Magnolia Gardens Convalescent Hospital

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a written course of action that helps a resident achieve outcomes that improve their quality of life) for two of five sampled residents (Resident 1 and Resident 3), by failing to: 1. Develop and implement a comprehensive care plan that addressed Resident 1's and Resident 3's indwelling urinary catheter (a flexible tube inserted into the bladder to continuously drain urine, which empties into a collection bag). 2. Develop and implement a comprehensive care plan that addressed Resident 1's back rash. These failures had the potential to result in Resident 1 and Resident 3 not receiving the necessary care and treatment to address their identified conditions.

Inspectors wroteBased on interview and record review the facility failed to ensure tracking or other mechanisms were in place to evaluate the effectiveness of training during annual competencies for three of three sampled licensed nurses (Registered Nurse 1 [RN 1]), Licensed Vocational Nurse 1 [LVN 1], and Treatment Nurse [TN 1]) in accordance with facility policy titled, Staffing, Sufficient and Competent Nursing, reviewed on 3/9/2026, by failing to ensure there was documented evidence that a competency assessment had been conducted for licensed nurses on providing indwelling urinary catheter (a flexible tube inserted into the bladder to continuously drain urine, which empties into a collection bag) care. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide treatment of an indwelling catheter (a flexible tube inserted into the bladder to continuously drain urine, which empties into a collection bag) consistent with professional standards for one of three sampled residents (Resident 3) by failing to:a. Ensure Resident 3's indwelling urinary catheter collection bag was not placed in a basin on the floor.b. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure timely physician notification was documented, failed to document physician follow-up when no return call or physician orders were received and failed to notify the resident's representative of a significant change in condition ( a major or noticeable change in the health, physical ability, mental status, or behavior that is different from the usual condition and may require new assessment, treatment, or a change in care plan) for one of three sampled residents (Resident 1), when on 7/1/2026 Resident 1 complained of bladder (a hollow, muscular and stretch organ in the lower abdomen that collects and stores urine) pain and inability to urinate, in accordance with the facility's policy and procedure (P&P). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a licensed nurse assessed, treated, and monitored a resident following a significant change in condition ( a major or noticeable change in the health, physical ability, mental status, or behavior that is different from the usual condition and may require new assessment, treatment, or a change in care plan) for one of three sampled residents (Resident 1), when on 7/1/2026 Resident 1 complained of inability to urinate. [...]

Inspectors wroteBased on interview and record review, the facility failed to assess, monitor, document, and manage pain for one of three sampled residents (Resident 1), when on 7/1/2026 Resident 1 complained of bladder (a hollow, muscular and stretch organ in the lower abdomen that collects and stores urine) pain and inability to urinate. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to honor a resident's right to refuse the use of a floor mat (a cushioned floor pad designed to help prevent injury should a person fall) on the right side of the bed for one of two sampled residents (Resident 1). This deficient practice had the potential to limit the resident's right to make choices regarding care and treatment and negatively affect the resident's dignity, autonomy, and quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment was free of accident hazards for two of two sampled residents (Resident 1 and Resident 2) by failing to ensure: 1. Resident 1 did not have an over- bed table on top of the floor mat (a cushioned floor pad designed to help prevent injury should a person fall) on the right side of the bed and a trash can on top of the floor mat on the left side of the bed. 2. Resident 2 did not have an over-bed table, and trash can on top of the floor mat on the left side. This deficient practice increased the risk of accidents such as slips, trips, and falls with injuries for Resident 1 and Resident 2.

Inspectors wroteBased on interview and record review, the facility failed to provide radiology services to meet the need of one of two sample residents (Resident 1) by failing to: 1. Notify the physician of the delay of the physician's order for Bilateral (both sides) Hip X-ray (type of medical imaging test that captures images of the structures inside the body) STAT (immediate action required). 2. Ensure that Bilateral Hip X-ray STAT was provided within the timeframe specified in the physician's order. These deficient practices resulted in a delay in care and treatment and had the potential to result in worsening clinical conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure privacy was maintained for one of four sampled residents (Resident 4) when Certified Nursing Assistant 5 (CNA 5) did not fully close the privacy curtain while providing post shower dressing care. This deficient practice had the potential to result in Resident 4 feeling embarrassed and having loss of self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe homelike environment for three of three sampled residents (Resident 12, 71, and Resident 10) during an initial pool observation by failing to:a. Ensure the black pipe insulation wrapped around Resident 12's side rails were not frayed, torn and had a large piece missing on the right-side rail.b. Ensure the black pipe insulation wrapped around Resident 71's side rails were not frayed and torn.c. Ensure the black pipe insulation wrapped on the side rails and foot board were not torn and frayed for Resident 10. These deficient practices had the potential to affect the resident`s self-esteem and self-worth while living in an environment that is not in good repair.

Inspectors wroteBased on interview and record review, the facility failed to monitor hours of sleep for a resident that was prescribed trazadone (medication used to treat depression [mood disorder that causes a persistent feeling of sadness and loss of interest] and insomnia [difficulty falling or staying a sleep]) that is also used to help a resident sleep) for one of five residents (Resident 11) investigated for unnecessary medications. This deficient practice had the potential to place the resident at risk of taking an unnecessary medication and experiencing adverse side effects (undesired harmful effect resulting from a medication or other intervention).

Inspectors wroteBased on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for three of five residents (Resident 85, 98 and 11) investigated under unnecessary medications by failing to:a. Rotate (a method to ensure repeated injections are not administered in the same area) Resident 85's insulin (a medication that regulates sugar in the blood) injections sites on several occasions from 2/4/2026 to 4/5/2026. This deficient practice placed Resident 85 at risk for developing bruises, pain, and/or lipodystrophy (lump or accumulation of fatty tissue under the skin). b. Ensure timely follow-up and implementation of physician ordered referrals to specialty services for Resident 98. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an environment that was free from accident hazards for three of five sampled residents (Resident 6, Resident 7, and Resident 71) investigated under accidents by failing to:1. Ensure Resident 6 who was accessed as needing supervision to smoke, according to the care plan, did not have access to a cigarette lighter.2. Ensure that Resident 7 was free of accident hazards by allowing unsupervised access to a lighter and cigarettes. 3. Ensure over half of the padding was not missing from the right-side rail for a resident with a history of seizures (a sudden surge of abnormal electrical activity in the brain, leading to a range of symptoms like muscle spasms, loss of consciousness). These failures had the potential to result in injuries to Resident 6, Resident 7, and Resident 71.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Controlled Drug Record (CDR, accountability record of medications that are considered to have a strong potential for abuse) coincided with the Medication Administration Records (MAR, a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for one of one sampled residents (Resident 35). This deficient practice had the potential to result in medication error and/or drug diversion (illegal distribution or abuse of prescription drug).

Inspectors wroteBased on observation, interview, and record review, the facility failed to label and store drugs and biologicals in accordance with accepted professional principles for two of four (West Station Medication Cart and Middle Station Medication Cart 1) affecting Residents 17 and 21) for failing to ensure: 1. Resident 17's artificial tears (drops to provide lubrication to the eyes) were labeled with first name and last name. 2. Resident 21's glaucoma (a group of eye diseases that damage the optic nerve, causing gradual, irreversible vision loss) eye drops were labeled with an open date. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to serve food in accordance with professional standards for food service safety by failing to:1. Ensure food items on the tray line (a system of food serving in which a tray is moved along an assembly line to ensure a resident receives their prescribed diet) were at the proper temperatures when [NAME] 2 failed to take the temperature of the Asian salad.2. Follow safe food handling procedures by leaving the resident's breakfast at the beside until she woke up four hours later for one of one resident (Resident 20) during an initial pool observation. These failures had the potential to result in the possibility of harmful bacterial growth and cross contamination leading to foodborne illness.

Inspectors wroteBased on observation, interview and record review, the facility failed to establish and implement a clear policy for controlled drug administration (refers to the process of safely managing medications that are regulated by the government due to their potential for misuse or dependency - often called controlled substances) when its policy did not indicate the required timeframes for documenting controlled substances, including when to sign the Controlled Drug Record (CDR - document used in healthcare settings to track and account for medications that are regulated due to their potential for misuse) and when to sign/complete the Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident). [...]

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 by failing to ensure a staff member was at eye level while providing feeding assistance for one of three residents (Resident 75) investigated under the dignity care area. This deficient practice had the potential to result in a decrease in the residents' psychosocial well-being and loss of dignity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote the resident's right to be informed of and participate in their treatment for two of four (Resident 7 and Resident 63) sampled residents by failing to inform the resident and provide the name of medications and their indications (reason for the use of the medication) prior to administration of the medications. This deficient practice violated Resident 7 and Resident 63`s rights to make decisions regarding their medication regimen and afford the residents the opportunity to refuse any or all the medications due for administration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that discharge documentation included all the required elements, including the reason for transfer/discharge, effective date, and receiving location for one of three residents reviewed for closed records (Resident 102). This deficient practice resulted in incomplete documentation of discharge information, which could impair coordination of care and continuity of services for Resident 102.

Inspectors wroteBased on interview and record review, the facility failed to accurately (in a correct or exact manner) complete a smoking and safety assessment (a tool used to measure and interpret information) for one of two sampled residents (Resident 7) reviewed under the Smoking care area. This failure resulted in missing information on the assessment used to determine whether Resident 7 could safely smoke independently or required assistance and supervision.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive, person-centered care plan (a document designed to facilitate communication among members of the care team that summarizes a resident's health conditions, specific care needs, and current treatments) for one of 19 residents investigated under Care Planning. Specifically, the facility failed to include and address the following in the care plan: a. Vascular Dementia (a decline in thinking skills caused by conditions that block or reduce blood flow to the brain, often following a stroke or chronic vessel damage) diagnosis, which requires individualized interventions to address safety, cognition, and supervision needs.b. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to:1. Update and revise a resident`s care plan (CP- a document outlining a detailed, individualized approach to care tailored to a resident's specific needs) to reflect that breakfast should not be left at the bedside until the resident awakens, for one of four sampled residents (Resident 20) reviewed under the Nutrition care area. This deficient practice had the potential to place Resident 20 at risk, as the resident consistently wakes approximately four hours after breakfast is served. Leaving food at the bedside for this duration could promote harmful bacterial growth, increasing the risk of foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals).2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident with visual impairment was provided with assistive devices to help one of one sampled resident communicate his needs to the care team (Resident 93) investigated under the care area Vision and Hearing. This deficient practice had the potential to result in frustration and unmet needs if the resident is unable to express his care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's low air loss mattress (LALM - designed to distribute a patient's body weight over a broad surface area and help prevent skin breakdown) was set to the resident's weight per physician`s order for one (Resident 54) of two sampled residents investigated for pressure ulcer/injury (a skin and soft tissue injury that occurs when skin is under pressure). This deficient practice placed the resident at risk of discomfort and development of new pressure ulcers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate continence care and interventions for one of five sampled patients (Resident 98). This deficient practice had the potential to result in a decline from continence to incontinence, increased skin breakdown and pressure injuries, compromised dignity and quality of life and an increase in urinary tract infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the enteral feeding (a feeding tube that provides liquid nutrition directly into the stomach) was properly labeled for medication and solution and failed to administer timely prescribed enteral feeding for one of five sample residents (Resident 8). This deficient practice had the potential to result in administering the wrong formula or contaminated fluid, placing patients at risk for gastrointestinal infection (inflammation or irritation of the digestive tract), fluid imbalance (body has either too much or too little fluid for proper function) or aspiration (accidental inhalation of food, liquids, or saliva into the lungs) for Resident 8.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of one sampled resident (Resident 31), who required hemodialysis (HD or dialysis, a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) treatment, received care in accordance with standards of practice by failing to: Update a resident's care plan for hemodialysis to address a resident's repeatedly elevated blood creatinine (a waste product from muscle metabolism, filtered from the blood by the kidneys, normal reference range is 0.73 to 1.30 milligrams per deciliter [mg/dL, a unit of measure for kidney function]) blood laboratory (labs) level. Ensure there was information exchanged between the facility and the hemodialysis center when the Resident 31's creatinine was elevated. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure residents were free from significant medication errors by failing to rotate (a method to ensure repeated injections are not administered in the same area) insulin (a medication that helps regulate blood sugar levels) injections sites on multiple occasions between 2/4/2026 and 4/5/2026 for one of five sampled residents (Residents 85) investigated under the care area of unnecessary medications. This failure had the potential to result in bruising, pain, and/or lipodystrophy (a buildup or abnormal distribution of fatty tissue under skin) for Resident 85.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide at least 80 square (sq.) feet (ft) per resident for 26 of 40 multiple resident rooms (room [ROOM NUMBER], 103, 105, 106,107,108,109, 110,111, 112,114, 115, 116,117,118,119, 120,123, 126,133,136,137,138, 139,140,141) This deficient practice had the potential to result in inadequate space to provide safe nursing care and privacy for the residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys [bean-shaped organs, typically two in number, located in the back of the abdomen] stop working properly) residents received care in accordance with standards of practice for two of three sampled residents (Resident 1 and Resident 2) by failing to ensure that Post Dialysis Assessments (refers to evaluations conducted after a dialysis treatment to monitor a resident's condition and effectiveness of the dialysis process) were accurately and completely documented. This deficient practice had the potential to result in an increased risk of harm due to potential undetected post-dialysis complications. a. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow the prescribed renal diet (a specialized diet designed for residents with kidney [bean-shaped organs, typically two in number, located in the back of the abdomen] disease) for two of three sampled residents (Resident 2 and Resident 3) as outlined in the facility's printed menu by serving broccoli instead of green beans, rice instead of wheat pasta, and omitting the parsley garnish on the resident's plate. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one of three sampled residents (Resident 3) food preferences were honored when rice, a documented disliked food item, was served during lunch on 7/29/2025. This deficient practice resulted in Resident 3 being served rice, which had the potential to lead to decreased food intake and subsequent weight loss. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper sanitation and food handling practices by failing to ensure dietary staff did not have their personal cell phone in the preparation area for one of three sampled staff. This deficient practice had the potential to result in foodborne illness (refers to illness caused by the ingestion of contaminated food or beverages) and had the potential of spreading infection for 95 out of 95 in-house residents living in the facility. During an observation on 7/29/2025 at 12:30 p.m., in the kitchen, observed DA's personal cell phone in the food preparation area. During a concurrent observation and interview on 7/29/2025 at 12:31 p.m., in the kitchen, observed DA reaching for her (DA) personal cellphone, which was located on the food preparation area. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain accurate and complete medical records in accordance with accepted professional standards for one of three sampled residents (Resident 1) by: 1. Failing to document the correct time on Resident 1's Resident Transfer Record. 2. Failing to ensure Resident 1's Resident Transfer Record was complete. These deficient practices had the potential to result in confusion regarding Resident 1's health status at the time of transfer and placed Resident 1 at risk of not receiving appropriate care due to inaccurate and incomplete resident medical care information.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure the Discharge Summary (a concise, written document that summarizes a patient's hospital stay, outlining the care received and the patient's condition upon discharge) included a recapitulation of the resident's stay for one of four sampled residents (Resident 1). 2. Ensure the Post Discharge Plan of Care was completed for one of four sampled residents (Resident 1). 3. Ensure discharge planning was part of the comprehensive care plan for one of four sampled residents (Resident 1). These deficient practices had the potential to cause confusion regarding the care and services rendered to Resident 1 and could cause a delay in the continuity of care after Resident 1's discharge.

Inspectors wroteBased on interview and record review, the facility failed to ensure a trauma (refers to an emotional, psychological, or physical response to a deeply distressing or disturbing event that overwhelms a resident's ability to cope) assessment was conducted for one of four sampled residents (Resident 1). This deficient practice had the potential to result in delayed identification of underlying trauma-related issues, which could compromise resident care, delay appropriate referrals, and negatively impact resident outcomes.

Inspectors wroteBased on interview and record review, the facility failed: 1. To develop a comprehensive person-centered care plan (a document designed to facilitate communication among members of the care team that summarizes a resident's health conditions, specific care needs, and current treatments) and implement care plan interventions for two of four sampled residents (Resident 2 and 4) to address the residents' low air loss mattress (LALM - a specialized mattress designed to prevent and treat pressure ulcers [a localized injury to the skin and underlying tissue caused by pressure, friction, or shear]) setting levels and modes. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify one of five sampled residents (Resident 1) physician, when on 1/1/2025, Resident 1 had a critically low blood sugar reading (normal blood sugar level is between 70 and 99 milligrams per deciliter [mg/dl - unit of measurement used to express the concentration of a blood sugar]) of 45 mg/dl. This deficient practice placed Resident 1 at risk for untreated hypoglycemia (low blood sugar level) which can lead to adverse effects such as dizziness, falls or further hypoglycemic episodes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident ' s low air loss mattress (LALM - a specialty bed that alternates pressure to help heal and prevent pressure ulcer/injuries [PU/PI - injuries that break down the skin and underlying tissue when an area of skin is placed under pressure]) was set to the correct setting for two of three sampled residents (Resident 2 and Resident 4). This deficient practice had the potential to place the residents at risk for discomfort and development of pressure ulcers/injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a call light (a device used by a resident to signal his/her need for assistance from staff) was within a resident's reach while in bed for one of four sampled residents (Resident 4). This deficient practice had the potential to delay the provision of services and residents' needs not being met.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care in a manner that maintained a resident's dignity and respect by failing to ensure a staff member knocked on a resident's door prior to entering a resident's room for four of four sample residents (Resident 77, Resident 70, Resident 2, and Resident 49). This deficient practice had the potential to affect Resident 77, Resident 70, Resident 2, and Resident 49's self-esteem and self-worth. a. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a written course of action that helps a resident achieve outcomes that improve their quality of life) for two of two sampled residents (Resident 25 and Resident 15), who were observed with a bed pad alarm (a device that uses a pressure-sensitive pad placed underneath the resident to alert caregivers when a person attempts to get up without assistance This deficient practice had the potential to negatively affect the delivery of care and services to Resident 25 and Resident 15.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Provide an environment free from accidents and hazards for one of seven residents (Resident 7) reviewed under the accidents care area by failing to ensure Resident 7 did not store medications at bedside readily accessible to other residents. This deficient practice had the potential to result in residents obtaining medication without staff knowledge resulting in accidental ingestion causing harm to residents. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: 1. Drugs and biologicals were stored in accordance with accepted professional principals when an expired first aid kit (a portable collection of supplies and equipment designed to provide immediate medical assistance for minor injuries and emergencies) was not removed and disposed of from the only Medication Storage Room inspected during the investigation of medication storage and labeling. This deficient practice had the potential for the use of less effective medications or supplies which may not produce the expected results. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection control practices by failing to: 1. Ensure Treatment Nurse 1 (TN 1) removed their isolation gown (type of personal protective equipment [PPE- specialized clothing or equipment worn by an employee for protection against infectious materials] used in healthcare settings to protect healthcare personnel from the spread of infection or illness, particularly from contact with blood and body fluids) prior to leaving a resident's room who was on enhanced barrier precautions (EBP -a set of infection control practices that use PPE to reduce the spread of multidrug-resistant organisms [MDROs -microorganisms that are resistant to multiple classes of antibiotics and antifungals] in nursing homes) for one of 13 sampled residents (Resident 86). 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a call light (a device used by a patient to signal his or her need for assistance from a professional staff) was within reach for two out of two sampled residents (Resident 13 and Resident 6) investigated under the environment care area. This deficient practice had the potential to result in the residents being unable to ask health care workers for assistance with care and services as needed.

Inspectors wroteBased on interview and record review, the facility failed to develop a complete baseline care plan within 48 hours of a resident`s admission to the facility by failing to address the resident`s indwelling catheter (a hollow tube inserted into the bladder to drain or collect urine) care interventions for one of one sampled resident (Resident 85) reviewed under the indwelling catheter care area. This deficient practice had the potential for Resident 85 not to receive appropriate care and treatment in the facility.

Inspectors wroteBased on interview and record review the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) injection sites to one of one sampled residents (Resident 41) reviewed under the unnecessary medication- anticoagulant (medications that help prevent blood clots from forming or getting bigger) care area. The deficient practice had the potential for adverse effect (unwanted, unintended result) of same site subcutaneous administration of anticoagulant such as lipodystrophy (abnormal distribution of fat), bruising and pain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a resident with a communication board (a device that can help residents communicate with care providers and family using symbols, photos, or illustrations) for one of two sampled residents (Resident 15) whose primary language was not English. This deficient practice had the potential to prevent the resident from communicating with the staff and had the potential to delay receiving care/treatment the resident needed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure that residents receive continuous oxygen as ordered by their physician for two of five sampled residents (Resident 16 and Resident 39) reviewed under the respiratory care area. This deficient practice had the potential to cause Resident 16 and Resident 39 to have shortness of breath that could lead to hypoxemia (a low level of oxygen in the blood). 2. Ensure residents' oxygen tubing was dated as indicated in the facility's policy and procedure for two of five sampled residents (Resident 39 and 87) reviewed under the respiratory care area. This deficient practice had the potential to place the residents at increased risk of developing an infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement the physician's order for fluid restriction (limiting the amount of liquid a person consumes daily, often prescribed to manage kidney disease) limited to no water pitcher at bedside for one of two sampled residents (Resident 33) reviewed under dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) care area. This deficient practice had the potential to place Resident 33 at risk for fluid overload (a condition where you have too much fluid volume in your body) which can result in health complications.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that its medication error rate was less than five (5) percent. Nine medication errors out of 28 opportunities contributed to an overall medication error rate of 32.14 percent (%) affecting one of five randomly selected residents (Resident 44) observed for medication administration. The medication errors were as follows: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure leftover food brought to residents by family and other visitors were labeled with resident identifier and use by date for two of two (Resident 50 and 82) sampled residents. This deficient practice had the potential to result in foodborne illness (also called food poisoning, illness caused by eating contaminated food) among the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide at least 80 square (sq.) feet (ft.) per resident for 26 of 40 multiple resident rooms (room [ROOM NUMBER], 103, 105, 106, 107, 108, 109, 110, 111, 112, 114, 115, 116,117,118,119,120123,126,133,136,137,138,139,140,141) This deficient practice had the potential to result in inadequate space to provide safe nursing care and privacy for the residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure the facility ' s social services department conducted residents ' psychosocial assessments upon admission for two of three sampled residents (Resident 2 and Resident 3) and failed to make follow up calls to residents after they were discharged home for three of three sampled residents. (Resident 1, Resident 2 and Resident 3) These deficient practices had the potential to result in negative psychosocial outcomes a for Resident 2 and Resident 3 and had the potential to result in an unsafe discharge for Resident 1, Resident 2 and Resident 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 three sampled residents (Resident 1) by failing to document efforts of calling the physician after Resident 1's apical pulse (a pulse point on your chest that gives the most accurate reading of your heart rate) was more than 100 beats per minute (bpm) on 1/8/2025, 1/13/2025, 1/15/2025, 1/16/2025, and 1/20/2025. This deficient practice placed the resident at risk of not receiving appropriate care due to inaccurate resident medical care information and the potential to result in confusion in the care and services for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure there was an adequate indication for the use of ivermectin (a medication that treats infections caused by roundworms, threadworms, and other parasites [organism that lives on or in a host organism and gets its food from or at the expense of its host]) for one of three sampled residents (Resident 1) not diagnosed with scabies (itchy skin condition caused by infestation with small mites that live under the skin). This deficient practice had the potential to result in the use of unnecessary medication and cause adverse side effects (undesired harmful effect resulting from a medication or other intervention).

Inspectors wroteBased on interview and record review, the facility failed to ensure licensed nurse staff completed reconciliation (a process that validates the controlled substance [medication with a high potential for abuse] amount at the end of a shift is the amount expected) of controlled medications for one of four medication carts (Medication Cart A). This deficient practice had the potential to result in inaccurate reconciliation of controlled medication and placed the facility at risk for the inability to readily identify loss and drug diversion (the illegal distribution of prescription drugs for unintended purposes) of controlled medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's call light (a device used by a resident to signal his/her need for assistance from staff) was within reach for two of six sampled residents (Resident 1 and 2). This deficient practice had the potential to delay the provision of services and residents' needs not being met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure no more than two layers of linen were used with the use of a low air loss mattress (LALM - a specialty bed that alternates pressure to help heal and prevent pressure ulcer/injuries [PU/PI - injuries that break down the skin and underlying tissue when an area of skin is placed under pressure]) for one of two sampled residents (Resident 1). This deficient practice had the potential to increase the resident's risk of skin breakdown.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control practices by failing to ensure a resident's indwelling urinary catheter (a flexible tube inserted into the bladder and left in place to continuously drain urine) tubing was not touching the floor for one of two sampled residents (Resident 1). This deficient practice had the potential to result in the spread of germs placing the resident with an indwelling urinary catheter at risk for infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who required assistance with nail trimming was provided care and services to maintain good personal hygiene for one of four sampled residents (Resident 1). This deficient practice resulted in Resident 1 having long fingernails that had the potential to result in self-injuries such as skin cuts or scratches and a negative impact on the resident's self-esteem and self-worth.

Inspectors wroteBased on interview and record review, the facility failed to ensure the History and Physical (H&P - contains relevant information about the resident's past medical history, current medical concerns, including review of any pre-existing medical conditions, past hospitalizations and surgeries, allergies, medications being taken, family medical history, physical examination and assessment of mental status [ability to understand and make decisions]) Examinations for two of four sampled residents (Resident 1 and Resident 3) were completed in its entirety by the physician by failing to assess for mental status. This deficient practice had the potential for inconsistent care coordination due to incomplete H&P and a delay in care and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure a licensed nurse documented the administration of Tylenol (medication used to relieve pain and fever) on the Medication Administration Record (MAR- a report detailing the medications administered to a resident by a healthcare professional) for one of three sampled residents (Resident 2) on 8/26/2024. This deficient practice had the potential to result in medication errors and had the potential to result in confusion on the delivery of care and services.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure Certified Nursing Assistant 1 (CNA 1) donned (put on) gloves and a gown, prior to entering a contact isolation (used when a resident has an infectious disease that may be spread by touching either the resident or other objects the resident has handled) room for one of three sampled residents (Resident 3). This deficient practice had the potential for the spread of infection and cross contamination among residents.

Inspectors wroteBased on interview and record review, the facility failed to report two suspected cases of scabies (a contagious skin condition characterized by a rash [an area of the skin that has changes in texture or color and may look inflamed or irritated] and intense itching), and one confirmed case of scabies, for three of five sampled residents (Residents 1, Resident 2, and Resident 4). This deficient practice had the potential to result in the spread of scabies and cross contamination (the physical movement or transfer of harmful bacteria [germs] from one person, object, or place to another) among staff and other residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of one sampled resident (Resident 1) was provided with a discharge summary report that included information regarding Resident 1 ' s current skin condition upon discharge home. This deficient practice had the potential to result in unsafe discharge, incomplete documentation, and communication of Resident 1's stay in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper food handling and storage practices by failing to ensure food kept in the refrigerator designated for residents' foods was dated and maintained according to the facility's policy for four of seven sampled residents (Resident 7, 8, 29, and 61). This deficient practice had the potential to result in food borne illness (when contaminated food is consumed which causes an infection resulting illness).

Inspectors wroteBased on interview and record review, the facility failed to maintain accurate medical records for one of one sampled resident (Resident 45), as evidenced by licensed nurses documenting the incorrect arm for taking blood pressure readings on Resident 45. This deficient practice had the potential to result in confusion regarding Resident 45's condition and what care and services were provided to Resident 45.

Inspectors wrote3.a. A review of Resident 46's admission Record indicated the facility admitted the resident on 6/20/2021 with diagnosis including emphysema (a lung condition that causes shortness of breath from lung damage). A review of Resident 46's MDS dated [DATE], indicated the resident required oxygen while at the facility. A review of Resident 46's physician's orders, dated 6/20/2021, indicated an order to change the oxygen nasal cannula tubing every Sunday night and as needed. During a concurrent observation and interview on 5/13/2024 at 9:19 a.m., with Licensed Vocational Nurse 4 (LVN 4) and the DON, observed Resident 46's nasal cannula oxygen tubing not labeled with a date. LVN 4 and the DON stated Resident 46's nasal cannula oxygen tubing was not dated. The DON stated the nasal cannula oxygen tubing should be dated when oxygen tubing is placed on the resident. 3.b. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's call light (a device used by a patient to signal his/her need for assistance from staff) was within reach for one of 20 sampled residents (Resident 188). This deficient practice had the potential to cause a delay in resident care and for the resident's needs to remain unmet.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a homelike environment for one of six residents (Resident 8) when the paint was found peeling and/or missing in three areas of Resident 8's bedroom ceiling. The deficient practice violated Resident 8's right to a comfortable, homelike environment and had the potential to cause psychosocial harm.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive care plan (CP- a written document that summarizes a patient's needs, goals, and care) for one of one sampled residents (Resident 45), to include measurable objectives and timeframes to care for Resident 45's left forearm arteriovenous shunt (AV shunt- a surgical connection between an artery and a vein that allows for blood to be removed and returned during dialysis [a treatment that removes waste and excess fluid from the blood when the kidneys are no longer functioning properly]). This deficient practice had the potential to result in failure to deliver necessary care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 20 sampled residents (Resident 61) smoked in the facility's designated area, the westside patio, and not in the outdoor activity area that was surrounded with flammable substances. This deficient practice had the potential to result in burns damaging Resident 61's skin, fire, and explosion.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the physician signed the Physician Order for Life- Sustaining Treatment (POLST - a written medical that helps give residents with serious illnesses more control over their own care by specifying the types of medical treatment they want to receive during serious illness) for one of one sampled resident (Resident 45) on 8/20/2023. This deficient practice had a potential to cause conflict with the resident's or resident's representatives wishes regarding health care in the event of an emergency.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Licensed Vocational Nurse 7 (LVN 7) administered aspirin (stops the production of certain natural substances that cause fever, pain, swelling, and blood clots [gel-like clumps of blood]) 325 milligrams (mg - unit of measurement) instead of aspirin 81 mg to one of 20 sampled residents (Resident 190), as ordered by the physician. This deficient practice had the potential to place the resident at increased risk of experiencing adverse side effects (undesired harmful effect resulting from a medication or other intervention) such as developing blood clots.

Inspectors wroteBased on interview and record review, the facility failed to ensure licensed nurses monitored a resident's targeted behavior for the use of quetiapine (an antipsychotic- a medication used to treat psychosis [a mental condition in which thought, and emotions are so affected that contact is lost with external reality]) for one of 20 sampled residents (Resident 39). This deficient practice had the potential to result in adverse reaction (undesired harmful effect resulting from a medication or other intervention) or impairment in the resident's mental or physical condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure one of one sampled resident's (Resident 63) insulin (a hormone that lowers the level of glucose [sugar] in the blood) stored in the refrigerator of Medication room [ROOM NUMBER] was stored under the temperature range of 36-46 degrees Fahrenheit (F- unit of temperature). 2. Label an opened medication bottle of hydromorphone solution (a drug used to relieve moderate to severe pain) with an opened by date for one of one sampled resident (Resident 187). These deficient practices had the potential to diminish the effectiveness of the medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet the required room size of 80 square feet (sq ft - unit of measurement) per resident for 26 of 40 multiple resident rooms (Rooms 102, 103, 105, 106, 107, 108, 109, 110, 111, 112, 114, 115, 116, 117, 118, 119, 120, 123, 126, 133, 136, 137, 138, 139, 140, 141). This deficient practice had the potential to result in inadequate space to provide safe nursing care and privacy for the residents.

Inspectors wroteBased on interview and record review, the facility failed to implement its abuse prevention policy for one of four sampled residents (Resident 1) by failing to provide one to one abuse training for Certified Nurse Assistant 3 (CNA 3) who was directly involved in an abuse allegation made by Resident 1. This deficient practice placed Resident 1 at increased risk for abuse.

Inspectors wroteBased on interview and record review, the facility failed to notify the physician and the resident's responsible party, following an unwitnessed fall once the resident was found lying on the floor for one of two sampled residents (Resident 3). This deficient practice had the potential to have a negative effect on Resident 3's treatment if any decisions were needed at the time of the change of condition.

Inspectors wroteBased on interview and record review the facility failed to provide the needed care and services that were resident centered, for one of two sampled residents (Resident 3), as evidenced by: 1. Failing to ensure a Change of Condition (COC- a sudden clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains) was documented and completed after Resident 3 had an unwitnessed fall and was found lying on the ground. 2. Failing to ensure a 72-hour neuro-check (assessment to determine nervous system [brain, spinal cord, and a complex network of nerves] function) was immediately initiated after Resident 3 had an unwitnessed fall. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the low air loss mattress (mattress designed to prevent and treat pressure wounds [injury to skin and underlying tissue resulting from prolonged pressure on the skin]) was on the proper setting per manufacture's guidelines for one of two sampled residents (Resident 3). This deficient practice had the potential to place residents at risk for developing or worsening pressure wounds. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure licensed nurses did not leave medications at residents' bedside unattended for one of two sampled residents (Resident 3). This deficient practice had the potential to result in theft and loss of medication with the potential to harm residents by accidental administration of medications.

Inspectors wroteBased on interview and record review, the facility failed to readmit one of three sampled residents (Resident 1) to the facility after hospitalization. Resident 1 was discharged to a different nursing facility after their hospitalization. This deficient practice violated Resident 1's rights to return to their facility and resulted in Resident 1's displacement in an unfamiliar facility requiring adjusting to new surroundings.