Mesa Verde Post Acute Care Center

Inspectors wroteBased on interview, closed medical record review, and facility P&P review, the facility failed to ensure the personal belongings for one of five sampled residents (Resident 1) were kept safe from loss or theft. * The facility failed to ensure the Personal Effects Inventory Form for Resident 1 was completed and signed by Resident 1's representative and facility staff upon Resident 1's discharge from the facility. This failure resulted in Resident 1 losing his personal belongings.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the medical records for two of five sampled residents (Residents 2 and 3) were accurate and complete. * The facility failed to ensure the Personal Effects Inventory Form for Resident 2 was reviewed and signed by the resident's representative and facility staff upon the resident's admission to the facility. * The facility failed to ensure the Personal Effects Inventory Form for Resident 3 was completed and signed by the resident's representative and facility staff upon the resident's admission to the facility. These failures had the potential to prevent the facility from accurately accounting for the personal effects and belongings of Residents 2 and 3.

Inspectors wroteBased on observation, interview, facility document, and facility P&P review, the facility failed to ensure the menus were followed for eight of eight residents (two final sampled residents, Residents 10 and 28, and six nonsampled residents Residents 15, 20, 24, 48, 54, and 59) who received a pureed diet when:1. The pureed Curry Lemon Chicken recipe was not followed;2. The pureed Peas with Onions recipe was not followed;3. The pureed Garlic [NAME] recipe was not followed; and4. The pureed starch recipe used for the pureed wheat rolls was not followed. This failure had the potential not to meet the residents' nutritional needs.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure the food safety and sanitation guidelines were followed when:1. The cool down process for time, temperature control for safety (TCS) food, food that needs to be kept at specific temperatures to prevent bacteria growth and foodborne illnesses, was not monitored correctly.2. One of one blender was not air dried. These failures posed the risk for foodborne illnesses in a highly susceptible resident population of 76 facility residents who received food prepared in the kitchen.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of five sampled residents (Resident 12) was free from unnecessary psychotropic medications. * The facility failed to ensure the targeted behaviors for the use of Ativan (antianxiety medication) were documented prior to administering the medication to Resident 12. This failure had the potential for the resident to experience adverse effects from the psychotropic medication and unnecessary use of the psychotropic medication.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to develop the comprehensive person-centered plan of care to reflect the individual care needs for three of 19 final sampled residents (Residents 18, 21, and 28). * The facility failed to develop a care plan to address Residents 18 and 28's change in condition related to weight loss. * The facility failed to develop a care plan to address Resident 21's use of the antidepressant medication. These failures had the potential to cause inconsistent, inappropriate, and inadequate plans of care for the residents in a vulnerable population and result in suboptimal outcomes for the affected residents.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure one of 19 final sampled resident (Resident 18) and two nonsampled residents (Residents 30 and 68) reviewed for accident hazards remained free from accident hazards. * The facility failed to ensure Resident 18's neuro check assessments were conducted after a fall on 1/2/25. * The facility failed to monitor Residents 30 and 68's Wander Guard for functionality. These failures had the potential to place the residents at risk for serious injuries and posed the risk for not having accurate information documented to prevent further accidents and or injuries to the residents.

Inspectors wroteBased on observation, interview, facility document review, and P&P review, the facility failed to ensure acceptable parameters of nutritional status were maintained for one of two final sampled residents (Resident 7) when: * A significant unplanned weight loss of 21.8 lbs., 10.2% in six months was not assessed by the Registered Dietitian (RD). * The Interdisciplinary Team (IDT) did not evaluate the significant unplanned weight loss of 21.8 lbs., 10.2% in a timely manner. These failures resulted in Resident 7's compromised nutritional status not monitored and addressed timely, which had the potential to lead to further medical complications.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to provide the appropriate care and services for the use of the GT for one of one final sampled resident (Resident 3) reviewed for GT feeding. * The facility failed to ensure the enteral water flush was programmed on Resident 3's enteral feeding pump as ordered by the physician. This failure posed the risk for developing dehydration complications for Resident 3.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary respiratory care services for one final sampled Resident (Resident 2) and one nonsampled Resident (Resident19) reviewed for respiratory care. * The facility failed to ensure Resident 2's CPAP's (Continuous Positive Airway Pressure) machine was cleaned as per the manufacturer's user cleaning guidelines. * The facility failed to ensure Resident 19's oxygen tubing storage bag was routinely changed. These failures had the potential to adversely affect the health and well-being for the residents and posed the risk for infection.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the failed to ensure the appropriate dialysis care was provided for one of two final sampled residents (Resident 2) reviewed for dialysis services. * The facility failed to ensure Resident 2's physician's order for 1500 ml fluid restriction was followed and carried out accordingly. In addition, the facility failed to monitor the resident's fluid intake accurately. This failure had the potential for the resident to not be provided with the appropriate care and treatment, and possibility experience medical complications related to dialysis.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of three final sampled residents (Resident 7) remained free from an accident/hazards due to the use of the side rails/ grab bars. * The facility failed to ensure the informed consent was obtained and completed for Resident 7's bilateral U grab bars. This failure had the potential to put the resident at risk for entrapment and serious injuries.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the pharmaceutical services to meet the residents' needs for two of 19 final sampled residents (Residents 9 and 12) and one nonsampled resident (Resident 71). * The facility failed to ensure the injection sites were rotated for the subcutaneous insulin medication administration for Resident 9. * The facility failed to ensure the administration of the divalproex delayed release tablet for Resident 12 was in accordance with the best practice standards. * The facility failed to ensure the administration of the controlled medication for Resident 71 was documented on the EMAR. These failures had the potential to negatively affect the residents' health condition and well-being.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the facility staff and resident visitors were educated on safe food handling practices when food from the outside was brought to the facility for resident consumption. This failure had the potential for unsafe food handling which could lead to foodborne illness in the 76 residents who resided and consumed food in the facility.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to implement the infection control practices in the facility designed to provide a safe and sanitary environment and help prevent the development and transmission of diseases and infections. * The facility failed to maintain an accurate and complete infection control surveillance program for June, July, and August 2025. This failure posed the risk for not identifying the residents' infections and preventing the implementation of the interventions to control the potential transmission of communicable diseases to other residents in the facility. * The facility staff failed to perform hand hygiene between changing of the gloves during the medication administration. This failure posed the risk for the transmission of infection to the resident.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the copy of the advance directive (a legal document stating a person's wishes about receiving medical care if the person is no longer able to make medical decisions) was maintained in the resident's medical record for one of 19 final sampled residents (Resident 33). * The facility failed to maintain a copy of Resident 33's advance directive in the resident's medical record. This failure had the potential for the facility to provide treatment and services against the resident's wishes.

Inspectors wroteBased on interview, medical record review, and facility document review, the facility failed to provide the written Notice of Medicare Non-coverage (NOMNC) form CMS-10123, and the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) form CMS-10055 for one of three residents (Resident 15) reviewed for beneficiary notification. The NOMNC and SNFABN forms are used to inform the residents of their potential financial liability, appeal rights, and protection should they wish to receive care and services that may not be covered by Medicare. * The facility failed to ensure followed up was made with Resident 15's responsible party to have him review and sign the NOMNC and SNF ABN forms. This failure had the potential of not allowing Resident 15 and/or their representative to make an informed decision regarding their Medicare servicesFindings: [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to ensure one of 19 final sampled residents (Resident 11) maintained good grooming and personal hygiene. * The facility failed to ensure Resident 11's long fingernails were trimmed. This failure posed the risk of the resident to experience physical discomfort and health complications.

Inspectors wroteBased on interview and facility document review, the facility failed to ensure the Facility Assessment addressed or included the following: 1. Active involvement of required individuals in developing Facility Assessment;2. A resources necessary to care for residents including weekends;3. A plan to maximize recruitment and retention of direct care staff; and4. A contingency plan for staffing needs. These failures had the potential to not meet the residents care needs if the assessed population's needs and resources were not comprehensively identified and addressed.

Inspectors wroteBased on interview, medical record review, and the facility P&P review, the facility failed to ensure the medical record for one out of 19 final sampled residents (Resident 28) was complete and accurate. * The facility failed to ensure the MAR documentation on 9/1/25, for Resident 28's oxygen saturation rate during a day shift was accurate. In addition, the MAR was incomplete for Resident 28's meal intake percentage for the dinner entry on 8/22/25. These failures had the potential for the resident's care needs not being met as their medical information was incomplete and inaccurate.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to report and investigate a resident-to-resident altercation to the State Survey Agency in accordance with the state law established procedures for two of five sampled residents (Residents 1 and 4). * Resident 1 stated a male resident (Resident 4) walked into her room unsupervised, screamed and threatened her. The incident was not reported to the appropriate parties (CDPH, the Ombudsman, the residents' responsible parties, the MD and the police department) nor was an investigation initiated. This failure had the potential to negatively impact the well-being of the resident of the facility.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure to coordinate the effective discharge planning process when the SSD failed to communicate to the IDT the development of the discharge plan and failed to document in the resident's medical record regarding the evaluation of the ALF waiver process. Additionally, the facility failed to notify the resident's family member about the ALF waiver was denied for one of six sampled residents (Resident 4). These failures had the potential to affect the resident's well-being after discharge.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the medications were not stored at the bedside for two of two sampled residents (Residents1 and 2) and one nonsampled resident (Resident D). * Resident 2's bubble pack of metformin (medication to treat diabetes) medication was found hidden in Resident 1's closet for 10 days. * Resident D's side table drawer had a medication cup filled with thick white cream and a tongue depressor. These failures had the potential to result in the unauthorized access to the medications and impact the residents' safety.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure one of three sampled residents (Resident 1) was properly discharged from the facility. This failure had the potential to place Resident 1 at risk for not receiving the proper care after the discharge.

Inspectors wroteBased on interview and medical record review, the facility failed to provide and document sufficient preparation to ensure the safe and orderly discharge for one of three sampled residents (Resident 1). * Resident 1 was discharged with home health services; however, there was no documentation if the home health agency referral was arrangedprior to the discharge. This failure placed Resident 1 at risk for not receiving the proper care after the discharge.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to obtain the appropriate consent prior to administering the COVID-19 (a contagious disease caused by the coronavirus SARS-CoV-2) and influenza vaccines for one of two sampled residents (Resident 1). This failure had the potential to result in the resident receiving the vaccines without the resident's responsible party being informed of the risks, benefits, and side effects prior to administering the vaccines.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the accurate and complete medical records for two of two sampled residents (Residents 1 and 2). * Resident 1's History and Physical examination had a strike-through without a date or initial to show when and who had completed the strike-through. * Resident 2's weekly Long Term Care Evaluation incorrectly showed the resident did not have any falls. These failures had the potential for the residents' care needs not being met as the medical records were incomplete and inaccurate.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of four residents observed for medication administration (Resident 23) and one of 18 final sampled residents (Resident 18) were assessed to safely self-administer the medications prior to performing the self-administering medications. This had the potential for the residents to incorrectly administer the medications.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to promote dignity and respect for two of 18 final sampled residents (Residents 18 and 23) and four nonsampled residents (Residents 4, 22, 60, and 62). * The call light was not within reach for Residents 18, 22, and 62. * The facility failed to ensure the resident's call lights were answered in a timely manner for Residents 4, 23, and 60. These failures posed the risk to negatively affect the residents' physical and emotional well-being.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the comprehensive care plan was formulated for two of 18 final sampled residents (Residents 17 and 423). * The facility failed to develop a care plan problem to address the use of CVAD (Central Venous Access Device - a type of intravenous catheter) for Resident 423. * The facility failed to develop a care plan problem to address Resident 17's need for a cervical collar and TLSO brace (Thoracic-Lumbar-Sacral Orthosis, used to limit motion and stabilize the back). These failures posed the risk of not providing the appropriate, consistent, and individualized care of the residents.

Inspectors wroteBased on observation, interview, medical record review, and facility document review, the facility failed to provide the necessary treatment and services for one of three residents who were reviewed for positioning and mobility (Resident 17). The facility failed to apply a cervical collar (c-collar) to Resident 17 as ordered by the physician. This failure had the potential to negatively affect the Resident 17's health and well-being.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide a safe environment free from potentially serious accident hazards for one of one residents who were reviewed for smoking (Resident 24). The facility failed to ensure the smoking materials for Resident 24 were securely stored. This posed the risk of fire and serious injuries to the residents who resided in the facility.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to provide the appropriate care and services to prevent UTI (urinary tract infection, a condition associated with invasion by disease causing microorganisms of some part of the urinary tract) for one of one resident (Resident 24) reviewed for urinary catheter or UTI. Resident 24 had a suprapubic catheter (a tube used to drain urine from the bladder through an incision in the abdomen) and a history of recurrent UTIs. The facility failed to ensure proper positioning of Resident 24's urinary drainage bag to prevent urine from flowing back into the bladder. This posed the risk for Resident 24 to develop a catheter-associated urinary tract infection (CAUTI).

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure four of four residents reviewed for respiratory care (Residents 14, 50, 44, and 623) were provided with the appropriate respiratory care when: * The facility failed to ensure the nasal cannula was dated and labeled, and the nebulizer mask was stored properly for Residents 14 and 50. * The facility failed to ensure the CPAP mask was stored properly for Resident 623. * The facility failed to ensure the nasal cannula was stored properly for Resident 44. These failures had the potential to affect the respiratory health and well-being of the residents in the facility.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the dialysis care was provided for one of one final sampled resident reviewed for dialysis services (Resident 29) as evidenced by: * The facility failed to ensure Resident 29's dialysis access site was assessed and monitored appropriately and consistently. The licensed staff failed to assess Resident 29's dialysis access site after returning from the dialysis clinic accurately. In addition, the licensed staff failed to document an assessment of Resident 29's dialysis access upon return from the dialysis clinic. These failures had the potential for Resident 29 not being provided with appropriate care and treatment and the possibility of medical complications related to the resident's dialysis access site.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P, the facility failed to provide the pharmaceutical services to meet the residents' needs for two of two residents (Residents 17 and 23) reviewed for controlled medication administration. *The facility failed to ensure Resident 17 and 23's controlled pain medications were accurately reconciled. The controlled pain medications removed as shown on the Individual Narcotic Record were not recorded as administered on the electronic MAR. This failure had the potential for drug diversion.

Inspectors wroteBased on interview, medical record review, and facility document review, the facility failed to ensure the Pharmacy Consultant's recommendations were acted upon for one of five residents reviewed for unnecessary medications(Residents 61). This failure had the potential to put Resident 61 at risk for adverse consequences related to the medication.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the expired and potentially deteriorated medications were removed from the supply for two of three medication carts (Medication Carts A and B). This had the potential for expired or deteriorated medications to be administered to the residents.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to follow the menu. *Cook 1 did not follow the recipe when preparing pureed Spinach Au Gratin (creamed spinach topped with cheese and baked in the oven) *Scoop #12 was used to serve regular Spinach Au Gratin instead of scoop #8 per the spreadsheet. These failures had the potential of the menu not meeting the residents' nutritional needs which could lead to nutritional related health complications.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen as evidenced by: * The facility failed to ensure proper labeling and dating of foods in the kitchen. *The facility failed to ensure the food items inside the refrigerator used for residents' food brought in from outside were properly stored per the facility's P&P. * The ice machine was dirty with yellowish slimy residue in the upper inside part of the ice maker area. * The kitchen exhaust hood was observed with brownish black residue. * The facility failed to ensure the proper sanitary condition of the kitchen equipment. The oven and heated plate dispenser were observed with food debris. * The facility failed to ensure the kitchen items were air dried. * The facility failed to ensure cutting boards were kept in a sanitary condition. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to follow the P&P for the resident's food brought by the visitors for one of 18 final sampled residents (Resident 58). * The facility failed to ensure the safe food handling guidelines were implemented to the resident's family/visitors who brought the resident food from the outside. In addition, the facility failed to provide resident and family with the P&P about the use and storage of brought in by family and visitors as part of their admission packet as per the facility's P&P. These failures had the potential for unsafe food handling and may cause foodborne illness to the residents who received food brought by the visitors.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to dispose of trash properly. One of three dumpsters was observed overflowing with boxes, which prevented the lid from fully closing. This had the potential to attract and harbor pests and/ or rodents.

Inspectors wroteBased on observation, interview, medical record review and facility document review, the facility failed to maintain accurate and confidential resident records. * The facility failed to ensure confidential resident rosters were not included in the CDPH Survey results binder for public review. * The facility failed to ensure Resident 29's monthly weight was documented correctly. These failures had the potential for protected information to be viewed by the public and the resident's care needs not being met as the medical information was incomplete and inaccurate.

Inspectors wroteBased on observation and interview, the facility failed to ensure the appropriate infection control practices were implemented to provide a safe and sanitary environment and prevent the spread of infections within the facility. * There were multiple briefs and blue chucks stacked on the top of an isolation chart located in front of room A. This failure posed the risk of transmission of infectious organisms from the floor to the residents in the facility.

Inspectors wroteBased on observation, interview, facility document review, equipment instruction manual review, and facility P&P review, the facility failed to maintain the essential equipments in safe operating condition. * The facility failed to ensure the ice machine was cleaned and sanitized according to the manufacturer's specification, and per the facility's P&P. An incorrect ratio of the nickel-safe cleaner was used to descale the ice machine, a hot water instead of a sanitizing solution was used to sanitize the inside of the machine, and an unidentified and unlabeled spray bottle was used to sanitize the panels of the ice machine. These failures had the potential for the equipment to not function in the way it was intended, which could cause food-borne illnesses for the residents. [...]

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the residents' entrapment assessments were accurate, complete and the measurements were recorded during the bed inspection when identifying areas of possible entrapment with the use of bed rails for all three residents (Residents 18, 50, and 423) with side rails. These failures had the potential to negatively impact the residents resulting in possible entrapment, serious injury, and death.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary GT care and services for one of one resident reviewed for GT care (Resident 45). *Resident 45's GT feeding bottle label did not indicate the start time of the feeding and the initials of the nurse who hung the tube feeding. This failure had the potential for the residents to develop complications related to tube feedings and/or risk for infections.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the necessary pharmacy services for two of two sampled residents (Residents 1 and 2) when Residents 1 and 2's controlled drug records and MARs were not maintained to ensure the accuracy reconciliation of the narcotic pain medications. * Resident 1's oxycodone HCl (narcotic pain medication) Individual Drug Record sheet did not match Resident 1's MAR. The oxycodone HCL was removed from the bubble pack for several occasions without documentation of the medication administration in the MAR. * Resident 2's hydrocodone-acetaminophen (narcotic pain medication) Individual Drug Record sheet did not match Resident 2's MAR. The hydrocodone-acetaminophen medication was removed from the bubble pack for several occasions without documentation of the medication administration in the MAR. [...]

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen as evidenced by the following: * The facility failed to ensure the food was stored in sanitary condition. * The facility failed to ensure proper labeling and dating of foods in the kitchen. * The facility failed to ensure the kitchen walk-in refrigerator was maintained in sanitary condition. * The facility failed to ensure the expired foods were discarded. * The facility failed to ensure the kitchen equipment was maintained in sanitary condition. * The facility failed to ensure the kitchen staff performed hand hygiene before donning and doffing gloves. * The facility failed to ensure the damaged or worn-out kitchen equipment was in good repair. * The facility failed to ensure proper sanitary condition of the hood over the stove. [...]

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to implement their infection control program in accordance with the facility's P&P. * The facility failed to implement their infection control surveillance program between the months of July 2021 and January 2022. The facility conducted surveillance of resident infections based on whether the residents were prescribed antimicrobials. The residents who were not prescribed antimicrobials (including residents diagnosed with COVID-19) were not included in the facility's infection control surveillance program. * The facility failed to ensure the monthly mapping of infections included information on the specific microorganism to identify possible outbreaks. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure care was provided in a manner which promoted dignity and respect for one of 21 final sampled residents (Resident 48), * The facility failed to cover Resident 48's urinary drainage bag. This failure has the potential to negatively affect the resident's emotional well-being.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the residents' advanced directives were obtained and maintained in the medical records for three of 21 final sampled residents (Residents 7, 20, and 36). These failures had the potential for the residents' decisions regarding their health care and treatment options to not be honored.

Inspectors wroteBased on observation and interview, the facility failed to maintain a safe environment for one of the five shower stalls used by the residents. * The facility failed to ensure one of the five shower stalls in the facility had a secured drain cover. This had to potential to result in injury as the residents could trip and get entrapped in the shower drain opening.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to develop and implement the comprehensive person-centered care plans for four of 21 final sampled residents (Residents 35, 36, 40, and 457). * The facility failed to develop a care plan to address Resident 40's isolation precaution and skin condition. * The facility failed to develop a care plan to address Resident 457's use of side rails. * The facility failed to develop an individualized care plan to address Resident 35's needs specific to risk for falls. * The facility failed to develop a care plan to address Resident 36's violent behavior when he threw items on the floor during a verbal altercation with another resident and when he was found in possession of a BB gun ( a type of airgun) and threatened to shoot the facility's camera. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the discharge instructions provided to one of two closed record sampled residents (Resident 56) was complete and in a language that was easily understood. * Resident 56's written discharge instructions for medications was not provided in layman's terminology as evidenced by containing medical abbreviations. In addition, the discharge instructions failed to show documentation for the home health agency contact information, in which Resident 56 was to coordinate care with post discharge from the facility. This had the potential to negatively affect Resident 56's disease management and placed Resident 56 at risk to experience adverse reactions from her medications should Resident 56 not understand the instructions. [...]

Inspectors wroteBased on interview and medical record review, the facility failed to provide the necessary care and services to maintain their highest physical well-being for one of 21 final sampled residents (Resident 48). * The facility failed to ensure Resident 48's venlafaxine (medication to treat depression) was administered as ordered by the physician. Resident 48's venlafaxine was discontinued without a physician's order. This failure had the potential to negatively affect the resident's physical and psychosocial outcomes due to complications related to the discontinuation of the medication.

Inspectors wroteBased on observation, interview, medical records review, and facility document review, the facility failed to ensure the environment remained free from accident hazards for two of 21 final sampled residents (Residents 7 and 35) * The facility failed to ensure Resident 7's bilateral floor mats were in place as ordered by the physician. * The facility failed to implement bilateral floor mats to mitigate the risk of injuries from falls for Resident 35. These failures had the potential to place the residents at risk for serious injuries.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the appropriate urinary catheter care was provided for one of 21 final sampled residents (Resident 48). * The facility failed to ensure Resident 48's urinary drainage tubing was off the floor. In addition, Resident 48's urinary tubing was coiled which prevented the free flow of urine into the drainage bag. These failures have the potential to cause the resident to have repeated urinary tract infections.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary services for respiratory care needs were provided for one of 21 final sampled residents (Resident 32). This posed the risk for complications related to respiratory treatment.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure two of 21 final sampled residents (Residents 32 and 457) remained free from accident hazards due to the use of elevated grab bars and full side rails in bed. * The facility failed to ensure Resident 32's side rail assessment was accurate to show the type of bed rails recommended for use. Full length side rails were installed on both sides of Resident 32's bed. In addition, the facility failed to assess Resident 32 for the risk of entrapment The facility failed to obtain an informed consent from Resident 32 prior to the use of full length bilateral bed rails. * The facility failed to obtain an informed consent and assess Resident 457's risk for entrapment for the use of bilateral 1/2 side rails. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to address resident's psychosocial, emotional, mental well being for one of 21 final sampled residents (Resident 36). * Residenr 36 had manifested violent behaviors towards another resident and a visitor in the facility. Resident 36 threw things on the floow during a verbal disagreement with another resident. Resident 36 was found in possession of a BB gun and warned a family member of another resident to leave to prevent shrapnels from hitting him when he fire at the facility's camera. The facility failed to ensure the behavioral interventions were put in place to address Resident 36's behaviors and protect the other residents and visitors from his violent behaviors. This failure posed the risk for harm toward others and himself.

Inspectors wroteBased on observation, interview, medical record review, and drug information review, the facility failed to ensure the pharmaceutical services were provided to meet the needs of one of 21 final sampled residents (Resident 7) and one nonsampled resident (Resident 25). * The facility failed to ensue Resident 25's Metformin (medication to treat high blood sugar levels) ER tablet was not cut in half as per the drug information. * The facility failed to ensure Resident 7's Voltaren gel (medication for pain) ordered for pain as needed was available for use. In addition, the facility failed to ensure Resident 7's Celebrex medication for pain was administered in a timely manner as ordered by the physician. These failures had the potential to negatively affect the residents' health.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the necessary pharmacy services for one of 21 final sampled residents (Resident 52). * The facility failed to promptly act on the recommendation made by the Pharmacy Consultant for a lipid panel for Resident 52's use of atorvastatin (medication to treat high cholesterol level). This placed Resident 52 at risk for complications and adverse effect from the medication.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure two of 21 final sampled residents (Residents 36 and 55) were free from unnecessary medications. * The facility failed to ensure Residents 38 and 55's midodrine medications (medication to treat low blood pressure) was administered as ordered by the physician. These failures posed the risk for the residents to experience adverse effects from the midodrine, including hypertension (high blood pressure).

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure three of 21 final sampled residents (Residents 31, 48, and 52) were free from unnecessary psychotropic medications. * Resident 31 had the orders for Zoloft (medication for depression), Xanax (medication for anxiety) and Depakote (medication for bipolar disorder). The facility failed to ensure Resident 31's use of Xanax and Depakote had a specific behavior manifestation for the provision of psychotropic medication use. The facility also failed to ensure Resident 31 provided informed consents for the use of these medications. Furthermore, the facility failed to ensure Resident 31's behaviors were being monitored for the specific use of each psychotropic medication. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure the medications were appropriately stored as evidenced by: *An unopened insulin bottle was stored in room temperature in Medication Cart A. This failure have the potential to alter the efficacy of the store medications. *An expired bottle of docusate sodium and personal car keys were observed stored with insulin pens in Medication Cart B. These failures have the potential for infection control issues and expose residents to expired medications with questionable potency and efficacy.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to provide the assistive eating device for one of 21 final sampled residents (Resident 31). * Resident 31 was not provided built-up handle utensils (used to assist people with limited or weakened grasping strength eat more independently) during meals as ordered by the physician. This failure had the potential for the resident to not eat effectively and independently.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the medial records for two of 21 final sampled residents (Residents 20 and 36) were accurately maintained. * Resident 20 had formulated an advance directive; however, Resident 20's POLST failed to show Resident 20 had formulated an advance directive. * Resident 36's treatment ordered in July 2021 for 14 days was still recapitulated in the February 2022 Physician's Orders. These failures posed the risk of the residents not receiving appropriate interventions as the medical record information was incomplete and/or inaccurate.

Inspectors wroteBased on interview, medical record review, facility P&P review, and CDC guideline review the facility failed to evaluate the needs for the influenza and pneumococcal vaccinations for one of five sampled residents (Resident 457). This failure had the potential for Resident 457 acquiring, transmitting, or experiencing complications from the flu and pneumonia.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to conduct the regular inspections of all resident bed frames and mattresses as part of a regular maintenance program to identify areas of possible entrapment. This had the potential to place the residents at risk for entrapment and injury.