Maclay Healthcare Center

Inspectors wroteBased on interview and record review, the facility failed to prevent a fall and injury for one of three residents (Resident 1) who had severely impaired cognition (resident had lost the ability to think, learn, remember, or make decisions to the point that resident cannot live independently and require full-time supervision or help with daily tasks like eating and dressing). The facility failed to ensure two or more nursing staff assisted Resident 1 when Certified Nursing Assistant (CNA) 1 repositioned (turned or moved a resident to a new position in bed) Resident 1 while providing bed bath (a care method used to clean a person who is unable to leave the bed), with no assistance from another staff, on 6/27/2026 at around 9:35 a.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to place one of three sampled residents (Resident 1) in a low air loss (LAL- a specialized medical-grade mattress used to prevent and treat bedsores) mattress in accordance with the physician order and care plan when the facility maintained Resident 1 on a standard mattress on 6/8/2026 who had a stage 2 pressure injury (localized damage to the skin and/or underlying tissue usually over a bony prominence). This failure had the potential to result in worsening of Resident 1's stage 2 pressure injury and increase the risk for further pressure related skin deterioration.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications were properly labeled and dated in accordance with facility policy in one of two inspected treatment carts (Station 2) when Treatment Nurse (TXN) 1 failed to: Label one tube of Ketoconazole cream with resident identification. Label three opened bottles of nystatin powder with resident identification and the date opened. Label container of silver sulfadiazine cream with resident identification and was labeled with an open date of [DATE]. These failures had the potential to result in medication errors, administration of medications to the wrong residents, and improper use of the medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Certified Nurse assistant (CNA) 1 was wearing personal protective equipment {(PPE) refers to protective items or garments worn to protect the body or clothing from hazards that can cause injury and to protect residents from cross-transmission)} on enhanced barrier precautions (EBP- infection control measures for high-risk residents, to reduce the spread of multidrug-resistant organism or MDRO due to open wounds) room for one of three sample residents (Resident 1). This deficient practice placed the staff and all residents in the facility at risk for the spread of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1), who was cognitively impaired (refers to difficulties with thinking, learning, remembering, and using judgment, among other mental abilities) and had documented history of falls, (as indicated in Resident 1's admission Record), was free from preventable falls and injury, by failing to: a. Monitor Resident 1's orthostatic blood pressure (a change in blood pressure that occurs when a person stands up from a sitting or lying position) in accordance with physician orders. b. Ensure Resident 1 wore nonskid (slip-resistant) footwear while ambulating (walking). c. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow professional standards of nursing practice for one of three sampled residents (Resident 1) by failing to:Ensure licensed nurses monitored Resident 1's orthostatic blood pressure related to the resident's orthostatic hypotension. Resident 1's orthostatic blood pressure was not taken from 2/13/2026 to 4/28/2026. Ensure licensed nurses appropriately assessed Resident 1's risk for falls following the resident's fall on 2/26/2026. Ensure licensed nurses appropriately assessed and monitored Resident 1's medical status following the resident's Change of Condition (COC - when there is a sudden change in a resident's condition) on 4/25/2026 related to the resident's fall. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the medical records of three of three sampled residents (Resident 1, Resident 2, and Resident 3) were maintained in accordance with accepted professional standards and practice, complete, and accurately documented by failing to:a. Ensure certified nursing assistants (CNAs) documented Residents 1, 2, and 3's percentage (% - per one hundred) of food eaten at the correct time. b. Ensure licensed nurses documented the accurate time Resident 1 arrived back at the facility from General Acute Care Hospital (GACH) 1 on 4/25/2026. These deficient practices resulted in inaccurate information on Residents 1, 2, and 3's medical records and had the potential for delayed and inaccurate medical interventions.

Inspectors wroteBased on interview and record review, the facility failed to create and implement a comprehensive, person-centered care plan with measurable objectives and interventions for one of three sampled residents (Resident 1). The facility failed to develop and implement an individualized care plan with interventions addressing the following: Resident 1's orthostatic blood pressure monitoring. Resident 1's preference in using a slip-on rubber slipper while ambulating (walking). Resident 1's refusal in using an assistive device while ambulating. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a person-centered care plan (a tool that ensures residents receive personalized, comprehensive, and goal-oriented care in a nursing home setting) for one of three sampled residents (Resident 3) by failing to:1. Implement Resident 3's care plan on monitoring for anticoagulant therapy (often called blood thinners, medication used to reduce the risk of dangerous blood clots forming in blood vessels or the heart) side effects (an unintended, often unpleasant reaction to medication, treatment, or procedure that occurs alongside its intended purpose).2. Implement Resident 3's care plan for constipation (a condition in which stool becomes hard, dry, and difficult to pass, and bowel movements do not happen very often).3. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident received care consistent with professional standards of practice to prevent pressure ulcers (localized damage to the skin and/or underlying tissue usually over a bony prominence) for one of three sampled residents (Resident 1) by failing to:1. Call the Wound Provider (WP) to obtain a physician wound care order and provide wound care treatment on 3/9/2026, to Resident 1's stage 4 pressure ulcer (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) from sacrococcyx (tailbone) extending to bilateral buttocks.2. Follow the WP order for wound treatment to right and left heel unstageable pressure ulcer (a severe wound where the true depth cannot be determined because it is completely covered by dead tissue) from 3/26/2026, to 3/31/2026. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the physician promptly (acting immediately, without delay, or exactly at a scheduled time) for one of three sampled residents (Resident 3) when Resident 3 had reported that she (Resident 3) had constipation (when the bowel movements become less frequent and stools become difficult to pass). This failure had potential for delay in the delivery of necessary care and services and had the potential for increased risk of abdominal discomfort and pain to Resident 3.

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) for one of three sampled residents (Residents 1) by failing to follow physician's order to administer hydralazine (medication used to treat high blood pressure [HTN]) for systolic blood pressure (sbp-measures the pressure the blood is pushing against the artery walls when the heart beats) above 110 millimeter mercury (mmHg- the standard unit of measurement used to record blood pressure, indicating how much force the blood exerts against artery walls). This failure had the potential to result in medication errors and could cause to Resident 1's uncontrolled hypotension (low blood pressure).

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 3), who was receiving apixaban (an anticoagulant medication that helps prevent the formation of blood clots) was monitored for its side effects of bleeding. This deficient practice had the potential to place Resident 3 at increased risk for side effects including bleeding.

Inspectors wroteBased on interview and record review, the facility failed to implement its abuse policy and procedure by failing to completely investigate two resident-to-resident allegations of physical abuse for four of five sampled residents (Residents 1, 2, 3 and 4) by: 1. Failing to interview or obtain a written witness statement from Licensed Vocational Nurse 2 (LVN 2) and Certified Nursing Assistant 2 (CNA 2) who were assigned to Resident 1.2. Failing to interview or obtain a written witness statement from LVN 1 and CNA 5 who were assigned to Resident 2.3. Failing to interview or obtain a written witness statement from CNA 4 who was assigned to Resident 3.4. Failing to interview or obtain a written witness statement from LVN 4 and CNA 3 who were assigned to Resident 4. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain accurate and complete medical record for one of five sampled residents (Resident 1) by failing to accurately document medication administrations. Licensed Vocational Nurse 6 (LVN 6) and LVN 7 documented administration of medication in Resident 1's Medication Administration Record (MAR), from 2/17/2026, to 2/19/2026, even when Resident 1 was in General Acute Care Hospital (GACH) from 2/15/2026, at 7:20 p.m., to 2/19/2026, at 3:02 p.m. These failures had the potential to result in medication errors, cause confusion in care and the medical records containing inaccurate documentation.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a person-centered care plan (a tool that ensures residents receive personalized, comprehensive, and goal-oriented care in a nursing home setting) for one of three sampled residents (Resident 2) by failing to develop a care plan on Resident 2's refusal for medication. This failure had the potential for delays in the delivery of necessary care and services to Resident 2.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare food in a form designed to meet individual needs (requirements for a person's well-being, such as food) for:1. Three (3) of eight (8) sampled residents (Resident 14, Resident 96, and Resident 24) on pureed diet (a texture modified diet that consist of smooth, pudding-like consistencies that are easy to swallow) by not following the recipe for puree oatmeal and in accordance with the International Dysphagia Diet Standardization Initiative (IDDSI - a framework for categorizing food textures and drink thickness) Level Four (4) Standards (puree foods and extremely thick drinks) when on 1/13/2026, Resident 14, Resident 96, and Resident 24 were served regular oatmeal with lumps, grains, and was not pureed.2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the confidential personal information of residents were protected by failing to ensure documents (meal tickets) containing protected information (PHI - any health information that can be used to identify specific individual which must remain confidential to prevent harmful consequences) were not shredded prior to disposing in the waste container. This failure had the potential to violate 127 of 127 residents' rights for privacy and confidentiality of personal and medical records.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, comfortable, and homelike environment for five (5) of five (5) sampled residents (Residents 65, 55, 33, 39 and 72) by failing to: 1. Maintain the cleanliness of Resident 65's electric stand fan. 2. Ensure Resident 55`s electric fan was free from dust buildup on the fan blades and the front and back safety enclosure grill of the fan. These deficient practices had the potential to negatively affect Resident 65 and Resident 55's quality of life and had violated the residents' right to a safe, clean, comfortable and homelike environment. 3. Provide Residents 33, 39, and 72 with a homelike environment when their room was damaged due to water leaks. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignity including the right to be free from physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the resident's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) for one (1) of 1 sampled resident (Resident 57) reviewed for physical restraints by failing to obtain a physician's order, informed consent, and complete a restraint assessment prior to placement of bed pad alarm (a pad with sensors that will alarm when a resident stands up unassisted to help prevent falls by alerting staff). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from unnecessary psychotropic medication (medications that affect the mind, emotions, and behavior) and the use of chemical restraints (any drug that is used for discipline or staff convenience and not required to treat medical symptoms) for two of five sampled residents (Residents 15 and 14) reviewed for unnecessary medications by failing to: 1. Ensure quetiapine fumarate (medication to treat symptoms of psychosis [occurs when a person becomes disconnected from reality]) and sertraline (medication used to treat depression [persistent feelings of sadness and loss of interest that can interfere with daily living]) was prescribed and monitored for specific, measurable behavioral manifestation for Resident 15. 2. [...]

Inspectors wroteBased on interview and record review, the facility's licensed nursing staff failed to provide care in accordance with professional standards of care for two of two sampled residents (Residents 4 and 35) reviewed for insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) use by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (sq, beneath the skin) insulin administration sites. The deficient practice had the potential for adverse effect (unwanted, unintended result) of the same site subcutaneous administration of insulin such as excessive bruising, lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin). Cross reference F760.

Inspectors wroteBased on interview and record review, the facility failed to provide treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plans by failing to notify the physician when the resident's blood pressure measured higher than the established parameters of systolic blood pressure (SBP - measures the pressure in your arteries [pathway that carries blood away from the heart]) greater than (>) 140 millimeters of mercury (mmHg - measurement of pressure) on multiple shifts in 1/2026 for one of one sampled resident (Resident 5). This deficient practice had the potential to result in further decline of the resident's kidney (body part that filters blood) function.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents` environment was free of accident hazards for eight (8) of nine (9) sampled residents (Residents 43, 53, 73, 18, 68, 111, 3, and 57) reviewed for accidents by failing to ensure: 1. Resident 43 did not have a furniture or equipment on top of the floor mat (specially designed mats provide cushioning and support to patients who are at risk of falling, helping to prevent serious injuries). 2. Resident 53 did not have frayed (torn) wires on the resident's bed remote control. This deficient practice increases the risk of accidents such as electrocution (the injury or killing of someone by electric shock) and falls with injuries on residents. 3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that its medication error rate was below five (5) percent (%- one per hundred). Three medication errors out of 37 opportunities contributed to an overall error rate of 8.11% affecting two of four residents observed for medication administration (Residents 108 and 122). The medication errors were as follows: 1.a. Resident 108 was not instructed to chew before swallowing after the administration of aspirin (medication inhibiting platelet [blood cells aiding clotting] aggregation). 1.b. LVN 10 administered lidocaine 5% ointment to Resident 108 without a dose indicated in the physician order. 1.c. LVN 10 did not follow the manufacturer's instructions after the administration of lidocaine 5% to Resident 108. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free of any significant medication errors (means the observed or identified preparation or administration of medications or biologicals which are not in accordance with the prescriber's order, manufacturer's specifications, and accepted professional standards) for two of two sampled residents (Residents 4 and 35) reviewed for insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) use by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (sq, beneath the skin) insulin administration sites. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to operate and execute overall safe and sanitary food and nutrition services operations when:1. The puree (pudding like consistency) pancake did not fall off the spoon during the spoon tilt test (a method used to determine the stickiness of the food and ability of the food to hold together) conducted by [NAME] 1 during breakfast service and there was no supervision available during the food preparation.2. Puree cranberry yogurt mousse did not fall off the spoon tilt test and was too thick during lunch service. These deficient practices had potential to cause the residents to not be able to eat their food and/or choke (when food gets stuck in your airway, blocking the flow of the air to your lungs) on the food to 11 of 11 residents on puree diet. 3. One (1) dented can was stored with non-dented cans 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the menu and did not meet nutritional needs when: 1. [NAME] 1 did not follow the recipe for green beans. 2. Residents on regular diet and therapeutic diet, including large portion diet (adding additional food to increase protein and calories) were not served three (3) ounces (oz - a unit of measurement) of pork. The menu did not clearly indicate portion size for pork and mushroom sauce. 3. Resident meal trays were not accurate:3.1 Resident 39 did not get puree oatmeal on resident's tray on 1/13/2026 3.2 Resident 46 did not have a bowl of puree oatmeal on the resident's tray on 1/13/2026. 3.3 Resident 66 did not have a cup of coffee on the resident's breakfast tray on 1/13/2026. 3.4 Resident 96 did not have margarine and jelly on the resident's breakfast tray on 1/16/20206. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare food by methods that conserved appearance, flavor and temperature when: 1. Herbed rice was hard on the outside and soft on the inside. 2. [NAME] beans were bland, no salt flavor and olive green in color. 3. Foods were not at a palatable temperatures: On 1/12/2026 during test tray (a process of tasting, temping, and evaluating the quality of food), peach pie at 66 degrees Fahrenheit ( F, degree of temperature), puree peach pie at 69 F. Pancake at 120 F, sausage patty 120 F, oatmeal 120 F, milk 48.8 F for breakfast on 1/13/2026. These failures had potential to result in 125 of 127 facility residents at risk of unplanned weight loss, a consequence of poor food intake, getting food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure therapeutic diets were prescribed by the attending physician to one of three sampled residents (Resident 66) by failing to ensure that the resident's four (4) ounces (oz., the smallest measurement of weight and volume) of Magic Cup (a high-calorie, protein-packed, single-serving, pudding-style dessert designed for people who need extra nutrition, particularly in healthcare settings) or high protein nutrition (HPN, is a concentrated, convenient source of protein-usually in the form of powder, shakes, or bars-designed to help people easily increase their daily protein intake) had a physician's order. The deficient practice had a potential for residents to receive and consume foods in the form inappropriate for the resident to consume.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide residents' meals at regular times scheduled in accordance with resident needs, preferences, and requests when lunch was served late on 1/12/2026 and breakfast was served late on 1/13/2026. This deficient practice had the potential to result in hunger and frustrations to 125 to 127 residents getting food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: 1. Food items were not properly labeled with the food item name. 2. Kitchen equipment and utensils were not free from dirt, dust, and food debris. a. Sticker residue on two (2) trays inside the walk-in refrigerator, walk-in freezer shelves, and dry storage room shelves. b. There was dirt, food, and food debris on the walk-in freezer floors. c. There were dried-up sauce spills on the dry storage walls. d. A cart with straw decoration (not cleanable surface) was used during trayline (an area where foods were assembled from the steamtable to resident's plate). e. Clean pans on the storage racks had rice grains and were not free from debris. f. Kitchen floors by pots and pans storage racks had dirt and food debris. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one of one sampled resident (Resident 11) by failing to document accurately the dialysis access site on the Dialysis Communication Records on 12/18/2025, 12/30/2025, 1/4/2026, and 1/6/2026. This deficient practice had the potential to result in Resident 11's dialysis access to go unmonitored and unchecked post-dialysis.

Inspectors wroteBased on interview and record review, the facility failed to ensure necessary care was provided consistently for one (1) of two (2) sampled residents (Resident 3) reviewed for hospice services (a program designed to provide a caring environment for meeting the physical and emotional needs of the terminally ill) by: 1. Failing to ensure hospice staff including Licensed Vocational Nurse (LVN), and Hospice Aide (HA), provided nursing and visitation notes to the facility. 2. Failing to ensure LVN and HA visited Resident 3 as indicated in the calendar of visits provided by Hospice Provider (HP) 2 to the facility. These deficient practices had the potential to negatively affect Resident 3's physical comfort and psychosocial well-being resulting in the delay or lack of necessary hospice care and 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 diseases and infections by failing to ensure: 1. Urinals (a portable container designed to collect urine from individuals who are unable to reach a toilet) were labeled with a resident identifier for two randomly sampled residents (Resident 109 and 91). 2. The resident's nasal cannula (NC - a small plastic tube, which fits into a patient's nostrils for providing supplemental oxygen) tubing and hand-held nebulizer (HHN, a small machine that turns liquid medicine into a mist that can be easily inhaled) were not touching the floor for one (1) out of eight (8) sampled residents (Resident 21) reviewed under infection control. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement its antibiotic stewardship program (a coherent set of actions which promote using antimicrobials responsibly) that includes antibiotic (ATB - a medicine that fights bacterial infections by killing bacteria or stopping them from multiplying) use protocols and a system to monitor antibiotic use for three of three sampled residents (Residents 35, Resident 7, and Resident 101) reviewed for antibiotic use by failing to ensure: 1. Resident 35's Cephalexin (also known as Keflex, a type of antibiotic that can treat various bacterial infections) and Fluconazole (a type of antibiotic that can treat various bacterial infections) had monitoring for its adverse effects (an undesired, harmful, or unexpected result caused by a medical treatment, such as a drug, surgery, or intervention). 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a functional and sanitary environment when water leaks were present in the laundry area, active water leaks from pipes resulting in wet floors a bath blanket used to soak up leaked water and wash basins placed under leaking pipes to catch water and soap suds. This deficient practice created a potential risk for slips, falls, and unsanitary conditions and had the potential to affect residents, staff and visitors. Cross-reference F584 and F880.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain sanitary conditions in the food services department when a fly (a type of insect) was observed flying around the trayline (an area where foods were assembled from the steamtable to resident's plate), dishwashing area, and food storage area during lunch service. This failure had the potential to result in 130 of 132 residents, who received food from the kitchen, to acquire food borne illnesses (illness caused by consuming contaminated foods or beverages) by consuming potentially contaminated food.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care in a manner that maintained a resident's dignity for one (1) of 1 sampled resident (Resident 39) reviewed for dignity by failing to ensure Certified Nursing Assistant (CNA) 8 was not standing over the resident while assisting the resident during mealtime. This deficient practice had the potential to negatively affect Resident 39's psychosocial wellbeing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep the call light (an alerting device for nurses or other nursing personnel to assist a patient when in need) within reach of one of two sampled residents (Resident 94) reviewed under environment task. The deficient practice had the potential to result in the resident`s inability to summon health care worker for help as needed.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident's medical records were updated to show documented evidence that advance directives (a legal document indicating resident preference on end-of-life treatment decisions) were discussed with one of three sampled residents (Resident 14) reviewed for advance directive by failing to provide the advance directive formulation information to the resident or the resident representative (RP). The deficient practice violated the resident's rights and/or representative's right to be fully informed of the option to formulate their advanced directives.

Inspectors wroteBased on interview and record review, the facility failed to document a significant change of condition (COC, is the formal written record of any significant, non-temporary change in a resident's physical, mental, or emotional health [e.g., sudden confusion, falls, weight loss]) on a resident's physical condition that had deteriorated for one of three sampled residents (Resident 81) by failing to do a change of condition documentation on a resident that was sent to the emergency room (ER) for right lower leg (RLL) venous ulcer (a shallow, slow-healing open sore that typically forms on the lower leg, usually around the ankle) with green exudate (a thick, protein-rich fluid that oozes out of blood vessels and collects in nearby tissues during inflammation, injury, or infection), fouls smell, with serosanguinous (a common type of fluid that drains from a healing wound, incision, or injury) [...]

Inspectors wroteBased on interview, and record review, the facility failed to develop and implement a baseline care plan (an initial, temporary care document that is developed within 48 hours of a resident's admission, providing essential, person-centered care instructions to staff to ensure safety and continuity of care while a more comprehensive plan is developed) on the use of Duloxetine (a medication to treat depression [a mood disorder that causes a persistent feeling of sadness and loss of interest]) for one of one sampled resident (Resident 130) reviewed for the use of antidepressant medication (prescription medications designed to treat depression, anxiety, and other mood disorders by balancing chemicals in the brain). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan (is a tool that ensures residents receive personalized, comprehensive, and goal-oriented care in a nursing home setting) for: 1. One of three sampled residents (Resident 66) during random observations conducted for medication pass observation and dining observations addressing the resident`s enhanced barrier precautions (EBP, an approach to the use of personal protective equipment (PPE) to reduce transmission of Multidrug-Resistant Organisms (MDROs) between residents in skilled nursing facilities (SNFs)). This deficient practice had a potential for cross-contamination (the process of making something dirty or poisonous, or the state of containing unwanted or dangerous substances) of infections to residents. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care consistent with professional standards of practice to prevent pressure ulcer/injury (ulcers that happen on areas of the skin that are under pressure from lying in bed, sitting in a wheelchair, or wearing a cast for a long period) to two of two sampled residents (Residents 130 and 72) reviewed for pressure ulcers by failing to: 1. Apply Resident 130's low air loss mattress (LALM, a special type of air mattress that uses a constant, gentle flow of air through microscopic holes to keep the skin dry and prevent pressure wounds) per physician's order. 2. Ensure Resident 72's LALM was set according to the resident`s weight or comfort. The deficient practices had the potential for development and worsening of pressure ulcers/injuries to residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents receiving enteral feeding (EF - also known as tube feeding, a method of supplying nutrients directly into the stomach) received appropriate care and services to prevent complications of enteral feeding for one (1) of one (1) sampled resident (Resident 72) reviewed for tube feeding when the water flush bag did not indicate the time the bag was started and the administration rate for the water flush. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pain management consistent with professional standards of practice and the resident's goals and preferences for one of five sampled residents (Resident 73) reviewed for unnecessary medication by failing to: 1. Ensure the Licensed Nurses (LN) administered as needed (PRN) acetaminophen (medication to treat mild pain) and hydrocodone - acetaminophen (an opioid [also called a narcotic - powerful pain-reducing medication) per the physician's orders and based on the assessed numeric pain rating scale (a standard pain scale with zero being no pain and ten [10] as the worst pain one can imagine) for Resident 73. 2. Ensure the LNs followed up with the physician to obtain an order for severe pain when Resident 73 complained of severe pain on the numeric pain scale. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that a resident who was receiving dialysis (clinical purification of blood as a substitute for the normal function of the kidney) treatment received services consistent with professional standards of practice for one of two sampled residents (Resident 11) investigated during a review of dialysis care area, by failing to complete the post-dialysis assessments form on 12/23/2025 per facility policy. This deficient practice placed Resident 11 at risk for developing complications related to renal disease such as swelling, high blood pressure, and uncontrolled bleeding which could result in death.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate administering of all drugs and biologicals) for one of one sampled resident (Resident 87) investigated under Medication Administration and Storage Labeling task by failing to ensure on 1/13/2026, Licensed Vocational Nurse (LVN) 3 documented the administration of oxycodone hydrochloride (a drug or chemical whose manufacture, possession, or use is regulated by a government) five (5) milligrams (mg- a unit of measurement) to Resident 87 immediately after administration in the Narcotic and Hypnotic Record (NHR - a document designed for dispensers of controlled substances to keep track of the pharmaceuticals as legally mandated). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to discard Resident 116's Ativan (lorazepam - a medication used to treat anxiety and restlessness) when the bubble pack (packaging that have a preformed plastic pocket or shell where a product sits securely in place) slot number (#) 27 was damaged, the seal was broken, and covered with tape in one of three inspected medication carts (Medication Cart 1 Station 200). This deficient practice increased the risk that Resident 116 could have received medication that had become ineffective or toxic due to improper storage.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the resident's right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) for one of three sampled residents (Resident 1). On 8/29/2025 at approximately 4:15 p.m., while Resident 1 and Resident 2 were both in Room A (Resident 1 and Resident 2's shared room), Resident 2, using his (Resident 2) three fingers (did not specify which hand), pushed Resident 1's back, between the shoulder blades (a large, triangular-shaped bone located on the back of the upper rib cage, one on each side of the body). This deficient practice resulted in Resident 1 being subjected to physical abuse by Resident 2 while under the care of the facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from verbal abuse (the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or to their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability) for one of three sampled residents (Resident 1). On 8/23/2025 at around 6:30 a.m., Certified Nursing Assistant (CNA) 1 flipped off (describes the act of extending the middle finger as a rude and offensive gesture to express anger, contempt, or annoyance toward someone, particularly in a non-verbal way) using two middle fingers of both hands, yelled obscenities, and called a derogatory and racial insult at Resident 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of verbal abuse (the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or to their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability) within two hours to the State Survey Agency (SSA). On 8/23/2025 at around 6:30 a.m., Certified Nursing Assistant (CNA) 1 flipped off (describes the act of extending the middle finger as a rude and offensive gesture to express anger, contempt, or annoyance toward someone, particularly in a non-verbal way) using two middle fingers of both hands, yelled obscenities, and called a derogatory and racial insult at Resident 1. The facility reported the verbal abuse incident on 8/26/2025 to the SSA. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its policies and procedures (P&P) affecting two of five sampled residents (Resident 1 & Resident 2) by failing to: A. Notify Resident 1's doctor and responsible party on 6/30/2025 that Resident 1 encountered a change of condition with injury. B. Provide Resident 2 with the right to refuse room changes. These deficient practices denied the residents and their responsible parties' their rights, and to information needed to make decisions related to residents' care needs.

Inspectors wroteBased on interview and record review, the facility failed to inform the attending physician (MD) for one of three sampled residents (Resident 1) when: 1. The Skilled Nursing Facility (SNF) 1, was unable to provide Speech Therapy (ST) on 5/15/2025 when MD ordered an ST and swallow evaluation (a test done by a Speech-Language Pathologist (SLP) to figure out why a person is having trouble swallowing). 2. Resident 1 continued to have difficulty swallowing and pocketing (the act of storing food inside the mouth without swallowing it) after the Change in Condition (COC) on 5/15/2025. These deficient practices resulted in Resident 1 not receiving the ST evaluation resulting in Resident 1 having a COC on 5/24/2025 where Resident 1 was noted with inability to eat, coughing and pocketing requiring transfer to General Acute Care Hospital (GACH) 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) received treatment and care in accordance with professional standards of practice when the facility failed to follow the Registered Dietitian's (RD- a food and nutrition expert who helps people improve their health through food choices and dietary changes) recommendations. This deficient practice had the potential for Resident 1 to have unplanned weight loss.

Inspectors wroteBased on interview and record review, the facility failed to provide Speech Therapy (ST) on 5/15/2025 when the Medical Doctor (MD) ordered an ST and swallow evaluation (a test done by a Speech-Language Pathologist (SLP) to figure out why a person is having trouble swallowing) for one of three sampled residents (Resident 1). This deficient practice resulted in Resident 1 not receiving the ST eval resulting in Resident 1 having a COC on 5/24/2025 where Resident 1 was noted with inability to eat, coughing and pocketing requiring transfer to General Acute Care Hospital (GACH) 1.

Inspectors wroteBased on interview and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices for one of three sampled residents (Resident 1) when: 1. The facility failed to accurately document on Resident 1's medication administration Records (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for calorie count for seven days. 2. The facility failed to accurately document Resident 1's Calorie Count. These deficient practices resulted in inaccurate documentation of Resident 1's records.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections by failing to ensure staff were not wearing gloves in the hallway after exiting the rooms of three of six sampled residents (Resident 1, Resident 2, and Resident 3). This deficient practice had the potential to spread infections and illnesses among residents and staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the resident ' s right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) for one of four sampled residents (Resident 1) when on 3/16/2025 at 8:26 a.m., Resident 1 and Resident 2, who were both in the facility ' s smoking patio (an outdoor area designed for residents to enjoy fresh air and engage in activities), had a verbal altercation (a noisy argument or disagreement) that led to a physical altercation (a confrontation or fight involving physical contact or force) in which Resident 2 used a knife in his (Resident 2) possession to cause an injury to Resident 1. This deficient practice resulted in Resident 1 being subjected to physical abuse by Resident 2 while under the care of the facility. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide supervision (refers to the ongoing monitoring and guidance provided by staff to ensure the safety and well-being of residents) for two of four residents (Resident 1 and Resident 2) when on 3/16/2025 at 8:26 a.m., Resident 1 and Resident 2, who were both in the facility ' s smoking patio (an outdoor area designed for residents to enjoy fresh air and engage in activities), had a verbal altercation (a noisy argument or disagreement) that led to a physical altercation (a confrontation or fight involving physical contact or force) in which Resident 2 used a knife in his (Resident 2) possession to cause an injury to Resident 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the confidential personal information of four of four sampled residents (Resident 9, Resident 10, Resident 11, and Resident 12) were protected by failing to: 1. Ensure Resident 9 ' s narcotic (a drug or other substances that affects mood or behavior) sheet was not left unattended, facing the hallway, on Nurse Station 3 ' s Telephone Orders Only bin. 2. Ensure the clinical records of Resident 10, Resident 11, and Resident 12 were not left unattended on Nurse Station 3 computer. These deficient practices had the potential to violate Resident 9, Resident 10, Resident 11, and Resident 12's rights for privacy and confidentiality of personal and medical records.

Inspectors wroteBased on interview and record review, the facility failed to ensure a face-to-face visit (a required in-person meeting between a healthcare provider and a resident) was made by a physician or alternate visits by a Nurse Practitioner (NP) was conducted timely according to the facility ' s policy and procedure on Physician Visits for three of four sampled residents (Resident 5, Resident 6, and Resident 8). This deficient practice had the potential to result in an undetected decline in Residents 5, 6, and 8's medical, health or psychosocial conditions and can lead to a delay in the necessary provision of care, treatment, and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure the medical records of three of four sampled resident ' s (Resident 5, Resident 6, and Resident 7) were maintained in accordance with accepted professional standards and practice, complete, and accurately documented by failing to: 1. Ensure Resident 5 and Resident 7 ' s physician telephone orders were dated and signed. 2. Ensure Resident 5, Resident 6, and Resident 7 ' s Attending Physician (MD) reviewed and signed the residents ' Order Summary every month. 3. Ensure Resident 6 ' s medical records do not contain blank worksheet forms and blank consent forms with Nurse Practitioner's (NP) signatures. These deficient practices had the potential for inaccurate medical interventions and inaccurate information on Residents 5, 6, and 7 ' s medical records.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident to resident altercation was thoroughly investigated for two of four sampled residents (Resident 1 and Resident 2). On 3/16/2025 at 8:26 a.m., Resident 1 and Resident 2, who were both in the facility ' s smoking patio (an outdoor area designed for residents to enjoy fresh air and engage in activities), had a verbal altercation (a noisy argument or disagreement) that led to a physical altercation (a confrontation or fight involving physical contact or force) in which Resident 2 used a knife in his (Resident 2) possession to cause an injury to Resident 1. This failure had the potential to place the residents at risk for further abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure Preadmission Screening and Resident Review (PASARR - a federal assessment requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care) Level I Screening (preliminary screening to identify individuals potentially needing specialized services due to mental illness or intellectual/developmental disabilities) was completed for one of four sampled residents (Resident 2). This deficient practice had the potential to result in a delay of necessary care and services to Resident 2.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement policy and procedure on safeguarding of all prescribed medications for one of three sampled residents (Resident 3) by failing to ensure Resident 3's prescribed medication was stored in the medication cart of the nursing station where Resident 3 was located. This deficient practice had the potential for non-authorized access to Resident 3's medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free from significant medication errors by failing to ensure the physician orders were followed. Resident 1's medication dose was not clarified with the attending physician. This deficient practice placed Resident 1 at risk for medication administration error that had the potential to result in difficulty in breathing.

Inspectors wroteBased on interview and record review, the facility failed to maintain a system-wide method for pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) for one of nine sampled residents (Resident 1) by failing to account for the exact whereabouts of Resident 1 ' s controlled substance (narcotics) medication. This deficient practice increases the risks for mishandling of a controlled substance increases the risks of diversion (the illegal distribution or abuse of prescription drugs or their use for purposes not intended by the prescriber) of medications, staff working in an impaired state, or accidental exposure of controlled substances to other residents possibly resulting in respiratory depression (the inability to breathe) leading to hospitalization or death.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were treated with respect and dignity in a manner that promotes maintenance or enhancement of the quality of life for one of three sampled residents (Resident 1) by failing to ensure Resident 1's preference to self-administer a medication was honored. This deficient practice had the potential to affect the resident's sense of self-worth and self-esteem.

Inspectors wroteBased on interview and record review, the facility failed to ensure a comprehensive assessment was done for one of three sampled residents (Resident 1) by failing to reassess Resident 1 for self-administration of medications. This deficient practice had placed Resident 1 at risk for medication administration error that had the potential to result in injection site infection and underdosage of the medication.

Inspectors wroteBased on interview and record review, the facility failed to ensure a comprehensive, person-centered care plan with measurable objectives and interventions for one of three sampled residents (Resident 1) was created and implemented that addressed Resident 1's self -administration of medication. This deficient practice had placed Resident 1 at risk for not receiving the necessary services and assistance that can result in resident injury or serious condition.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) had a physician order to self-administer Trulicity (a medication used in the treatment of type 2 diabetes mellitus [a chronic condition that affects the way the body processes blood sugar]). This deficient practice had the potential to create confusion in the delivery of care and services to Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free from significant medication errors by failing to ensure the physician orders were followed. Resident 1 was allowed to self-administer a medication without an order for self-administration. This deficient practice placed Resident 1 at risk for medication administration error that had the potential to result in uncontrolled blood sugar.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from physical abuse (intentional bodily injury) for one of eight sampled residents (Resident 1) when on 12/3/2024, Resident 7 witnessed Resident 2 hit Resident 1 left arm causing a scratch using Resident 2's left hand. This deficient practice resulted in Resident 1 being subjected to physical abuse by Resident 2 while under the care of the facility.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of employee to resident abuse within two hours to the State Survey Agency (SSA), the Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities), and law enforcement as per its policies on abuse for one of three sampled residents (Resident 1). This deficient practice had the potential to place Resident 1 at risk for further abuse.

Inspectors wroteBased on interview and record review, the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards of practice for one of three sampled residents (Resident 1). This deficient practice had the potential to result in confusion in the care and services rendered to Resident 1 and resulted in inaccurate information entered into Resident 1's medical record.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm by one resident towards another) for one of 11 sampled residents (Resident 9). On 10/17/2024 at 7:30 p.m., Certified Nursing Assistant 4 (CNA 4) witnessed Resident 10's left arm was around Resident 9's neck from behind, while Resident 10 punched Resident 9 with his (Resident 10) right closed fist multiple times on the face while Resident 9 was sitting on the wheelchair watching television (TV) in their (Resident 9 and Resident 10's) room. This deficient practice resulted in Resident 9 being subjected to physical abuse by Resident 10 while under the care of the facility. Resident 9 sustained swelling on the lips with bleeding and pain. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure four of 11 sampled residents (Resident 1, Resident 2, Resident 3, and Resident 4) were provided a safe and homelike environment. The facility failed to: 1a. Ensure Resident 1, 2, and 3 had a restroom with functioning plumbing system. b. Ensure safe and private alternative restrooms were provided for Residents 1,2, and 3's toileting needs. 2. Ensure Resident 4 was informed that other residents were directed to use Resident 4's restroom. These deficient practices resulted in Residents 1,2,3, and 4 not having a homelike comfortable and safe environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one of one sampled resident (Resident 135) was not given food containing allergens (a substance that causes an allergic [a condition that causes illness when someone eats certain foods or touches or breathes in certain substances] reaction) when on 10/8/2024, Resident 135, who was allergic to onions, was served baked beans containing onions for lunch. This deficient practice resulted in Resident 135 being served baked beans containing onions which had the potential to result in a life-threatening condition such as anaphylactic shock (severe allergic reaction including closure of airways), severe tachycardia (increased heart rate), cardiac arrest (sudden loss of heart function, breathing, and consciousness [the state of being awake and aware of one's surroundings]) and/or death for Resident 135. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents were treated with respect and dignity in a manner that promotes maintenance or enhancement of his or her quality of life and by failing to: 1. Ensure Licensed Vocational Nurse 6 (LVN 6) knocked before entering the resident's room, requested permission to enter the resident's room, and did not loudly state the resident's name in a decibel heard 35 feet (a unit of measurement) away at Station A for one of three sampled residents (Resident 68) reviewed during the Dignity care area. 2. Ensure LVN 6 treated Resident 68, and an additional two of seven resident's present during the Resident Council task, with professionalism for one of three sampled residents (Resident 68) reviewed during the Dignity care area and two of seven additional residents interviewed during the Resident Council task. 3. [...]

Inspectors wrote3. During a review of Resident 66's admission Record (AR), the AR indicated the facility admitted the resident on 12/21/2022, and readmitted the resident on 7/31/2024, with diagnoses including displaced fracture of the right femur (a break in the thigh bone where the bone fragments are not aligned), abnormalities of gait (manner of moving on foot) and mobility, and history of falling. During a review of Resident 66's History and Physical (H&P), dated 1/16/2023, the H&P indicated the resident had the capacity to understand and to make decisions. During a review of Resident 66's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 8/9/2024, the MDS indicated the resident has the ability to make self-understood and to understand others. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a baseline care plan for one of eight sampled residents (Resident 385) during initial sampling by failing to develop and implement a care plan for the use of oxygen therapy (a t]treatment in which a storage tank of oxygen or a machine called a compressor is used to give oxygen to people with breathing problems), psychotropic medications (Donepezil, Mirtazapine, Trazadone [are drugs or substances that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior]), and anticoagulant (warfarin, an anticoagulant drug used to prevent and treat blood clots). The deficient practice had the potential to result in a delay in care and treatment decreasing quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and/or implement a comprehensive person-centered care plan for two of nine sampled residents (Resident 102 and 107) investigated under the accidents care area, two of two (Resident 17 and 23) sampled residents investigated under the activities of daily living (ADL, routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) care area, and two of five sampled residents (Resident 66 and 75) investigated under the unnecessary medications care area when the facility failed to: 1. Develop Resident 102's care plan for medication storage at the bedside. 2. [...]

Inspectors wroteBased on interview and record review, the facility's licensed nursing staff failed to provide care in accordance with professional standards for two of two sampled resident (Residents 70 and 75) reviewed under the insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) care area and one of one sampled residents (Resident 70) reviewed under the anticoagulant (a drug used to prevent blood clots) care area by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (SQ - beneath the skin) administration sites. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the resident environment was free of accident hazards for nine (9) of twelve (12) sampled residents (Residents 66, 75, 114, 70, 80, 103, 68, 80, and 96) investigated under accidents by failing to ensure: 1. Resident 66, 75, and 114's fall mat (a floor mat designed to reduce the risk of injury from fall by providing a soft-landing surface) did not have medical equipment or furniture on top of them for a longer period of time. These deficient practices had increased the chances of the resident incurring an injury such as falls with fracture (a break or crack in a bone) and even death. 2. Resident 70, 80, 102, 103, and 68's medications were not left unattended at the resident's bedside. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents who require dialysis (also known as renal dialysis and hemodialysis, a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) receive services, consistent with professional standards of practice, for one of two sampled residents (Resident 19) investigated under the dialysis care area when Resident 19's pre and post dialysis weights were not documented into the electronic medical record. This deficient practice had the potential for the facility's ability to monitor the resident's drastic weight changes from dialysis.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were assessed, including a review of risks including entrapment (when a resident is trapped in the spaces in between or around the bed rails [adjustable metal or rigid plastic bars that attach to the bed that are available in a variety of types, shapes, and sizes], mattress, or bed frame), provided and maintained a copy of the informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered), and failed to obtain a physician's order for the use of bed rails for three of seven residents (Resident 66, 90, and 61) investigated under the physical restraints care area and two of nine sampled residents (Resident 75 and 107) investigated under the accidents care area by failing to: 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free of any significant medication errors (means the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order, manufacturer's specifications, and accepted professional standards) for one of one sampled residents (Residents 70), investigated under insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) and enoxaparin (a drug used to prevent blood clots), by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) insulin administration sites. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure kitchen staff were routinely trained and evaluated for competency skills when staff: a. Failed to maintain safety and sanitation in the kitchen when: 1. There were cracked racks in the walk-in freezer. 2. Mixer had food debris and residue. 3. Food preparation roof rack had food splatters and food buildup. 4. Chopping boards had scratches and stains. b. Failed to perform hand hygiene after picking up a potato on the floor then continued washing the other batch of potatoes in the preparation sink. c. Failed to follow menus for lunch on 11/20/2024 when [NAME] 1 cooked green peas with onions instead of seas greens without a Registered Dietitian approval. d. Failed to serve breads without hard crust on soft mechanical diets (diet that are soft and chopped). e. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to follow the menu and did not meet nutritional needs of 138 of 139 residents on regular texture diets (diet with no restrictions) when: a. The staff served pork BBQ without weighing portion sizes on all the diets, including Resident 105. b. The cook did not follow the recipe of baked beans for lunch service on 10/8/2024. c. The facility failed to follow the lunch menu on 10/9/2024 by omitting gravy from the mashed potatoes for Resident 74. These deficient practices had the potential to cause difficulty in eating, chewing, and swallowing to the residents, cause resident dissatisfaction, and decrease food and nutrient intake resulting to unintended (not done on purpose) weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare food by methods that conserved temperatures when breakfast food temperatures in Station Four (4) had the following temperatures: - Sausage patty 113 degrees Fahrenheit (°F, a degree of temperature) - Biscuit with gravy 108°F - Milk 49°F - Juice 45°F This deficient practice placed 138 of 140 facility residents, including Resident 19, on regular consistency texture (texture with no restriction) and texture modified diets at risk of unplanned weight loss, a consequence of poor food intake, getting food from the kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to prepare foods in a form designed to meet individual needs when residents on soft mechanical-chopped diet (diet consisted of food that are chopped half inches ([in] a unit of measurement) and soft foods) received whole hard biscuit on the plate for lunch service. This deficient practice had the potential to cause coughing, choking (to keep from breathing the normal way) and death for 17 of 17 residents on soft mechanical chopped diet.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: a. Two (2) vents had dust buildup in the walk-in refrigerator. b. Five (5) of six (6) blue racks were chipped, cracked and rusted in the walk-in refrigerator and one (1) of 6 racks was chipped in the walk-in freezer. c. There was an ice buildup in the walk-in freezer, curtains and door. d. Cook 1 was wearing a gold bracelet during food preparation. e. Internal parts of the mixer had dry food residue. f. Roof rack had dried food splatters and buildup. g. Chopping boards had scratches and were sticky to touch. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to have a policy regarding the use and storage of food brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption when the policy did not include shelf life for prepared foods for storing food brought in by family and other visitors and there was no designated refrigerator for resident's outside food sources. This deficient practice had the potential to cause a decrease food intake resulting to unintentional (without trying) weight loss, frustrations, and psychosocial harm to 138 of 139 facility residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose garbage and refuse properly by not maintaining the trash area free from trash, plastic, plastic cups, plastic containers, soiled gloves, paper bag of food, papers on the dumpster's (a large trash metal container designed to be emptied into a truck) floor. This deficient practice had a potential to attract birds, flies, insects, pest and possibly spread infection to 138 of 139 facility residents.

Inspectors wrote2. During a review of Resident 385's admission Record (AR), the AR indicated the facility admitted the resident on 10/3/2024, with diagnoses including chronic respiratory failure (a long-term condition that makes it difficult for the body to exchange oxygen and carbon dioxide), chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing), and dependence on supplemental oxygen (a medical treatment that provides extra oxygen to people who have breathing problems or low blood oxygen levels). During a review of Resident 385's MDS dated [DATE], the MDS indicated the resident had intact cognition (the ability to maintain a relatively high level of mental functioning, including thinking, learning, memory, and perception). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain sanitary conditions in the food services department when seven (7) flies (a type of insect) were observed in the kitchen. This deficient practice had a potential to result in 138 of 139 residents, who received food from the kitchen, to acquire food borne illnesses (illness caused by consuming contaminated foods or beverages) by consuming potentially contaminated food.

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep the call light (an alerting device for nurses or other nursing personnel to assist a patient when in need) within reach of the resident for one of six sampled residents (Resident 112) investigated under environment facility task. The deficient practice had the potential to result in residents not being able to summon a health care worker for help as needed.

Inspectors wroteBased on observation, interview and record review, the facility failed to offer and assist the resident's choice to wear personal clothing for one of one sampled resident (Resident 23) investigated under the Choices investigative area. This deficient practice has the potential to result in a decline in the resident's self-esteem and self-worth.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident received an accurate assessment, reflective of the resident's status at the time of the assessment, for one of one sampled residents (Resident 83) investigated under the communication-sensory care area when the facility failed to accurate assess Resident 83's ability to hear in the minimum data set (MDS, a federally mandated resident assessment tool). This deficient practice had the potential for the resident to not receive the appropriate interventions. Cross-reference F685.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary services to maintain good grooming and personal hygiene for two of two sampled residents (Resident 17 and 23) when: 1. The facility failed to shave Resident 17's, a female resident, facial hair. 2. The facility failed to offer and assist Resident 23 to wear their personal clothing. These deficient practices had the potential to negatively affect the residents' psychosocial wellbeing. Cross-reference F656.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents receive treatment and assistive devices to maintain hearing abilities for one of one sampled resident (Resident 83) investigated under the communication-sensory care area when the facility failed to refer Resident 83 to an otolaryngologist (ENT, also known as an ear, nose, and throat physician) and/or audiologist (physician who specializes in hearing, balance, and ear problems) for his impaired hearing. This deficient practice resulted in a delay in care for Resident 83.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents received care consistent with professional standards of practice to prevent pressure injuries (PI - localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) by failing to ensure the low air loss mattress (LALM- A mattress composed of inflatable air cushions that is used to relieve pressure on body parts) was set to the correct weight for one of four sampled residents (Resident 74) investigated under the Pressure Ulcer / Injury care area. This deficient practice had the potential to affect the redistribution capabilities (to evenly spread pressure to other areas across the body) of the LALM surface resulting in the development or worsening of pressure ulcers.

Inspectors wrote2. During a review of Resident 66's admission Record (AR), the AR indicated the facility admitted the resident on 12/21/2022, and readmitted the resident on 7/31/2024, with diagnoses including cirrhosis of liver (a condition in which the liver is scarred and permanently damaged), encephalopathy (damage or disease that affects the brain), and viral hepatitis C (an inflammation of the liver caused by the hepatitis C virus). During a review of Resident 66's History and Physical (H&P), dated 1/16/2023, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 66's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 8/9/2024, the MDS indicated the resident had the ability to make self-understood and to understand others. The MDS indicated the resident was on a high-risk drug class antibiotic. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the entire medication regimen of the resident was managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being for two of five sampled residents (385 and 65) investigated under unnecessary medications review by failing to: 1. Obtain an informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) for Resident 385's use of psychotropic medication (Donepezil, used to treat dementia [memory loss and mental changes] associated with mild, moderate, or severe Alzheimer's disease [a disease characterized by a progressive decline in mental abilities]). 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain medical records with accepted professional standards to one of five sampled residents (Residents 57) selected for immunization review by failing to ensure to document vaccine (medications used to prevent diseases usually given by injection or by mouth) administration on the Medication Administration Record (MAR) when influenza vaccine (flu shot) and coronavirus disease-2019 (COVID-19 - a highly contagious respiratory illness capable of producing severe symptoms) vaccine they were administered. This deficient practice had the potential to result in inaccurate documentation in the medical record regarding Residents 57's immunization record.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain mechanical, electrical, and patient care equipment in safe operating condition investigated during random observations by: 1. Failing to ensure the bed controller (device used to change the height and angle of the bed) cords for Resident 114 and Resident 22 did not have exposed wires. 2. Failing to ensure the call light (a device used by a resident to signal his or her need for assistance from staff) cord for Resident 104 did not have exposed wires. These deficient practices had the potential to place the residents at risk for injury. 3. Failing to ensure the Hoyer lift (a medical device that helps caregivers move patients from one place to another with minimal physical effort) was plugged in the wall outlet to charge when not in use. [...]

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from physical abuse for two of four sampled residents (Resident 3 and Resident 4) when on 9/1/2024 at 9:30 a.m.: 1. Resident 3 stated Resident 4 punched Resident 3 on the left side of his cheek. 2. Resident 3 stated he hit Resident 4 on his right cheek. 3. Resident 4 stated he punched Resident 3. This deficient practice resulted in Resident 3 and Resident being subjected to abuse while under the care of the facility.

Inspectors wroteBased on interview and record review, the facility failed to readmit one of four sampled residents (Resident 4). This deficient resulted in Resident 4's rights to be violated.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from physical abuse by a resident for for two of seven sampled residents (Resident 1 & Resident 2). Resident 1 and Resident 2 were observed in the facility ' s surveillance camera recordings having a physical altercation with each other. This deficient practice affects the safety and well-being of the residents, exposing the residents to physical or mental trauma. Findings During a review of Resident 1 ' s admission Record, the admission Record indicated the facility admitted the resident on 4/27/2023 with diagnoses of muscle weakness, unspecified dementia (a decline in mental capacity affecting thought and decision-making tasks), and personal history of transient ischemic attack (a temporary loss of blood flow to a part of the brain). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure resident had the right to receive an unopened package for one of five sampled residents (Resident 2). This deficient practice violated Resident 2's right to receive an unopened package and had the potential to negatively affect the resident's psychosocial wellbeing.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident was not subjected to a physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) for a second time by a resident who was physically abusive for one of three sampled residents (Resident 3). The facility failed to: 1. Ensure Resident 4 did not hit Resident 3 ' s left leg with his (Resident 4) wheelchair on 7/19/2023. 2. Ensure the facility ' s policy and procedures (P&P) titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, was followed to ensure Resident 3 was free form physical abuse. This deficient practice resulted in Resident 3 being subjected to physical abuse by Resident 4 while under the care of the facility resulting in Resident 3 ' s left leg pain requiring pain medication.

Inspectors wroteBased on interview and record review, the facility failed to implement its abuse prevention, investigation, and policies and procedures for one out of three sampled residents (Resident 3) by failing to complete a thorough investigation regarding allegations of abuse involving Resident 3. This deficient practice had the potential to result in unidentified abuse in the facility and failure to protect residents from abuse.

Inspectors wroteFacility failed to ensure that staff followed proper infection control procedures when moving between isolation rooms for two of five sampled residents (Resident 5 and Resident 4). Staff did not remove their used PPE and put on new PPE before entering the isolation room (room [ROOM NUMBER]) of Resident 5 after being in Resident 4's isolation room (room [ROOM NUMBER]). Additionally, the Kitchen Aid (KA 1) threw his used gloves on the residents' coffee cart instead of disposing them in the trash can. This deficient practice had the potential of spreading infection to other residents.

Inspectors wroteBased on interview and record review, the facility failed to protect residents right to be free from abuse for two of three sampled residents (Resident 1 and Resident 3) by: 1. Failing to ensure Resident 1 was free from physical abuse inflicted by Resident 2. On 7/4/2024 at 3:45 p.m., Licensed Vocational Nurse 1 (LVN 1) witnessed Resident 2 punched Resident 1's right side of the head. 2. Failing to ensure Resident 3 was free from verbal abuse inflicted by Certified Nursing Assistant 2 (CNA 2). On 6/29/2024 at 2:05 a.m., CNA 1 heard CNA 2 telling Resident 3 to shut up and be quiet in a loud voice. These deficient practices resulted to: 1. Resident 1 being subjected to physical abuse by Resident 2 while under the care of the facility. 2. Resident 3 being subjected to verbal abuse by CNA 2 while under the care of the facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of six sampled residents (Resident 1), who was cognitively (mental action or process of acquiring knowledge and understanding) intact and had a history of right-sided weakness following a cerebral infarction (stroke-a loss of blood flow to part of the brain, which damages brain tissue), was free from sexual abuse (sexual behavior or a sexual act forced upon a woman, man, or child without their consent). On 5/26/2024 at 8:45 p.m., Certified Nursing Assistant 2 (CNA 2) and CNA 3, after hearing Resident 1 yelling for help, went to Resident 1 ' s room. CNA 2 and CNA 3 witnessed Resident 2, Resident 1 ' s roommate, on top of Resident 1 and was kissing Resident 1 ' s neck area. Resident 1 was lying in his bed with both feet on the floor and Resident 2 was pulling Resident 1 ' s jeans down to his knees. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the face-to-face visit was made by a physician or alternate visits by a nurse practitioner was conducted timely according to the facility ' s policy and procedures on Physician Visits for four of 17 sampled residents (Resident 14, Resident 15, Resident 16, and Resident 17). This deficient practice had the potential to result in an undetected decline in medical, health or psychosocial condition and can lead to a delay in necessary care, treatment, and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure eight of eight sampled facility staff (Director of Staff Development [DSD], Social Services Director [SSD], Licensed Vocational Nurse 7 [LVN 7], LVN 11, LVN 12, Certified Nursing Assistant 2 [CNA 2], CNA 16, and CNA 17) were competent to provide appropriate services to assure residents were free from abuse by failing to: 1. Provide in-service education that included sexual abuse prevention for the facility ' s resident population. 2. Ensure the in-services (staff training) lesson plan content was accurate. 3. Ensure annual competencies (measurable pattern of knowledge, skills, abilities, behaviors in order to perform occupational functions successfully) were completed for the SSD, LVN 11, CNA 16, and CNA 17. As a result, Resident 1 was subjected to sexual abuse from Resident 2. [...]

Inspectors wrote3a. A review of Resident 14 ' s admission Record indicated the facility admitted the resident on 9/2/2023 with diagnoses including type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), angina pectoris (chest pain or discomfort that kept coming back), and essential hypertension (an abnormally high blood pressure that was not a result of a medical condition). A review of Resident 14 ' s Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 5/8/2024, indicated the resident ' s cognitive (problems with a person ' s ability to think, learn, remember, use judgement, and make decisions) skills were severely impaired. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide reasonable accommodations for residents needs and preferences for one of six sampled residents (Resident 2), when Resident 2 requested for a room change. This deficient practice had the potential to negatively impact the psychosocial wellbeing of the resident.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of six sampled residents (Resident 2) ' s Family Member 2 (FM 2) was notified of Resident 2 ' s change in condition when on 5/11/2024, Resident 2 ' s lips, left eye and left cheek were swollen. This deficient practice had the potential to result in delayed provision of necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to implement its abuse policy and procedure by failing to thoroughly investigate a resident to resident sexual abuse for two of six sampled residents (Resident 1 and Resident 2) by: 1. Failing to interview and clarify written statements of witnesses (Certified Nursing Assistant 2 [CNA 2] and CNA 3). 2. Failing to interview and document Resident 1 and Resident 2 ' s roommates (Resident 6 and Resident 7). 3. Failing to verify one to one staff monitoring (involves a nurse or carer providing support specifically to one individual) were provided to Resident 2 as indicated in Resident 2 ' s Progress Note, Care Plan and Administrator ' s (ADM) facility Investigation Report. 4. Failing to document incident date correctly in the facility ' s Investigation Report. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive care plan for two of six sampled residents (Resident 1 and Resident 2) by: 1. Failing to implement one on one staff monitoring (involves a nurse or carer providing support specifically to one individual) to Resident 2 as indicated in Resident 2 ' s care plan on at risk for safety dated 5/27/2024. 2. Failing to develop a care plan to address Resident 1 ' s refusal to walk with Restorative Nursing Assistant (RNA) on 5/29/2024. These deficient practices had the potential for delayed provision of necessary care and services.

Inspectors wroteBased on interview, and record review, the facility failed to follow professional standards of practice for one of six sampled residents (Resident 1) when Licensed Vocational Nurse 1 (LVN 1) and Registered Nurse 1 (RN 1) did not check Resident 1 ' s vital signs (measurements of the body's most basic functions that includes blood pressure [the force of your blood pushing against the walls of your arteries], heartrate, respiratory rate [the number of breaths a person takes per minute], oxygen saturation [amount of oxygen level of the blood], and temperature) when Resident 1 had a change in condition on 5/26/2024. This deficient practice had the potential to place Resident 1 at risk for undetected elevated high blood pressure, heart rate, respiration and temperature which could negatively impact the resident's healh and safety.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Facility Assessment (an examination of the resident population to determine the resources necessary to care for its residents competently during day-to-day operations and emergencies) was completed and reviewed annually. This deficient practice had the potential to place residents at risk for functional, physical, mental, and psychosocial needs to not be met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a comprehensive person-centered plan of care with measurable objectives and interventions for one of three sampled residents (Resident 1). The facility failed to ensure Resident 1's care plan indicated the specific interventions addressing the resident's risk for falls. As a result, on 4/10/2024 at 9:30 a.m., Resident 1 fell while Certified Nursing Assistant 1 (CNA 1) was transferring the resident from the bed to the wheelchair and sustaining a left elbow skin tear and a right knee abrasion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1), who was identified as high fall risk, was assessed after the resident had a witnessed fall from the wheelchair. This deficient practice had the potential to result in inaccurate assessment that can lead to Resident 1 not receiving timely medical interventions.

Inspectors wroteBased on interview and record review, the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one of five sampled residents (Resident 1). This deficient practice had the potential to result in confusion in care and delivery of services to Resident 1 and may result in medication error.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program regarding Coronavirus disease 2019 (COVID-19, a viral infection that is highly contagious and easily transmits from person to person, causing respiratory problems and may cause death) for three of ten sampled residents (Resident 5, Resident 7, and Resident 8) by failing to: 1. Ensure Housekeeping 1 [HKP 1], Activity Assistant 1 [AA 1], Patio Supervisor [PS], and Payroll Personnel [PRL 1]) wore the N95 mask (respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) properly. 2. Ensure that a used facemask was not placed on a clean kitchen surface. These deficient practices placed other residents and staff at risk for exposure and contracting COVID-19.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of ten sampled residents (Resident 3) was treated with respect and dignity in a manner that promotes maintenance or enhancement of the quality of life by failing to ensure the urinary catheter (a flexible tube used to empty the bladder and collect urine in a drainage bag) drainage bag was fully covered by the dignity bag (a dark colored bag that conceals the front and back of the urine drainage bag). This deficient practice had the potential to affect Resident 3 ' s sense of self-worth and self-esteem.

Inspectors wroteBased on interview and record review, the facility failed to promptly notify the attending physician (MD 1) on a change of condition after an unwitnessed fall incident that required physician intervention for one of ten sampled residents (Resident 2). On 1/29/2023, during the night shift (11 p.m. to 7 a.m. nursing shift), Resident 2 had an unwitnessed fall as reported to Licensed Vocational Nurse 1 (LVN 1) on the morning change of shift report. LVN 1 documented Resident 2 ' s fall on the Change of Condition Evaluation Form (COC) at 1:18 p.m. on 10/30/2023. Resident 2 ' s physician was notified at 6 p.m. on 10/30/2023. This deficient practice had the potential for delayed medical interventions for Resident 2.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident ' s pain was managed as indicated in the facility ' s Pain Assessment and Management policy for one of ten sampled residents (Resident 1), by failing to ensure Resident 1 ' s pain medication, oxycodone-acetaminophen (medication to manage moderate to severe pain) scheduled every 4 hours as needed, was administered according to the physician order. This deficient practice resulted in Resident 1 ' s unnecessary pain experienced during daily activities and had the potential to lead to Resident 1 ' s decline in the quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure pain medications were available for one of ten sampled residents (Resident 1) by failing to acquire Resident 1 ' s pain medication, oxycodone-acetaminophen (medication to manage moderate to severe pain) scheduled every 4 hours as needed, as indicated in the facility ' s policy on medication refill. This deficient practice resulted in Resident 1 ' s unnecessary pain experienced during daily activities and had the potential to lead to Resident 1 ' s decline in the quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure medical records were complete and accurately documented for one of ten sampled residents (Resident 2). On 1/29/2023, during the night shift (11 p.m. to 7 a.m. nursing shift), Resident 2 had an unwitnessed fall as reported to Licensed Vocational Nurse 1 (LVN 1) on the morning change of shift report. LVN 1 documented Resident 2 ' s fall on the Change of Condition Evaluation Form (COC) at 1:18 p.m. on 10/30/2023. Resident 2 ' s physician was notified at 6 p.m. on 10/30/2023. Registered Nurse 1 (RN 1) documented Resident 2 ' s fall on 10/31/2023. This deficient practice resulted in inaccurate information on Resident 2 ' s clinical record and had the potential for delayed medical interventions for Resident 2.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of six sampled residents (Resident 1), who needed an indwelling urinary catheter (a flexible plastic tube [a catheter] inserted into the bladder [a hollow organ that stores urine] to provide continuous urinary drainage) because of a diagnosis of urinary retention (inability to voluntarily void urine), was provided treatment and care based on the comprehensive assessment and plan of care. The facility failed to: 1. Monitor the amount of urine eliminated (urinary output) after Resident 1 ' s urinary catheter was pulled out and was not replaced on 11/3/2023, as ordered by Resident 1 ' s attending physician (Physician 1). 2. Inform Physician 1 that the facility did not have policies and procedures (P&Ps) on monitoring the urinary output on incontinent (unable to control voiding) residents. 3. [...]

Inspectors wroteBased on interview and record review the facility failed to provide a safe environment and supervision for one of four resident (Resident 1). On 6/23/2023 at 10:40 a.m. Resident 1, while unsupervised, was walking out of room became dizzy and fell. Resident 1 was observed with laceration (cut) to forehead and sent to General Acute Care Hospital 1 (GACH 1). On 6/24/2023 at 7:17 a.m. Resident 1 returned to facility. At 8:18 a.m. Resident 1 was found in her room lying on her left side with reopened wound on left forehead and bleeding, Resident 1 was transferred to GACH 2. As a result, Resident 1 fell and sustained a laceration on the left side of the forehead requiring transfer to GACH 2 where she was diagnosed with cervical vertebra fracture (C2 fracture- a break in the second vertebra [the small circular bones that form the spine of a human being or animal] of your neck).

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a comprehensive person-centered care plan for one of three sampled residents (Resident 1) to address resident ' s refusal for nail care. This deficient practice had the potential to negatively affect Resident 1 ' s self-esteem and placed him at risk for infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care in a manner that maintained or enhance a resident's dignity and respect in full recognition of their individuality for three of four sampled residents (Residents 281, 33, and 116) investigated for dignity by: 1. Failing to ensure that Resident 281 who had an indwelling urinary catheter (a tube that is inserted into the bladder, allowing urine to drain freely) had a privacy bag to cover the urinary catheter drainage bag. 2. Failing to ensure that Resident 33's privacy curtain was fully drawn, was wearing clothing, fully covered with sheets, and incontinence brief not exposed. 3. Failing to ensure Resident 116 was served her meal tray simultaneously with the other residents in the dining room during lunch. These deficient practices had the potential to affect the residents' self-worth and self-esteem.

Inspectors wroteBased on observation, interview, and record review the facility failed to keep the call light (an alerting device for nurses or other nursing personnel to assist a patient when in need) within reach of the resident for five out of five sampled residents (Resident 33, 55, 63, 98, and 104). This deficient practice had the potential to result in the residents not being able to call for facility staff assistance and increase their risk for injury or fall.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents had the right to receive mail for two of 10 sampled residents (Resident 50 and Resident 81). Resident 50 and Resident 81 stated they do not receive mail on Saturdays. This deficient practice violated the residents' right to receive mail on Saturdays and had the potential to negatively affect the resident's psychosocial well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the residents were provided with a safe, clean, comfortable, and homelike environment for four of four sampled residents (Resident 34, 76, 118, and 27) by: 1. Failing to ensure electrical wire were not exposed on Resident 34's bed remote control. This deficient practice had the potential to place Resident 34 at risk for accidents such as electrocution. 2. Failing to maintain a clean, pleasant, and neutral-scent environment for Resident 76's who had a sticky bedroom floor with strong foul odor. This deficient practice had the potential negatively affect the resident's quality of life. 3. Failing to ensure Resident 118's bathroom sink was not loosely attached to the bathroom wall. This deficient practice had the potential to make residents feel uncomfortable and place residents at higher risk for accidents. 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive plan of care with measurable objectives and interventions for six of six sampled residents (Resident 57, 88, 97, 101, 123, and 281) by: 1. Failing to develop a care addressing Resident 57's pain management. 2. Failed to implement Resident 88's care plan interventions of monitoring of medication, vital signs, and behavior on 9/28/2023. 3. Failing to implement Resident 97's care plan interventions to monitor for side effects of antipsychotic (medication for mental disorders) medication on 9/25/2023. 4. Failing to develop a care plan addressing Resident 101's smoking. 5. Failing to develop care plan for addressing Resident 123's activities. 6. [...]

Inspectors wroteBased on interview and record review, the facility's licensed nursing staff failed to provide care in accordance with professional standards to four out of five sampled residents (Residents 29, 57, 98, and 282) by: 1. Failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) insulin (a hormone that lowers the level of sugar in the blood) administration sites to Residents 19 and 57. 2. Failing to rotate Lovenox (enoxaparin sodium injection) (medication that helps prevent the formation of blood clots) administration sites to Resident 98. The deficient practices had the potential for adverse effect of same site subcutaneous administration of insulin and anticoagulant medications such as lipodystrophy (abnormal distribution of fat). 3. [...]

Inspectors wroteBased on observation, interview and record review, the facility staff failed to provide appropriate treatment and services for three (Resident 102, 117, and 76) of four sampled residents with an indwelling urinary catheter (a tube that is inserted into the bladder, allowing urine to drain freely) by: 1. Failing to provide daily catheter care and catheter assessments to Residents 102 and 117. 2. Failing to place a catheter tubing securement device (to secure an indwelling urinary catheter) on Resident 117. 3. Failing to assess Resident 76 prior to placement of an indwelling urinary catheter. These deficient practices had the potential for residents to develop catheter associated urinary tract infection (CAUTI, an infection of the urinary tract caused by a tube [urinary catheter] that has been placed to drain urine from the bladder).

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the kitchen in a clean, safe, and sanitary condition in which food was stored, prepared, and served in accordance with professional standards of food service safety by: 1. Failing to ensure that a pack of fresh blueberries observed with white spots was discarded. 2. Failing to ensure an open bottle of non-alcoholic [NAME] cocktail mix was labelled with open date. 3. Failing to ensure open bags of French fries, white bread, and yellow bread were labelled with open date. 4. Failing to ensure yellow cheese in a container was labeled with the content and open date. 5. Failing to ensure white cheese in a container was labelled with the content and discarded past the date indicated 9/27/2023 - 9/31/2023. 6. [...]

Inspectors wroteBased on interview and record review, the facility staff failed to arrange provision of hospice services (a type of care and philosophy of care that focuses on the care of the terminally ill patients' pain and symptoms, and attending to their emotional and spiritual needs) for two of two sampled residents (Resident 76 and 124) by failing to ensure hospice staff, including registered nurse (RN), licensed vocational nurse (LVN), and hospice aide (HA) provided nursing visits based on the hospice calendar and failed to provide the hospice visitation notes to the facility. These deficient practices had the potential to negatively affect Residents 76 and 124's physical comfort, psychosocial well-being, and not receiving the needed and necessary hospice care services timely.

Inspectors wrote3. A review of Resident 25's admission Record indicated the facility admitted the resident on 6/18/2011 and readmitted the resident on 2/23/2020 with diagnoses including gastrostomy (gastrostomy (G-tube - a surgical procedure for inserting a tube through the abdomen wall and into the stomach and used for feeding or drainage), heart failure (a condition that develops when the heart doesn't pump enough blood for the body's needs, and dysphagia (difficulty swallowing). A review of Resident 25's History and Physical dated 9/26/2022, indicated the resident did not have the capacity to understand and make decisions. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program so that the facility is free of pests (e.g. mosquitoes and flies) when the following occurred: 1. Flying insects were observed inside Resident 50 and Resident 118's room. Resident 118's bathroom window screen had a hole in it. 2. The conference room bathroom window screen had an opening, not sealed to the window, and multiple mosquitoes were observed on the ceiling and walls. These deficient practices resulted in Resident 50 unable to eat her dinner due to exposure to flies and Resident 118 feeling annoyed due to the pests. These also placed the potential for residents and staff to be exposed to mosquito bites.

Inspectors wroteBased on observation, interview and record review, the facility's interdisciplinary team (IDT-a coordinated group of experts from several different fields who work together) failed to determine if self-administration was clinically appropriate for two of two sampled (Resident 89 and Resident 62) residents investigated under the self-administer medications care area by failing to: a. Ensure that the self-administration of medication assessment was completed for Resident 89. b. Ensure the medications were not left at the bedside for Resident 62, who was not capable to self-administer medications investigated under the self-administer medications care area. These deficient practices placed the resident at risk for unsafe medication administration or omission.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident's clinical records were updated regarding advance directive (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them) for one of eight sampled residents (Resident 227) when Resident 227's Advance Directive Acknowledgement form was left blank. This deficient practice had the potential to cause conflict with a resident's wishes regarding their care.

Inspectors wroteBased on interview and record review, the facility failed to implement its abuse reporting policy and procedure (P&P) by failing to report an allegation of resident-to-resident altercation to the State Survey Agency (Department of Public Health) within two hours for two of eight sampled residents (Resident 67 and Resident 227). This deficient practice had the potential to result in an unidentified abuse in the facility and had the potential for the residents to experience further abuse.

Inspectors wroteBased on observation, record review, and interview the facility failed to ensure Minimum Data Set (MDS-a resident assessment and care screening tool) assessments accurately reflect the resident's status for three of four sampled residents (Residents 101, 60, and 125) by: 1. Failing to ensure the assessment did not indicate Resident 101 was receiving anticoagulant medication. This deficient practice had the potential to cause errors in medical treatment and care planning for the resident. 2. Failing to ensure the assessment did not indicate Resident 125 was discharged to acute hospital. This deficient practice had the potential to negatively affect Resident 125's plan of care and delivery of necessary care and services upon discharge.

Inspectors wroteBased on interview and record review, the facility failed to ensure that a preadmission screening assessment was done for a resident who was diagnosed with a mental illness prior to admission in the facility for one of eight sampled residents (Resident 88). This deficient practice had the potential for not receiving the necessary and appropriate psychiatric level of treatment and evaluation in the facility.

Inspectors wroteBased on interview and record review, the facility failed to develop a baseline care plan (initial written guide that organizes information about the resident's care) within 48 hours of admission for one out of seven sampled residents (Resident 281) investigated under care planning care area. This deficient practice had the potential for the resident not to receive appropriate care and treatment specific to his needs.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the interdisciplinary team (IDT) review and revise the resident's care plan for two (Resident 55 and Resident 282) of two residents by: 1. Failing to indicate in the care plan an order by the physician to change the resident's peripherally inserted central catheter (PICC - a long, thin tube that's inserted through a vein in the arm and passed through to the larger veins near the heart) to a midline catheter (vascular access device placed into a peripheral vein) for Resident 282. 2. Failing to update the resident's care plan to reflect changes in the fall risk assessment for Resident 55 after readmission on [DATE]. These deficient practices placed the residents at risk for inconsistent implementation of the care plan that may lead to a delay in or lack of delivery of care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were provided a communication device to allow communication between staff and residents for one of eight sampled residents (Resident 227), when Resident 227 was not provided a dry erase marker for the white board that the resident uses to communicate with staff and visitors. This deficient practice had the potential to delay Resident 227's care and communication with staff and visitors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one (Resident 27) of one sampled resident investigated under the activities of daily living (ADL- basic tasks that must be accomplished every day for an individual to thrive) was provided care and services to maintain good grooming and personal hygiene. This deficient practice resulted in Resident 27 having poor grooming and personal hygiene. This had the potential to have a negative impact on the resident`s quality of life and self-esteem.

Inspectors wroteBased on interview and record review the facility failed to provide the necessary treatment and services consistent with professional standards of practice to two out of three sampled residents (Residents 102 and 117) by failing to consistently assess and document the pressure injuries (also known as pressure injuries, the breakdown of skin integrity due to pressure) of Residents 102 and 107. The deficient practice had the potential for infection, delayed healing of the pressure injuries and development of new pressure ulcer to residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure for one out one sampled resident (Resident 97) investigated for limited range of motion (ROM - movement of the joints) received the appropriate treatment and services to maintain ROM. This deficient practice placed the resident at risk for decline in mobility and range of motion.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the resident environment remains as free of accident hazards as is possible by failing to ensure the floor in for one of two (Resident 277) sampled residents reviewed under Accidents care area by failing to ensure the floor in Resident 277's room was kept dry and a wet floor sign placed on the floor to alert the resident that the floor was wet. This deficient practice placed the resident at risk for falls and serious injuries.

Inspectors wroteBased on interview and record review, the facility failed to evaluate and address the needs of residents at risk or already experiencing impaired nutrition for one of eight sampled residents (Resident 118), when Resident 118's plan of care to perform weekly weights were not performed by the facility. This deficient practice had the potential for additional weight loss and resulted in Resident 118's delay in care to address his weight loss.

Inspectors wroteBased on observation, interview, and record review the facility: 1. Failed to remove Resident 4's expired Albuterol solution (a medication used to prevent and treat breathing problems such as asthma) from Medication Cart A. The medication's expiration date was on 9/14/2023. 2. Failed to remove Resident 327's medication, Alendronate Sodium 70 mg tab (a medication used to help strengthen bones) from Medication Cart B. Resident 327 was discharged from the facility on 7/25/2023. These deficient practices had the potential for placing the residents at risk for receiving expired medications that can cause adverse effects (unwanted symptoms or side effects).

Inspectors wroteBased on observation, interview and record review, the facility failed to monitor adverse side effects (any unexpected or dangerous reaction to a drug) of Lovenox (a type of medication used to prevent blood from clotting) every shift as ordered by the physician for one of two sampled residents (Resident 98). This deficient practice placed the resident at risk for unidentified or unreported side effects of Lovenox reactions including bleeding easily and bruising.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident who was receiving a psychotropic (any drug capable of affecting mood, emotions, and behavior) medication was adequately monitored for the use of Sertraline HCl (medication to treat depression) as ordered by the physician for one of three sampled residents (Resident 64) by failing to: 1. Monitor and document the side effects of Sertraline HCl use every shift. 2. Monitor and document episode of depression m/b poor appetite AEB < 50 meal intake every shift. This deficient practice placed Resident 64 at risk of receiving unnecessary psychotropic medication without monitoring and evaluating the effectiveness of the medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored appropriately by failing to label Resident 86's acetylcysteine (medication that helps thin and loosens mucus in the airways due to certain lung diseases) medication with an open date for one of four sampled medication storage refrigerator (Med Ref 1). This deficient practice had the potential to place the residents at risk for receiving medications that have become ineffective or toxic due to improper storage leading to health complications and negative outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide residents with food that is palatable (referring to the taste and/or flavor of the food) for one of eight sampled residents (Resident 123) when Resident 123 stated the broccoli served during lunch on 10/4/2023 was overcooked and mushy. This deficient practice had the potential for residents to not consume their meals.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 11 sampled residents (Resident 4) was free of any significant medications errors when Resident 4 was ordered Percocet (a type of pain medication containing oxycodone [an opioid pain medication used to treat moderate to severe pain] and acetaminophen [a pain medication used to treat minor aches and pain]) 5-325 milligrams (mg - a unit of measure) two tablets every four hours as needed for severe to worst pain and was administered Percocet 10-325 mg two tablets. This deficient practice had the potential for Resident 4 to experience signs and symptoms related to opioid overdose (a life-threatening event that includes symptoms including shallow breathing, confusion, lessened alertness, and loss of consciousness). There was also a delay in Resident 4's administration of the next scheduled pain medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free from physical and mental abuse (deliberate aggressive or violent behavior with the intention to cause harm by one resident to another) inflicted by Resident 2. On 9/16/2023 at 9 a.m. while Resident 1 was sitting on his bed, one of his three roommates (the room was a four-bed room occupied by Residents 1, 2, 4, and 5), Resident 2, approached Resident 1 propelling himself in the wheelchair, took the metal footrest from his wheelchair with the right hand, stood by Resident 1 and tried hitting Resident 1 with the metal footrest. Resident 1 reacted by holding Resident 2's right arm (which was holding the footrest) and avoiding being injured by the metal footrest but then, Resident 2 hit Resident 1 several times with his left hand. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive care plan for the use of the anticoagulant (blood thinner, medication used to prevent blood clot) Lovenox for one of three sampled residents (Resident 3). Resident 3 was injected Lovenox every 12 hours as ordered on 7/4/2023, but there was no care plan, from 7/4/2023 to 9/26/2023, to monitor for side effects including bleeding and bruising. This deficient practice placed the resident at risk for experiencing unidentified side effects.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident's drug regimen is free from unnecessary drugs when used without adequate monitoring for one of four sampled residents (Resident 3). Resident 3 was receiving the anticoagulant (blood thinner, medication used to prevent blood clot) Lovenox every 12 hours as ordered on 7/4/2023, but the nursing staff were not monitoring Resident 3 for side effects including bleeding and bruising from 7/4/2023 to 9/26/2023. This deficient practice placed the resident at risk for experiencing unidentified side effects.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper sanitation and food handling practices by failing to ensure that one of three kitchen staff (Dishwasher 1 [DW 1]) was wearing a hair restraint (cover) while inside the kitchen. This deficient practice had the potential to compromise the integrity of food and placed the residents at risk for foodborne illnesses (illness caused by the ingestion of contaminated food or beverage).

Inspectors wroteBased on interview and record review, the facility failed to implement its abuse policy by not conducting a thorough investigation for a resident-to-resident abuse for two of three sampled residents (Resident 1 and Resident 2) when Resident 2 hit Resident 1 with the wheelchair footrest on 9/16/2023. This deficient practice had the potential to result in unidentified abuse and placed the residents at risk for further abuse.

Inspectors wroteBased on observation, interview and record review, the licensed nursing staff failed to follow professional standards of nursing practice for one of two sampled residents (Resident 1) by failing to notify the physician when Resident 1's systolic blood pressure (measures the pressure in the arteries when the heart beats) was greater than 180 millimeters of mercury (mmHg-measurement of pressure). This deficient practice had the potential to place Resident 1 at risk for complications of high blood pressure.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect a resident ' s right to be free from neglect (the failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress) for one of three sampled residents (Resident 1) by: 1. Failing to monitor Resident 1 ' s whereabouts and failing to provide supervision to Resident 1 who was at risk for wandering (going about from place to place) and high risk for falls. 2. Failing to ensure Resident 1 ' s wander guard bracelet (a device designed to activate alarms when a resident gets closer to entry and exit points) activated the wander guard alarm or system when Resident 1, in his wheelchair, exited the exit door near Station 1 while wheeling himself going outside the building to the smoking patio. 3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who was assessed as high risk for wandering (going about from place to place), with a wander-guard (a device designed to activate alarms when a resident gets closer to entries and exit points) in place as ordered by the physician was kept free from accidents and hazards by: 1. Failing to monitor and provide supervision to Resident 1 who was at risk for wandering and high risk for falls. 2. Failing to ensure Resident 1 ' s wander guard bracelet (a device designed to activate alarms when a resident gets closer to entry and exit points) activated the wander guard alarm or system when Resident 1, in his wheelchair, exited the exit door near Station 1 while wheeling himself going outside the building to the smoking patio. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for two of three sampled residents (Resident 1 and Resident 4) by failing to document holding the medications despite physician ' s order. This deficient practice may result in confusion in the care and services rendered to residents and may result in inaccurate information entered into residents ' medical records.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control practices for two of three sampled residents (Resident 1 and Resident 5) by failing to ensure Restorative Nursing Assistant 1 (RNA 1), wore N95 mask (respiratory protective device designed to achieve a very close facial fit) covering her nose and mouth while inside the dining area during a Coronavirus Disease- 2019 (COVID-19, a highly contagious respiratory illness in humans capable of producing severe symptoms) outbreak (a sudden rise in the number of cases of a disease). This deficient practice had the potential to result in the spread of COVID-19 to staff and residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure call lights were within residents ' reach while in bed for two out of three sampled residents (Resident 2 and Resident 3). This deficient practice had the potential to result in resident falls and residents not being able to summon health care workers for assistance when needed.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled resident (Resident 5) was seen by attending physician at least every 60 days while in the facility. This deficient practice had the potential to result in an undetected decline in medical, health or psychosocial condition and can lead to a delay in necessary care, treatment, and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure that a resident was assessed by a Registered Nurse (RN) after an unwitnessed fall incident that occurred on 8/20/2023 for one of three sampled residents (Resident 1). This deficient practice had the potential for Resident 1 to receive an inaccurate assessment and can lead to a delay in necessary care, treatment, and services.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one of three sampled staff (Payroll Staff [PS]), wore mask (a loose-fitting, disposable device that creates a physical barrier between the mouth and nose of the wearer and potential contaminants in the immediate environment) while seated in front of Dietary Supervisor (DS) inside the payroll room. This deficient practice had the potential to result in the spread of Coronavirus Disease 2019 (COVID-19- highly contagious respiratory infection that spreads from person to person when an infected person coughs, sneezes or talks) to staff and residents.