McKinley Park Care Center

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) for three residents (Resident 1, Resident 2, and Resident 3) of four sampled residents when:1. Resident 1 struck Resident 2 in the face; and,2. Resident 2 struck Resident 3 in the face. These failures resulted in resident to resident physical abuse and had the potential for Resident 2 and Resident 3 to suffer physical and emotional injury.

Inspectors wroteBased on observation, interview and record review the facility failed to follow proper food storage, hygienic dish handling and hand hygiene techniques in the kitchen when:Undated and unlabeled raw green squash were observed in the kitchen food refrigerator; Kitchen staff stacked wet meal tray lids on top of one another before allowing them to dry;Kitchen staff failed to follow proper hand hygiene during handling of soiled dishes during dishwashing; and,Kitchen staff failed to follow proper hand hygiene during food preparation. These failures had the potential for all 77 residents in the facility to receive expired food, place all residents at risk for food-borne illness related to improper hand hygiene and place all residents at risk for exposure to possible biological growth on wet meal tray lids.1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Quarterly Minimum Data Set (MDS-a federally mandated resident assessment tool) assessments for 10 of 13 sampled residents (Resident 22, Resident 35, Resident 36, Resident 5, Resident 45, Resident 48, Resident 49, Resident 4, Resident 83, and Resident 92) were completed within the required timeframe, for a census of 77. These failures increased the potential for care plans not to be updated to reflect resident's current condition. A concurrent interview and record review was conducted with the MDS Coordinator (MDSC) on 1/22/26 starting at 2:34 p.m. The MDSC stated the facility has 14 days after Assessment Reference Date (ARD-look back or observation period) to complete the assessments and 14 days to transmit once the assessment was completed. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS-a federally mandated resident assessment tool) assessments for 13 of 13 sampled residents (Resident 22, Resident 24, Resident 35, Resident 36, Resident 5, Resident 45, Resident 48, Resident 49, Resident 4, Resident 82, Resident 83, Resident 92, and Resident 6) were completed and transmitted within the required timeframe, for a census of 77. These failures had the potential for residents not to receive individualized plan of care based on their specific needs. A concurrent interview and record review was conducted with the MDS Coordinator (MDSC) on 1/22/26 starting at 2:34 p.m. The MDSC stated the facility has 14 days after Assessment Reference Date (ARD-look back or observation period) to complete the assessments and 14 days to transmit once the assessment was completed. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to follow therapeutic diets (a nutritionally tailored meal plan prescribed by a physician and planned by a dietitian to treat, manage, or prevent specific medical conditions) for four of 77 residents who receive meals from the kitchen (Resident 44, Resident 78, Resident 90, and Resident 94). These failures had the potential to cause negative health outcomes for Resident 44, Resident 78, Resident 90, and Resident 94. During an observation on 1/21/26, at 11:53 a.m., during tray line (the placing of prescribed diets on residents meal trays) in the kitchen, Dietary Aid (DA) 1 did not place the fortified diet (a prescribed diet, deliberately increasing the calorie and protein density of regular meals to combat involuntary weight loss and malnutrition) item (2 individual packs of margarine) on Resident 78's lunch tray. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow infection prevention and control standards and provide a safe and sanitary environment for census of 77 residents, when:Enhanced Barrier Precautions (EBP-an infection control policy to reduce transmission of multi-drug resistant organisms, MDRO, using personal protective equipment, PPE, for residents with wounds, indwelling devices, or known colonization with specific pathogens) were not followed when performing resident care for Resident 94; and,Sanitary conditions in the laundry were not maintained and the cover for the carts were not in good condition. These failures had the potential to result in the spread of infection among residents and staff. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete an annual MDS assessment (Minimum Data Set assessment is a mandatory, standardized clinical evaluation of residents in U.S. Medicare/Medicaid-certified nursing homes, assessing their overall health, functional abilities like activities of daily living, cognition, mood, diagnoses, and preferences to create individualized care plans and ensure quality) timely for one of 22 sampled residents (Resident 82). This failure had the potential for Resident 82 to not receive quality care. During a concurrent interview and record review with the Minimum Data Set Coordinator (MDSC) on 1/22/26, at 3:15 p.m., Resident 82's MDS assessments were reviewed. Resident 82's annual MDS assessment ARD (assessment reference date: 14 days after the resident is admitted ) indicated 12/4/25. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a significant change in status assessment (SCSA- a comprehensive assessment that needs to be completed when the interdisciplinary team determined resident meets the guidelines related to improvement or decline in condition) was completed within 14 days from the time the change was identified for one of 22 sampled residents (Resident 24). This failure increased the potential for Resident 24 to not receive appropriate care. A review of the admission Record indicated Resident 24 had a diagnosis of palliative care (specialized medical care focusing on providing relief of pain and symptoms of serious illness) in June of 2025. A review of Resident 24's HOSPICE DISCHARGE SUMMARY indicated effective end of day on 12/4/25, Resident 24 was discharged from Hospice due to .stabilized & no longer meets criteria. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet professional standards of care for one of twenty-two sampled residents (Resident 9) when Resident 9 received a dose of medication that was ordered for another resident (Resident 40). This failure had the potential to result in Resident 9 experiencing adverse effects from receiving a medication not ordered for her. A review of Resident 9's admission Record indicated Resident 9 was initially admitted to the facility in January 2025 and readmitted in December 2025 with multiple diagnoses including cellulitis (bacterial skin infection) of left lower leg, lymphedema (tissue swelling caused by accumulation of fluid due to damaged or blocked lymph nodes), and dyspnea (difficulty breathing). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident's fingernails were maintained in a clean and trimmed manner for one of 22 sampled residents (Resident 7), when Resident 7 was observed with long, untrimmed fingernails. This failure had the potential to negatively impact Resident 7's psychosocial well-being and placed him at risk for skin injury leading to infection. A review of the admission Record indicated the facility admitted Resident 7 in the beginning of 2025 with multiple diagnoses, which included Parkinson's disease (a progressive disease of the nervous system that affects movement, balance and muscle control, characterized by tremors, stiffness, slowness, and balance issues) and left-sided hemiplegia (paralysis of the arm, leg, and trunk). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents environment was free of accident hazards, received adequate supervision and safe use of mechanical lift (used in transferring resident from bed to chair or vice versa) for one of 22 sampled residents (Resident 77), when Resident 77 was not safely transferred using a mechanical lift. This failure placed Resident 77 at risk for serious injuries, including fall, harm, or death and had the potential to affect Resident 77's psychosocial well-being. A review of the admission Record indicated the facility admitted Resident 77 in the summer of 2025 with multiple diagnoses, which included right-sided hemiparesis and hemiplegia (weakness and paralysis of the arm, leg, and trunk), left leg below the knee amputation, and muscle weakness. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respiratory care was provided according to professional standards for three of 22 sampled residents (Resident 104, Resident 42, and Resident 27) when:Resident 104 and Resident 42's nebulizer masks were not stored in a bag after use;Resident 42's BiPAP (bilevel positive airway pressure- breathing device providing higher pressure when breathing in to help open the lungs and a lower pressure when breathing out making it easier to exhale) order was incomplete; andResident 27 did not have an order for CPAP (continuous positive airway pressure - treatment for obstructive sleep apnea) in the clinical record and CPAP was not used until over one month after admission to the facility. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pain management in accordance with professional standards and resident centered care plans for two of 22 sampled residents (Resident 73 and Resident 18) when:The facility failed to reassess Resident 73 for pain within the required one-hour timeframe after receiving a PRN (as needed) pain medication. The facility failed to consistently assess Resident 18's pain and offer non-pharmacological (strategies that do not involve use of pain medications) interventions. These failures had the potential for Resident 73 and Resident 18 to be in pain and have ineffective pain management.1. During an observation on 1/20/26, at 10:49 a.m., in Resident 73's room. Resident 73 was observed to be moaning that her stomach was hurting. [...]

Inspectors wroteBased on interview and record review, the facility failed to identify trauma triggers for one of 22 sampled residents (Resident 83) with post-traumatic stress disorder (PTSD- a disorder in which a person has difficulty recovering after experiencing or witnessing a traumatic event). This failure had the potential for Resident 83 to experience re-traumatization (re- experience a traumatic event causing similar stress reactions) and possible increased symptoms such as restlessness, irritability and social withdrawal. A review of the admission Record indicated Resident 83 was admitted to the facility May of 2022 with diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought) and PTSD. Resident 83's Minimum Data Set (MDS- a federally mandated resident assessment tool) dated 12/4/25 indicated Resident 83 was cognitively intact. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the medication error rate was less than five (5) percent (%). The facility had a cumulative medication error rate of 7.4% consisting of two errors for one Resident (Resident 42) in a sample size of 27 opportunities for error. This failure had the potential to jeopardize Resident 42's health and well-being. During a medication pass observation on 1/21/26 at 7 a.m., with Licensed Nurse (LN 3), LN 3 was observed preparing Resident 42's morning medications. LN 3 placed Resident 42's medications, including Ferrous Sulfate (iron supplement for anemia) and Carvedilol (heart failure and blood pressure medication) in a small plastic cup, added less than one teaspoon of apple sauce and administered to the resident. LN 3 explained that the resident prefers to take her medications with small amount of apple sauce. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe storage, labeling and effective accountability of the medications in accordance with accepted professional standards, when a bottle of Lyrica (a prescription medication to treat pain; controlled medication with potential for abuse) tablets was stored unsecured on the open shelf in medication room and Fluticasone Propionate and Salmeterol Inhalation Powder (inhalation medication to treat lung disease and relieve allergic symptoms) for Resident 73 was stored inside Medication Cart 1 not dated when opened. These failures had the potential for controlled substance medication diversion due to lack of secure storage and for Resident 73 to receive expired medication with reduced potency. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide 80 square feet (sq ft) per resident in 8 resident rooms. This failure had the potential to affect residents' care and residents' quality of life. A review of the facility's room measurements conducted on 1/20/26 indicated: room [ROOM NUMBER]- 156 sq ft- 2 residents- 78 sq ft per residentroom [ROOM NUMBER]- 154 sq ft - 2 residents-77 sq ft per residentroom [ROOM NUMBER]-156 sq ft-2 residents-78 sq ft per residentroom [ROOM NUMBER]-230 sq ft-3 residents-76.7 sq ft per residentroom [ROOM NUMBER]-228 sq ft-3 residents-76 sq ft per residentroom [ROOM NUMBER]-238 sq ft-3 residents-79.3 sq ft per residentroom [ROOM NUMBER]-220 sq ft-3 residents-73.3 sq ft per residentroom [ROOM NUMBER]-223 sq ft-3 residents-74.3 sq ft per resident During an interview on 1/20/26 at 8:07 a.m. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a comfortable environment for 14 of 14 sampled residents, when the temperature in the residents' rooms were above 81 degrees Fahrenheit (F). This failure had the potential for the residents to have an uncomfortable room temperature and possible heat exhaustion. During a tour of the facility on 8/15/25 at 4:50 p.m. accompanied by the Administrator (ADM), the following resident's room temperatures were obtained with the facility's infrared (IR) temperature gun (an instrument that measures the temperature by detecting the IR radiation emitted by an object) which indicated the temperatures of the following rooms:room [ROOM NUMBER] - 84 degrees F;room [ROOM NUMBER] - 83 degrees F;room [ROOM NUMBER] - 83 degrees F; androom [ROOM NUMBER] - 82 degrees F. [...]

Inspectors wroteBased on interview, and record review, the facility failed to protect one of four sampled residents from abuse (Resident 2) when another resident (Resident 1) hit Resident 2 on the thigh repeatedly. This failure had the potential to cause injury, fear and distress to Resident 2.

Inspectors wroteBased on observation, interview and record review, the facility failed to treat one of five sampled residents (Resident 4) with respect and dignity when Resident 4 stated, through an interpreter, that Certified Nursing Assistant (CNA 2) was rough, aggressive, and raised her voice when she performed care to Resident 4. This deficient practice had the potential to cause psychological harm and emotional distress to Resident 4.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the comprehensive care plan was updated and revised for one of four sampled residents (Resident 1), when the fall care plan was not revised timely after Resident 1's fall. This failure decreased the facility's potential to prevent Resident 1 from sustaining another fall and had the potential to result in Resident 1 not attaining his highest practicable well-being.

Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, and serve food in accordance with professional standards when: 1. Food equipment was not working properly, 2. Employees were unable to state sanitation process, 3. Expired food, food without proper labeling/dating, and foods that were not covered were found in food storage, 4. A dirty lid, and 6 wet containers were found in the ready to use storage area, 5. Worn food preparation equipment that was no longer able to be sanitized was not discarded, 6. Vents and sprinklers over trayline and residents' microwave found dirty, 7. Buckets containing sanitizer found on food preparation counter, and 8. An air gap was not found under the fruit/vegetable preparation sink. These failures had the potential to lead to food borne illness for the 78 residents eating facility prepared meals.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services in accordance with acceptable professional standards of quality for three (3) of 20 sampled residents (Resident 25, Resident 73, Resident 63) when: 1. Magnetic resonance imaging (MRI, a non-invasive medical imaging technique) prescriber's order for osteomyelitis (a type of bone infection) for Resident 25 was not processed promptly per facility policy. 2. Resident 73's medication order was not clarified with the prescribing physician. 3. Resident 63's feeding formula was not labeled. These failures had the potential for Resident 25, Resident 73, and Resident 63 to received inaccurate and inadequate care.

Inspectors wroteBased on interview and record review, the facility failed to ensure sufficient staffing was provided for a census of 80 residents when: 1. Multiple staff stated the facility was insufficiently staffed; and 2. Resident 55 had five unwitnessed falls in one month. These failures decreased the facility's potential to provide residents with timely, necessary care and services to maintain their highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide food that was palatable when one of 20 sampled residents (Resident 60) was served a burnt cookie. This failure had the potential for Resident 60 to experience dissatisfaction with food served, leading to decreased intake with possible weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection prevention and control practices designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections when: 1. The Treatment Nurse (TN) did not perform hand hygiene (handwash with soap and water or alcohol-based hand rub) in between glove change during the wound dressing change to Resident 70; and, 2. A blood glucose machine was not sanitized after use. These failures had the potential to result in infection and spread of infection among census of 80.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an antibiotics stewardship program for one (1) of 20 sampled residents (Resident 25) when infection screening evaluation was not conducted for Resident 25's two newly prescribed antibiotics to treat osteomyelitis (bone infection). This failure had the potential for antibiotics to be used when it was not indicated and the development of antibiotic-resistant bacteria.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five residents reviewed for immunizations (Resident 25) received the pneumococcal vaccine (a medical treatment that helps to prevent or reduce severity of pneumonia, a lung infection). This failure had the potential for the Resident 25 to be at higher risk for pneumonia and related complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a correct discharge notice to one of three sampled residents (Resident 1), when Resident 1 received a Discharge Notice for a facility-initiated discharge that did not contain the discharge location, or the updated date of discharge. This failure had the potential to result in an unsafe discharge for Resident 1.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that nursing staff had the necessary competencies and skill sets to meet the care and services for two out of five sampled residents (Resident 2 and Resident 4) when: 1. Certified Nursing Assistant (CNA) 3 transferred Resident 2 using a mechanical lift by herself 2. Nursing staff did not answer resident call lights 3. Resident 4 had to wait for about 15 minutes or longer to get changed. These failures resulted to Resident 2 sustaining a fall and had the potential to result in Resident 4's physical and psychosocial harm.

Inspectors wroteBased on interview and record review, the facility failed to provide a safe and homelike environment for one of five sampled residents (Resident 2) when the Resident's personal property was not protected from theft or loss, and it was not promptly investigated. This failure resulted in Resident 2 losing her personal property.

Inspectors wroteBased on interview and record review, the facility failed to ensure effective pain management was provided for one of three sampled residents (Resident 1), when the facility's licensed staff did not notify Resident 1's physician that the resident's pain medications were not effective. This failure resulted in unnecessary pain for Resident 1, affected his sleep, and had the potential to result in further decline in the resident's overall health condition.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide adequate supervision to ensure the safety for one resident (Resident 1) of four sampled residents, when Resident 1 eloped from the facility unaccompanied via unmonitored sliding doors and was found in the adjacent office building. This failure decreased the facility's potential to prevent physical injury and psychosocial harm to Resident 1 during her unsupervised time away from the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure sufficient staffing was provided for a census of 77 residents when: 1. Multiple residents reported long call light response times from facility staff; and 2. Multiple staff stated the facility was insufficiently staffed. These failures decreased the facility's potential to provide residents with timely, necessary care and services to maintain their highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide adequate supervision and required assistance for one resident (Resident 4) of five sampled residents when nursing staff did not respond to Resident 4's request for assistance to use the restroom in a timely manner and Resident 4 fell attempting to transfer herself from the toilet to the wheelchair (WC). This failure resulted in Resident 4's fall while attempting to transfer herself from the toilet to the wheelchair.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Resident 1's use of medical transport service was properly coordinated ahead of time by the Social Services Department. This failure resulted in Resident 1 experiencing anxiety and missing her doctor's appointment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet the needs of the residents for a census of 63 when: 1. The narcotic (medication that may be abused or cause addiction) count sheet for Resident 24 was not filled out after medication administration; 2. Emergency Kit (E-Kit, limited number of medications for use in an emergency) log was not properly filled out for two opened refrigerator E-Kits (E-Kit number 086 and 052) which was missing six vials of lorazepam (a controlled medication used to treat anxiety); and, 3. Opened E-Kits (E-Kit number 067 and 056) were not properly sealed, logged, and replaced within 72 hours. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain a sanitary kitchen for a census of 63 residents when there were multiple brown spots on the ceilings and walls near the food preparation area. This failure increased the potential for food contamination from the brown spots dropping onto resident trays. Findings During the initial tour of the kitchen on 11/1/22 at 8:38 a.m. multiple brown areas were observed on the ceiling near the dishwashing station and steam table (tables which keep ready-to-serve food at set temperatures). In an interview on 11/1/22 at 8:40 a.m., the Dietary Manager (DM) confirmed the presence of brown spots on the ceilings by the dishwashing machine and the steam table. The DM stated she did not know what the brown spots were composed of, but they should not be there. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper infection prevention and control practices were followed for a census of 63 when: 1. A reusable blood pressure device was not disinfected between resident use; 2. Hand hygiene was not performed during medication administration; 3. Resident 8's oxygen tubing was undated and unlabeled; and, 4. The facility's water management for the prevention of Legionella disease was not conducted. These failures had the potential to transmit infectious disease among residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the required minimum square footage of 80 square feet per resident for a census of 63. This failure had the potential to affect residents' safety due to the reduced space for staff to deliver care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain complete and accurate maintenance logs for the kitchen dish machine. These failures decreased the facility's potential to ensure sanitation of dishes for a census of 63 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to update and revise the care plans for four residents (Resident 31, Resident 124, Resident 75, Resident 22) of 19 sampled residents. These failures resulted in residents' person-centered plan of care not reviewed and revised timely to meet the residents' needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nursing standards of practice were practiced for two residents (Resident 31 and Resident 22) of 19 sampled residents when: 1. Licensed Nurses did not follow Resident 31's physician order for a left-hand contracture (a permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff); and, 2. Licensed Nurses did not monitor Resident 22's use of a boot to prevent pressure injury of the lower extremities. These failures decreased the facility's potential to meet residents' needs and prevent further decline in the use of their upper and lower extremities.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a communication binder for one resident (Resident 22) of 19 sampled residents for use during the provision of care. This failure decreased the facility's potential to meet Resident 22's ability to communicate her basic needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure activity care plan approaches were consistently implemented for three residents (Resident 75, Resident 90, and Resident 22) of 19 sampled residents. These failures increased the risk of deterioration of social and psychological well-being among residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate did not exceed 5% for two of 19 sampled residents (Resident 86 and Resident 124) during observation of medication administration when: 1. A wrong medication of Vitamin D3 (a vitamin needed to build and maintain healthy bones) was administered to Resident 86; and, 2. A wrong dose of amlodipine (a medication to treat high blood pressure and heart disease) was administered to Resident 124. These failures resulted in two medication errors out of 27 opportunities which resulted in the facility having a medication error rate of 7.41%.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications were labeled, stored, and disposed of consistently according to standards of practice for a census of 63, when: 1. Expired medications were not removed from the medication cart and the medication storage room; 2. Resident's medications were found in medication cups on top of the medication cart; 3. Loose pills were found in the first drawer of the medication cart; 4. Pharmaceutical products were found in the medication cart without an opened date; 5. A bottle of antifungal powder with an unclear and torn label was found in the treatment cart; and, 6. discharged resident's medications were not removed from the treatment cart. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident (Resident 42) of 19 sampled residents received assistance to obtain Resident 42's full dentures. This failure decreased the facility's potential to ensure Resident 42 was able to properly chew her food.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide timely replacement for one resident's missing clothing (Resident 338) of five sampled residents. This failure resulted in residents' expression of discontent with the facility's quality of care and negatively impacted his dignity and quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident (Resident 42) of 19 sampled residents was assessed within 14 calendar days of admission to determine her dental needs. This failure decreased the facility's potential to ensure Resident 42 was able to properly chew her food and independently feed herself.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a comprehensive care plan regarding Post-Traumatic Stress Disorder (PTSD, a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event) for one resident (Resident 75) of 19 sampled residents. This failure decreased the facility's potential to address Resident 75's mental and behavioral care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary services to maintain grooming for one resident (Resident 31) of 19 sampled residents. This failure decreased the facility's potential to meet Resident 31's grooming needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident (Resident 75) of 19 sampled residents was referred to psychiatry services. This failure increased Resident 75's risk for delayed psychiatry evaluations and interventions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident (Resident 86) of five sampled residents was provided a cock-up wrist splint with adaptive feeding handle (an assistive device enabling a resident with weak grasp to hold eating utensils). This failure decreased the facility's potential to ensure a resident's ability to reach their highest potential physical and psychosocial wellbeing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect resident health information when meal tickets were disposed of in the facility's regular trash. These failures decreased the facility's potential to protect sensitive health information for a census of 63 residents.