately documented on Resident #1's February 2023 MAR. The facility failed to ensure LVN B and LVN C documented accurate skin assessments for Resident #1. These failures could place residents at risk of pressure injuries, medication errors, and not receiving medications and required treatments as ordered by the physician.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside, for 1 of 4 residents (Resident #2) reviewed for call lights. The facility failed to ensure Resident #2's call light was functioning properly. This failure could place residents at risk of injury, falls, and unmet needs.

Inspectors wroteBased on observation, interviews and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation in that: 1. Hamburger meat was thawed improperly. 2. The paper towel dispenser was empty at the handwashing station. These deficient practices could place residents who received meals from the kitchen at risk for food borne illness.

Inspectors wroteBased on interview and record review, the facility failed to ensure the right to be free from misappropriation of property was provided for 1 of 2 residents reviewed for misappropriation of property. (Resident #15) The facility failed to prevent a diversion (misappropriation) of Resident #15's Hydrocodone-Acetaminophen (Norco) 7.5-325mg tablets (a combined hydrocodone/acetaminophen narcotic pain reliever) on 11/4/23 and 11/27/23. This failure could place residents at risk for decreased quality of life, unrelieved pain, misappropriation of property, and dignity.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop, and implement a comprehensive care plan to meet the medical, nursing, mental and psychosocial needs for 4 of 24 residents reviewed for care plans. (Resident #44, Resident #89, Resident #98, and Resident #106) The facility failed to implement fall prevention intervention of fall mats at bedside for Resident #44. The facility failed to implement the care plan intervention for Resident #89 to administer wound care treatment as ordered. The facility failed to develop care plan interventions after Resident #98 had a fall. The facility failed to ensure LVN B performed Resident #106's wound care to multiple wounds as ordered by the physician per the care plan. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for 6 of 24 residents (Resident #38, #61, #7, #56, #82 and #90) reviewed for ADLs. The facility failed to provide oral care for Resident #38 and #61. The facility failed to provide scheduled showers and/or bed baths to Resident #7, Resident #56, Resident #82, and Resident #90. The facility failed to provide nail care to Resident #56 and Resident #90. The facility failed to removal facial hair from Resident #56. The facility failed to provide scheduled hair washing for Resident #82. These failures could place residents at risk of not receiving services/care and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents who needed respiratory care were provided such care, consistent with professional standards of practice for 6 of 10 residents (Resident #7, # 14, # 18, # 20, # 23, and Resident # 82) reviewed for respiratory care in that: The facility failed to ensure Resident #7 had water in his humidification canister (aids in preventing a patient's airways from becoming dry). The facility failed to ensure Resident #7 nebulizer mask (provide vaporized medicine into the airway) was stored in a bag after use. The facility failed to ensure Resident #7, Resident #23, and Resident #82's nasal cannula (is a medical device to provide supplemental oxygen therapy to people who have lower oxygen levels) were labeled and dated. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure that licensed staff were able to demonstrate the specific competencies and skill sets necessary to care for resident's needs for 2 of 4 licensed staff (LVN W, LVN N) reviewed for nursing competencies. The facility failed to ensure LVN W and LVN N followed Resident #88's physician orders to not give Novolog (is a fast-acting injectable insulin that can be prescribed for people with Type 1 or Type 2 diabetes) when blood glucose results were less than 120. This failure had the potential to affect residents by placing them at an increased and unnecessary risk of exposure to staff who lack the appropriate skills competencies to provide care that is safe and capable of minimizing accidents from procedural errors and errors in medication administration.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide separately locked, permanently affixed compartments for storage of controlled drugs for 1 of 2 medication rooms reviewed for storage of medication. (Medication room [ROOM NUMBER]) The facility failed to ensure the narcotic box was permanently affixed inside the refrigerator in Medication room [ROOM NUMBER]. This failure could place residents that take narcotics that required refrigeration at risk of misappropriation of drugs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote care for residents in a manner and in an environment that maintained or enhanced each resident's dignity and respect in full recognition of his or her individuality for 1 of 3 residents reviewed for dignity. (Resident #89) The facility failed to provide Resident #89 a privacy bag (helps maintains dignity of catheterized patients by restoring a sense of privacy) for his suprapubic catheter bag (collects urine by attaching to a drainage bag). This failure placed residents at risk for diminished quality of life, loss of dignity and self-worth.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the residents had the right to participate in the development and implementation of his or her person-centered plan of care, and to ensure that the planning process facilitated the inclusion of the residents and/or representatives for 1 (Resident #82) of 22 residents reviewed for care planning. The facility failed to schedule Resident #82's care plan meeting on a non-dialysis day (Mondays, Wednesdays, and Fridays) so she could attend. This failure could affect residents by placing them at risk for not receiving adequate or individualized care.

Inspectors wroteBased on interview, and record review the facility failed to immediately consult with the resident physician when there was significant change in the resident physical condition for 1 of 4 residents reviewed for change in condition. (Resident #88) The facility failed to notify MD U of Resident #88's elevated blood sugar glucose. This failure could result in diabetic residents not receiving appropriate treatment for elevated blood sugars.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for 2 of 6 residents (Resident #22 and Resident #89) reviewed for environment. The facility failed to ensure Resident #22's room did not have peeling ceiling plaster (room [ROOM NUMBER]). The facility failed to ensure Resident #89's bathroom did not have plumbing issue and a warped vanity (room [ROOM NUMBER]). These failures placed resident at risk for diminished quality of life, harm, injury, and falls.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure individuals with mental disorders were evaluated and received care and services in the most integrated setting appropriate to their needs for 1 of 5 residents, (Resident #11) reviewed for PASRR Level 1 screenings. The facility failed to complete a PASRR Level 1 screening for Resident #11 following a discharge from a mental health hospital with a new diagnosis of mental illness. This failure could place residents at risk of not being evaluated for PASRR services and receiving needed services.

Inspectors wroteBased on observation, interview, and record review, the facility has failed to ensure that the resident environment remains as free of accident hazards as possible and provide supervision to prevent avoidable accidents for 2 of 2 residents (Resident #36, Resident #89) and 4 of 4 staff (CNA O, CNA S, CNA R, and CNA AA) reviewed for transfer. The facility failed to ensure CNA O, CNA S, CNA R, and CNA AA performed a safe mechanical lift transfer (devices used to assist with transfers and movement of individuals who require support for mobility beyond the manual support provided by caregivers alone) for Resident #36 and Resident #89. This failure could place residents at risk of injury from accident and hazards.

Inspectors wroteBased on interview and record review, the facility failed to ensure dialysis service were provided consistently with professional standards of practice for 1 of 3 resident reviewed for dialysis services. (Resident #82) The facility failed to consistently document Resident #82's dialysis communication form. This failure could place residents who received dialysis at risk for complications and not receiving proper care and treatment to meet their needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items for 1 of 8 resident personal refrigerators reviewed for food safety. (Resident #62). The facility failed to ensure the refrigerator for Resident #62 did not contain expired foods. This failure could place resident at risk for food borne illnesses.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 24 residents reviewed for infection control. (Resident #112) The facility failed to ensure LVN B performed proper hand hygiene while performing wound care for Resident #112. The facility failed to ensure LVN B change residents soiled linens before allowing resident to return to bed after clean wound dressing applied to his posterior buttocks. These failures could place residents and staff at risk for cross- contamination and the spread of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 2 of 6 resident wheelchairs reviewed for essential equipment. (Resident #20 and #54) The facility failed to ensure Resident #20's wheelchair had a non-functioning left break. The facility failed to ensure Resident #54's wheelchair had two non-functioning breaks. This deficient practice could result in resident falls and injury while using their wheelchairs.