Los Arcos Del Norte Care Center

Inspectors wroteBased on interview and record review the facility failed to ensure that each resident has a right to make choices about aspects of his or her life in the facility that are significant to the resident for 1 of 8 residents (Resident #2) reviewed for self -determination. The facility failed to ensure that Resident #2 received incontinence care before or during mealtimes when requested. This failure could place residents at risk for avoidable discomfort, compromised dignity, and potential complications such as urinary tract infections and skin breakdownFindings included: Record review of Resident #2's face sheet dated 08/21/25, revealed, admission on [DATE] and re-admission on [DATE] to the facility. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure the prompt resolution of all grievances to include ensuring that all written grievance decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the residents' concerns, a statement as to whether the grievance was confirmed, any corrective action or to be taken by the facility as a result of the grievance, and the date when the decision was issued for 1 (Resident #2) of 8 residents reviewed for resident rights. The facility failed to complete a grievance for Resident #2 RP who requested Resident #2 to be changed during a mealtime. This failure could place residents at risk for grievances not being addressed or resolved promptly. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to assess the resident for risk of entrapment from an enabler (bed rail) prior to installation or review the risks prior to installation for 1 (Resident #3) of 4 residents reviewed for enablers (bed rails). The facility failed to ensure that Resident #3 had a Scoop/Booster Mattress Assessment done to ensure the scoop/booster mattress was appropriate for use as an enabler. The facility failed to ensure that Resident #3 had orders for the scoop/booster mattress (enablers) use. The facility failed to obtain a Consent for use of the scoop/booster mattress for Resident #3. This failure could place residents who have scoop/mattresses (enablers) at risk of having inappropriate or unnecessary enablers in place increasing their risk of injury.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure medical records, in accordance with accepted professional standards and practices, were maintained on each resident that were accurately documented for 1 of 6 residents (Resident #2) reviewed for medical records. The facility failed to ensure Resident #2's facility provider report to the state agency failed to accurately document the treatment and administration in the record for perineal care for Resident #2. This failure could place residents at risk of having incomplete and inaccurate medical records possibly resulting in inadequate treatment/care.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident medical and nursing needs for 4 of 6 residents (Resident #1, Resident #6, Resident #10, Resident #12) reviewed for care plans. The facility failed to implement a comprehensive person-centered care plan that addressed Resident #1's refusal of showers. The facility failed to implement a comprehensive person-centered care plan that addressed Resident #6's wandering into other resident rooms. The facility failed to implement a comprehensive person-centered care plan that addressed Resident #10 ' s sexual inappropriateness. The facility failed to implement a comprehensive person-centered care plan that addressed Resident #12 ' s sexual inappropriateness. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure medical records, in accordance with accepted professional standards and practices, were maintained on each resident that were accurately documented for 2 of 3 residents (Resident #3, Resident #8) reviewed for medical records. The facility failed to ensure that the incident on 04/25/25, with Resident #3 who alleged ST had said something negative was documented in the resident's chart. The facility failed to ensure that the incident on 05/14/25, with Resident #8 who alleged that someone stole $40 out of his wallet was documented in the resident's chart. These failures could place residents at risk of records being inaccurate and not receiving potential needed services due to documentation errors.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement their written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents for 1 of 7 (Resident #1) residents reviewed for abuse. The facility failed to follow their abuse policy when they did not perform a skin assessment following an incident. This failure placed Residents at risk for abuse and neglect.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for 2 of 12 residents (Resident #48 and Resident #146) reviewed for environment, including but not limited to receiving treatment and supports for daily living safely. The facility failed to ensure Resident# 48's belongings were not damaged when moved from rooms. Resident# 48's portable closet was broken by the facility staff and was not replaced. The facility failed to ensure Resident # 146 resided in a room with a homelike environment by aiding with personalization of the side of his room with personal items. These failures placed residents and staff at risk of living, working and visiting in an uncomfortable environment and a decreased feeling of well-being and satisfaction within their physical surroundings.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide pharmaceutical services that assured the accurate acquiring, receiving, dispensing, safe and secure storage of medications for 3 of 4 medications carts (Hall 100 medication cart, Hall 200 medication cart and Hall 300 treatment cart ) reviewed for medication storage. -The facility failed to ensure liquid medication stored in medication cart did not have dried drippings on the sides of the bottles in the 100 Hall. - The facility failed to ensure the bottle of Betadine stored in the treatment cart and in medication cart (Hall 300) was free of dried drippings. -The facility failed to ensure a bottle of Chlorhexidine Gluconate solution stored in medication cart (hall 200) was free of dried drippings. This failure could result in drug diversion of controlled substances. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food that was palatable and served at an appetizing temperature for 1 of 1 meal viewed for food temperatures. -The facility failed to maintain food hot on diet serve test trays. This failure could place residents 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 store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation and food storage. -The facility failed to ensure the kitchen staff used beard restraints to prevent food contamination. -The facility failed to keep a deep fryer covered, free of food particles and burnt oil. -The facility failed to store opened food containers in the food preparation area and dry storage room in sealed containers. -The facility failed to label, and date opened foods stored in the dry storage room and refrigerator. These failures could place residents at risk of food borne illnesses.

Inspectors wroteBased on interviews and record review the facility failed to ensure a facility with more than 120 beds employed a qualified social worker on a full-time basis. The facility failed to have a full-time social worker since [DATE]. This failure could have placed residents in need of social services at risk of psycho-social decline and poor-quality of life.

Inspectors wroteBased on interviews and record review the facility failed to include effective communication as a mandatory training for direct care staff for 7 of 12 staff (Interim Administrator, Interim DON, Med Aide J, ADON, LVN I, [NAME] D, and LVN A) reviewed for training on effective communication. The facility failed to ensure direct care staff received training on effective communication for the Interim Administrator, Interim DON, Med Aide J, ADON, LVN I, [NAME] D, and LVN A. This failure could place residents at risk of not having a way to effectively communicate their wants or needs.

Inspectors wroteBased on interviews and record review the facility failed to ensure that all staff members were educated on the rights of the resident and the responsibilities of a facility to properly care for its residents for 8 (Interim Administrator, Interim DON, Med Aide J, ADON, LVN I, Social Worker L, [NAME] D, and LVN A) of 12 employees reviewed for training on the rights of the resident and the responsibilities of a facility to properly care for its residents. The facility failed to ensure the Interim Administrator, Interim DON, Med Aide J, ADON, LVN I, Social Worker L, [NAME] D, and LVN A, received training on the rights of the resident and the responsibilities of a facility to properly care for its residents. This failure could put residents at increased risk of not having their rights respected or not receiving proper care.

Inspectors wroteBased on interviews and record review, the facility failed to provide the required annual or new hire abuse training including all activities that constitute abuse, neglect, exploitation, and misappropriation of resident property, procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property, dementia management, and resident abuse prevention for 8 of 12 employees (Interim Administrator, Interim DON, Med Aide J, RN K, ADON, [NAME] D, LVN A, and Social Worker M) reviewed for Abuse and Dementia training. [...]

Inspectors wroteBased on interviews and record review the facility failed to include as part of its QAPI program mandatory training that outlines and informs staff of the elements and goals of the facility's QAPI program for 12 ( Interim Administrator, Interim DON, Med Aide J, RN K, ADON, LVN I, Social Worker L, [NAME] D, LVN A, Maintenance, Social Worker M, and the Dietary Manager) of 12 employees reviewed for QAPI training. The facility failed to include trainings regarding the facility's QAPI program in its training for employees. This failure put residents at risk of receiving poor-quality services because of staff being unaware of quality control concerns the facility was working to address.

Inspectors wroteBased on interviews and record review, the facility failed to provide the mandatory training on standards, policies, and procedures for an infection prevention and control program for 11 of 12 staff (Interim Administrator, Interim DON, Med Aide J, RN K, ADON, LVN I, [NAME] D, LVN A, Maintenance, Social Worker M, and the Dietary Manager) reviewed for training. The facility failed to ensure an infection prevention and control training was provided to the Interim Administrator, Interim DON, Med Aide J, RN K, ADON, LVN I, [NAME] D, LVN A, Maintenance, Social Worker M, and the Dietary Manager. This failure could place residents at risk of illness due to lack of staff training.

Inspectors wroteBased on record review and interviews, the facility failed to ensure all staff received training in compliance and ethics for 8 of the 12 staff members (Interim Administrator, Interim DON, Med Aide J, ADON, LVN I, COOK D, LVN A, and Social Worker M) reviewed for mandatory training. The facility failed to ensure an ethics training was provided to Interim Administrator, Interim DON, Med Aide J, ADON, LVN I, COOK D, LVN A, and Social Worker M. This failure could place residents at risk of receiving inadequate care from staff who are uneducated on compliance and ethics.

Inspectors wroteBased on record reviews and interviews, the facility failed to maintain a training program to ensure staff were trained for 12 of 12 (Interim Administrator, Interim DON, Med Aide J, RN K, ADON, LVN I, Social Worker L, [NAME] D, LVN A, Maintenance, Social Worker M, and the Dietary Manager) reviewed for behavioral health training. The facility failed to ensure behavioral health training was provided to Interim Administrator, Interim DON, Med Aide J, RN K, ADON, LVN I, Social Worker L, [NAME] D, LVN A, Maintenance, Social Worker M, and the Dietary Manager. This failure could place residents at risk of not receiving care from incompetent/untrained staff.

Inspectors wroteBased on observation, interview and record review the facility failed to provide reasonable accommodation of resident needs and preferences for 2 of 10 residents (Resident #41 and #246) observed for call lights: - The facility failed to ensure Resident #41 had access to his call light which was lying on the floor at the foot of his bed. - The facility failed to ensure Resident #246 had access to his call light which was lying on the floor next to his bed. This deficient practice could affect the residents by not maintaining and/or achieving independent functioning, dignity, and well-being.

Inspectors wroteBased on, interviews, and record review 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 medical, nursing and mental and psychosocial needs for 1 (Resident #52) of 8 residents reviewed for care plans. -The facility failed to ensure Resident # 52's dialysis was addressed on her care plan. This failure could place the resident at risk for not having their individual needs met in a timely manner and communicated to provide and could result in injury and a decline in physical well-being.

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 2 of 9 residents (Resident #43 and Resident #46) reviewed for nail care. The facility failed to trim Resident # 43 and Resident #46's fingernails. This failure could place residents at risk of cross contamination and skin scratches that could result in infection.

Inspectors wroteBased on interview and record review, the facility failed to provide assistance to resident who required dental care for 1 of 8 residents (Resident #20) reviewed for dental services. The facility failed to assist in providing routine dental services for Resident #20. This failure could affect residents by placing them at risk for oral complications and diminished quality of life. Findings Included: Record Review of Resident #20's face sheet dated 03/13/25 revealed an [AGE] year-old female with admission date 07/14/16 and readmission date 09/18/24. Her diagnoses included: disorder of tooth development and dysphagia (difficulty swallowing). Record Review of Resident #20's Annual MDS revealed a score of 15, indicating little to no cognitive impairment. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined the facility failed to ensure a resident who is incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 resident (Resident #13) reviewed for incontinent care. CNA G failed to perform hand hygiene after disposing dirty briefs and before putting on new clean briefs for Resident #13. This practice had the potential to affect residents identified by the facility as incontinent of bladder by putting them at risk for skin breakdown, cross contamination, and urinary tract infections.

Inspectors wroteBased on observation, interview, and record review the facility failed to have a safe, clean , comfortable and homelike environment including but not limited to receiving treatment and supports for daily livening safely for 4 (hall 100, hall 200, hall 300, hall 400) of 4 hallways reviewed for infection control in that: The facility failed to pick up the trash in the resident rooms and in the hallway(s). This failure could have placed residents at risk for of residing in an unsafe, unsanitary, and uncomfortable environment.

Inspectors wroteBased on observation, interview, and record review the facility failed to assess the resident for risk of entrapment from an enabler (bed rail) prior to installation or review the risks prior to installation for 1 (Resident #1) of 4 residents reviewed for enablers (bed rails). Resident #1 did not have a Bed Rail Assessment done to ensure the bed rails (enablers) were appropriate for the use of Resident #1's needs. Resident #1 did not have orders for the bed rail (enablers) use. This failure could place residents who have bed [NAME] (enablers) at risk of having inappropriate or unnecessary enablers in place increasing their risk of injury.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that the MDS assessment accurately reflected the resident's status (use of bed rails) for 1 (Resident #1) of 4 residents reviewed for accuracy of MDS assessment. Resident #1's quarterly MDS dated [DATE], did not accurately reflect the residents' use of bed rails (enablers). This deficient practice could place residents at risk of not receiving adequate care.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident medical and nursing needs to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being for 1 of 4 residents (Resident #1) reviewed for care plans. The facility failed to implement a comprehensive person-centered care plan for Resident #1's use of bed rails (enablers). This deficient practice could place residents in the facility at risk of not receiving the necessary care or services and having personalized plans developed to address their needs.

Inspectors wroteBased on the observation, interview, and record review the facility failed to ensure that the residents environment remains free of accidents hazards as was possible and each resident received adequate supervision to prevent accidents for 1 (Resident #15) of 2 resident reviewed for accidents. CNA G and CNA H were observed 01/28/2025 using the mechanical lift to lift Resident #15 without engaging the brakes as the mechanical lift was observed moving slightly. This failure could affect residents who required the use of a mechanical lift for transfers, by placing them at risk of improper transfers resulting in injury.

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 of 5 (Resident #14) reviewed for pharmacy services. The facility did not provide Resident #14's Cilostazol (vasodilator medication) 100 mg tablet given two times a day on 12/21/24 per physician orders. These failures could place residents at risk for a delay in medication administration and could place residents at risk for medical complications due to missed doses.

Inspectors wroteBased on interview and record review, the facility failed to ensure medical records were maintained on each resident that were complete and accurately documented for 2 (Resident #6 and Resident #11) of 11 residents reviewed for administration. -The facility failed to document in Resident #6's medical records the resident's desire to transfer from the facility. -The facility failed to ensure Resident #11's Care Plan intervention tasks regarding falls, was free of error. These failures could place residents at risk of not receiving needed services or errors in treatment based on incorrect information.

Inspectors wroteBased on interview and record review, the facility failed to ensure that it employed a qualified social worker on a full-time basis for one of one social worker positions reviewed for administration. -The facility, which was licensed for 124 beds, failed to employ a qualified social worker on a full-time basis since on 08/05/2024 This failure put facility residents at risk of not having their psychosocial or discharge planning needs met.

Inspectors wroteBased on interviews and record review, the facility failed to send a copy of the notice of transfer or discharge and the reasons for the transfer or discharge in writing to the Office of the State Long-Term Care Ombudsman for one (Resident #1) of two residents reviewed for transfer and discharge. The facility failed to send a transfer or discharge notice in writing to the facility's Ombudsman as soon as practicable when Resident #1 was discharged home on 5/10/24. This failure could affect residents at the facility by placing them at risk of being discharged and not having access to available advocacy services, discharge/transfer options, and the appeal processes.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the resident environment remained free of accidents hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 (Resident #7) of 5 residents reviewed for accidents hazards. -The facility failed to ensure that Resident #7's fall mat was positioned bedside while resident was lying in bed. This failure could place residents at risk of falls and/or injuries.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice for 1 (Resident #8) of 3 residents observed for oxygen management. -The facility failed to ensure Resident #8 had an oxygen sign posted outside of her bedroom. This failure could place residents on oxygen therapy at risk exposure to a fire hazard if staff and visitors are not aware of oxygen present.

Inspectors wroteBased on, interview and record review the facility failed to ensure medical records, in accordance with accepted professional standards and practices, were maintained on each resident that were accurately documented for 1 (Resident #7) of 6 residents reviewed for medical records. -The facility failed to ensure nursing documentation was accurate for Resident #7. This failure could lead to errors in treatment based on incorrect information.

Inspectors wroteBased on interviews and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan for 2 (Resident #3 and Resident #5) of 4 residents reviewed for neurological checks. -The facility failed to ensure Resident #3 had neurological checks done after a fall on 02/25/24. -The facility failed to ensure Resident #5 had neurological checks done after a fall on 03/13/24. This failure could affect others by placing them at risk of changes in condition due to not conducting neurological checks.

Inspectors wroteBased on interviews and record review the facility failed to ensure that the residents environment remains free of accidents hazards as was possible and each resident received adequate supervision to prevent accidents for 1 (Resident #1) of 4 residents reviewed for accidents and hazards. The facility failed to use the Hoyer lift (a patient lift used by caregivers to safely transfer patients) to transfer Resident #1. The noncompliance was identified as past noncompliance. The noncompliance began 02/20/24 and ended on 02/21/24. The facility had corrected the noncompliance before the investigation began. This failure could place residents at risk of having an improper transfer used on them.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to establish and maintain an infection 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 (Resident #4) of four residents observed for infection control. Resident #4's catheter drainage collection bag was left on the floor. This deficient practice could affect residents with catheters and could result in cross contamination of germs and could result in a urinary tract infection (a painful infection of the urinary system, which includes the kidneys, bladder, urethra, and ureters).

Inspectors wroteResident #4 PASARR 12/06/23 10:08 AM PASSAR I 08/03/2022 - No evidence of MI New PASSAR I submitted 1/27/23 showing Yes to MI with diagnosis of Schizophrenia 8/11/2022; Schizoaffective Disorder - 8/22/2022 Form 1012 - Completed 1/27/2023- Primary diagnosis is not dementia. Diagnosis of Schizophrenia and of Schizophrenia Diagnosis PASSAR Eval dated 1/30/2023 - does not meet PASSR definition of MI. Based on observation, interview, and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 2 of 16 (Resident #10 and Resident #69) residents reviewed for accuracy of MDS assessments. 1. The facility failed to ensure Resident #10's MDS reflected her refusal of care and treatments. 2. The facility failed to ensure Resident #69 MDS assessment documented the use of wander guard. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident medical and nursing needs to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being for 4 (Resident #69, Resident #35 , Resident #32 and Resident #54) of 24 residents reviewed for care plans in that: 1.-The facility failed to implement a comprehensive person-centered care plan for Resident #69 history of wandering and/or elopement behavior and wander guard. 2. The facility failed to include the Resident #35's psychiatric diagnosis, use of antipsychotic medications, or for COVID-19 on her care plan. 3. The facility failed to implement the accurate code status for Resident #32 and Resident #54. [...]

Inspectors wroteBased on 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) and failed to keep drug records to account of all controlled drugs to be maintained and periodically reconciled for 2 (Resident #289 and Resident #48) of 5 residents and 1 out of 4 (300 Hall) hallways reviewed for pharmacy services. -MA K administered the incorrect dosage of Aspirin medication to Resident #289. -LVN L failed to stay in the room and assess Resident #48 while breathing treatment was being administered per facility policy. -The facility failed to ensure the narcotic count sheet for the 300 hall was accurate for one controlled medication. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure that residents did not receive psychotropic drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record for one (Resident #35) of 5 residents reviewed for unnecessary medications. The facility failed to ensure Resident #35 did not receive the antipsychotic Risperidone for the diagnosis of depression. This failure puts residents at increased risk of side-effects of antipsychotic medications and receiving unnecessary medications.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that food and drink that is palatable, for one (pureed enchiladas) of three pureed food items reviewed for palatability, in that: Pureed enchiladas lacked flavor found in regular texture enchiladas. This failure puts residents who receive pureed foods at risk of dissatisfaction with food and decreased desire to eat.

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 service safety in 1 of 1 kitchen reviewed for professional standards for food service safety. The following were observed: -1 flat of raw pasteurized in-shell eggs with four cracked eggs stored over another flat of eggs. -1 opened, unsealed package of aged Mexican cheese with a date opened label of 10/27/2023 without facility use by date and manufacturer best by date of 12/01/2023. These failures could place residents at risk of food-borne illness.

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 disease and infection for of 24 (Resident #44, Resident #35) residents reviewed for infection control -The facility failed to ensure Resident #44 who was in isolation precautions for Covid-19, door was closed. -The facility failed to ensure that Resident #35 was placed in an isolation room when she returned from the hospital with diagnosis of COVID-19. These deficient practices could place residents at risk for infection due to improper care practices.

Inspectors wroteBased on interviews, and record reviews the facility failed to ensure the residents has the right to be informed of the risks and participate in, his or her treatment which included 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 or treatment options and to choose the alternative or options he or she preferred, for 1 of 8 (Resident #69) reviewed for resident rights. The facility failed to obtain a signed informed consent based on information of the benefits, risks, and options available for Resident #24's prior to placing wander guard bracelet on. This failure placed residents at risk of unnecessary restriction of their freedom of movement and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote and facilitate resident self-determination through support of resident choice for 1 of 8 (Resident #69) residents reviewed for physical restraints. The facility failed to remove a wander guard bracelet from Resident #69 although the resident was not at risk of elopement and requested its removal numerous times. This failure placed residents at risk of unnecessary restriction of their freedom of movement and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents have the right to receive visitors of his or her choosing at the time of his or her choosing for 1 of 10 (Resident #25) residents reviewed for residents' rights. The facility failed to ensure Resident #25 had the right to receive visitors inside the facility. This failure placed residents at risk of isolation, decreased emotional well-being, and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure that a resident with urinary incontinence received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for one (Resident #21) of 12 residents reviewed for urinary catheters. The facility failed to follow physician ' s orders to change Resident #21 ' s urinary catheter. This failure could result in an increased risk for urinary tract infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident who is fed by enteral means receives the appropriate treatment and services for 1 of 2 residents (Resident #70) reviewed for enteral feeding. -The facility failed to ensure Resident #70 ' s enteral feeding bag label had the date and time the administration of the feeding was begun, the rate of administration, and the initials of who had hung the feeding container. This failure could place residents receiving enteral feedings at risk of insufficient nutritional supplementation and possible weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice for 1 (Resident #289) of 3 residents observed for oxygen management. 1. The facility failed to ensure Resident #289 had an oxygen order for oxygen being administered 2. The facility failed to ensure Resident #289 did not ensure his room had an oxygen sign outside the room. This failure could place residents on oxygen therapy at risk of receiving incorrect or inadequate oxygen support and at risk of harm and exposure to a fire hazard if staff and visitors are not aware of oxygen present.

Inspectors wroteBased on record review, interview and observation, the facility failed to ensure residents with pressure ulcers receive necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 2 of 4 residents reviewed for pressure ulcers. - The facility failed to perform wound care according to physician orders for Resident #1 on 09/02/23 and 09/03/23 that lead to worsening of the wounds. Resident #1's stage IV pressure sore on his left hip increased in size and depth and left heel unstageable (full-thickness pressure injuries in which the base is obscured by slough and/or eschar) pressure sore increased in size. - The facility failed to perform repositioning and offloading for Resident #2 on 10/06/23, 10/09/23, 10/10/23, and 10/11/23. [...]

Inspectors wroteBased on observation, interviews and record review the facility failed to ensure residents the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 (Residents #17) of 10 of residents reviewed for call light button placement. The facility failed to ensure that Resident #17 ' s call light was within their reach. This failure put residents at risk of not being able to call for assistance when needed.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan that included measurable objectives and time frames to meet a resident medical and nursing needs and described the services to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being for 1 (Resident #3) of 6 residents reviewed for care plans in that: - The facility failed to follow the comprehensive person-centered care plan for risk of falling by keeping bed brakes locked for Resident #3. This deficient practice could place residents in the facility at risk of not receiving the necessary care or services as indicated in their comprehensive person-centered plans developed to address their needs.

Inspectors wroteBased on observation interview, and record review the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 (Resident #16) of 3 residents reviewed for foley catheter. -The facility failed to ensure Resident #16's catheter leg strap was in place to secure the catheter. This failure could place residents with foley catheter at risk of catheter pulling causing pain and/or infection.

Inspectors wroteBased on the observations, interviews, and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for hairnets. The Dietary Manager did not wear a hair net when entering the kitchen on 10/5/23. This failure could affect residents by placing them at risk of food borne illness.

Inspectors wroteBased on interview and record review the facility failed to ensure medical records were maintained on each resident that were accurately documented for 2 of 6 residents (Resident #14 and Resident #5) reviewed for medical records. The facility failed to ensure Resident #14 ' s record accurately documented behavioral monitoring for Resident #14 ' s behaviors. Resident #5 had a resident to resident altercation in which it was not accurately documented in her progress notes of the incident. This failure could place residents at risk of having incomplete and inaccurate records with the risk of not receiving potential needed services.

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 disease and infection for 1 (Gray Bin) of 2 bin containers and 2 (Residents #16 and #20) of 4 residents reviewed for infection control in that: - One gray bin container full of trash and adult briefs was left open and had a foul odor coming out from it. - Resident #16's and Resident #20's catheter bags were on the floor and not contained. These deficient practices could place residents at risk for infection due to improper care practices and cross contamination.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure nurse staffing data was posted and readily accessible to residents and visitors for 1 (10/6/2023) of 26 days reviewed for nurse staffing information. The facility failed to post the required staffing information for 10/6/2023. This failure could place residents, their families, and facility visitors at risk of not having access to information regarding staffing data and facility census.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the residents receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident ' s comprehensive assessment and plan of care. for 2 (Resident #65 and Resident #13) of 7 reviewed for call light placement. The facility failed to ensure Resident #65 and Resident #13 had call lights within reach. This failure could have placed residents at risk for needs not been met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide treatment and care in accordance with the comprehensive person-centered care plan and in accordance with professional standards of practice for 2 (Resident #47 and Resident #267) out of 7 residents reviewed for positioning and transfers and 1(Resident #66) out of 6 residents reviewed for intravenous lines in that: A. The facility failed to ensure Resident #47 was repositioned by using a gait belt or two-person physical assist. B. The facility failed to use the proper transferring techniques when providing care for Resident #267 on [DATE]. C.The facility failed to change Resident #66 PICC line dressing within 7 days . This failure could place residents requiring extensive assistance with ADLs at risk for more than minimal physical harm.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 2 (Resident #3 and Resident #44) of 7 reviewed for respiratory care. A. The facility failed to ensure Resident #3 nebulizer mask was kept in a bag while not in use. B. The facility failed to ensure Resident #44 nasal cannula was kept in a bag while not in use. These failures could have placed residents at risk for infections and transmission of communicable diseases.

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 residents for 4 residents (Resident #17, #118, #66 and #267) of 8 reviewed for medication administration, failed to ensure that medications and supplies were not expired for 2 of 2 medication storage rooms reviewed for expired medications and failed to keep drug records to account of all controlled drugs to be maintained and periodically reconciled for 1 (100 hallway) out of 4 narcotic count sheets reviewed for controlled medications in that: Residents #17 and #118 were administered blood pressure medications although their blood pressures or pulse were too low. [...]

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 service safety for 1 of 1 kitchen reviewed for dietary services. Food in the Freezer were open and unsealed properly. Food in the refrigerator were open and unsealed properly. Foods in the Dry Food Storage were open and unsealed properly. Dry Food Storage had items with accumulation of dust, encrusted grease deposits and other soiled accumulations. Food prep areas had items with accumulation of dust, encrusted grease deposits and other soiled accumulations. The refrigerator and Freezer logs did not have a temperature recorded for the dated of 10/10/22 The test strips used to test the chlorine level in the dishwasher were expired. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to dispose of garbage and refuse properly for 1 out of 1 kitchen observed. The facility failed to properly contain garbage in the kitchen, by using garbage cans with a lid that has a hole cut in the middle for easy access. This deficient practice posed a sanitary and safety hazard which could result in the attraction of vermin and rodents and affect all residents who ate food from the kitchen exposing them to germs and diseases carried by vermin and rodents.

Inspectors wroteBased on observation, interview and record review the facility failed to promote and facilitate residents self-determination through support of resident choices for 1 out of 1 resident reviewed. Resident #44 was given showers on a schedule that disregards her preferences, if Resident #44 was not present for her the facility scheduled shower time Resident #44 was not showered until the next facility scheduled date. This failure could place residents at risk for a decline in health due to loss of self-determination.

Inspectors wroteBased on interview and record review the facility failed to coordinate assessments with the pre-admission screening and resident review (PASARR) program under Medicaid including referring residents with newly evident or possible serious mental disorder for level II resident review upon a significant change in status assessment for one (Resident #15) of one resident reviewed for PASARR. Resident #15 was admitted to a behavioral health unit because of behaviors and returned with a new psychiatric diagnosis and medication but a new PASARR screen was not conducted. This failure could put residents at risk of not receiving specialized services that may help them attain and/or maintain their highest practicable level of psychosocial functioning.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition for 1 (Resident #44) of 1 resident reviewed Resident #44 routinely misses breakfast due to the facility not assisting Resident #44 out of bed to a sitting position. This failure could place residents at risk for weight loss and choking hazards.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure that residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs in 1 (Resident # 56) of 2 residents reviewed for unnecessary medications in that: Resident #56 did not receive GDR for antipsychotic medication she had been receiving for more than 6 months. This failure could cause the resident to have side effects from medication causing a decline in health.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain medical records on each resident that are accurately documented for 1 (Resident #67) of 7 residents reviewed for physician orders. The facility failed to ensure Resident #67 full code physician order was updated when DNR was signed. This failure could have placed residents at risk for advance directives not been followed.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for 1 (Resident #300) of 6 residents reviewed for infection prevention. The facility failed to discard Resident #300 soiled briefs. This failure could have placed residents at risk for odors, infections and transmission of communicable diseases.