Mirage Post Acute

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) for one of three sampled residents (Resident 2) by failing to:1. Ensure the residents respiratory rate (the number of breaths taken per minute) was counted and documented before administering Ativan (medication used to quickly calm the brain and nerves, primarily for severe anxiety, panic attacks, and insomnia).2. Ensure the physician order was followed to hold (temporarily stop) Ativan for a respiratory rate over 12 breathes per minute. These failures had the potential to result in medication errors and could potentially result in respiratory depression (a person is breathing too slowly or too shallowly).

Inspectors wroteBased on interview and record review, the facility failed to maintain accurate and complete medical record for one of three sampled residents (Resident 2) by failing to:1. Ensure Resident 2's medical records indicated the correct last name of Responsible Party 1 (RP 1).2. Ensure Registered Nurse 1 (RN 1) documented that RP 1 was notified of the purpose of the intravenous (IV-within the vein) hydration (the process of providing or maintaining the adequate fluid levels needed for the body).3. Ensure Licensed Vocational Nurse 6 (LVN 6) documented the accurate date of the Physician and RP 1 notification on the Change in Condition, dated 4/20/2026. These failures had the potential to cause confusion in care and the medical records containing inaccurate documentation.

Inspectors wroteBased on interview and record review, the facility failed to promptly (to do something quickly, without delay, or exactly at a scheduled time) notify one of three sampled residents (Resident 2) Responsible Party 1 (RP 1) of Resident 2's change in condition on 4/21/2026. This failure had violated RP 1's right to be informed and had the potential to increase RP 1's level of anxiety (an intense, persistent, and often overwhelming feeling of worry, dread, or unease).

Inspectors wroteBased on interview, and record review, the facility failed to ensure an accurate assessment was conducted for one of three sampled residents (Resident 1). Resident 1 did not have an accurate assessment on 6/16/2026, when Resident 1 was using a single point cane (a standard, classic walking stick with one rubber tip at the bottom) instead of a walker (provides a wide, stable base of support so that the user can lean their weight on the device while moving forward, offering more stability than canes) and a wheelchair (chair with wheels). This failure had the potential to result in a delay in necessary care and treatment.

Inspectors wroteBased on interview, and record review, the facility failed to develop and implement a person-centered care plan (a tool that ensures residents receive personalized, comprehensive, and goal-oriented care in a nursing home setting) for two of three sampled residents (Residents 1 and 2) by failing to:1. Develop a care plan to address Resident 1's fabrication of stories (deliberately inventing or constructing false information, often with the intent to deceive, manipulate, or impress others) as per Change in Condition on 6/18/2026.2. Develop a care plan to address Resident 2's refusal of intravenous (IV- within a vein) IV insertion for hydration (giving the body the fluid and electrolytes it needs). These failures had the potential to result in delays in the delivery of necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents received care consistent with professional standards of practice for one of three sampled residents (Resident 2) by failing to ensure Resident 2 had a diagnosis of dehydration (when the body uses or loses more fluid than it takes in) and was not drinking before providing intravenous (IV- within the vein) fluid hydration (giving the body the water it needs to function). This failure had the potential to place Resident 1 at risk for fluid overload (excess fluid).

Inspectors wroteBased on interview, and record review, the facility failed to ensure the resident received care consistent with professional standards of practice to prevent pressure ulcers (localized damage to the skin and/or underlying tissue usually over a bony prominence) for one of three sampled residents (Resident 2) by failing to administer pressure ulcer treatment on 4/16/2026. This failure had the potential to result in the development and worsening of pressure ulcers.

Inspectors wroteBased on interview and record review, the facility failed to promptly notify Family Member (FM) 1, the resident's responsible party and legally recognized decisionmaker, regarding the change in condition (COC) on 6/4/2026 of one of three sampled residents (Resident 1), before Resident 1 was transferred to General Acute Care Hospital (GACH) 1. Resident 1 had a Do Not Resuscitate (DNR - a medical instruction that tell the healthcare team what kind of care a person wants or did not want at the end of the person's life) status. This deficient practice violated Resident 1's right designating FM 1 as the legally recognized decisionmaker and had the potential to increase FM 1's anxiety (an intense, persistent, and often overwhelming feeling of worry, dread, or unease).

Inspectors wroteBased on interview and record review, the facility failed to ensure necessary care was provided for one of three sampled residents (Resident 1), who was receiving Hospice services (a program designed to provide a caring environment for meeting the physical and emotional needs of the terminally ill) by failing to:Ensure Resident 1's Family Member (FM) 1 was informed and agreed with Resident 1's transfer to General Acute Care Hospital (GACH) 1. Ensure Resident 1's Hospice agency (HA) 1 was informed and agreed with Resident 1's transfer to GACH 1. These deficient practices resulted in failure to comply and coordinate with Resident 1's family and Hospice services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a comfortable and safe temperature level for three of three sampled residents (Residents 1, 2, and 3) by failing to ensure the facility temperature was between 71 degrees Fahrenheit ( F, unit of measurement for temperature) to 81 F.This failure had the potential to cause serious medical problems and altered comfort level.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its infection control measures for one of three sampled residents (Resident 1) by failing to:1. Ensure Certified Nursing Assistant (CNA) 1, CNA 2 and CNA 3 wear a gown when providing incontinent (the loss of control over the bladder or bowels) care to Resident 1, who was on enhanced barrier precaution (EBP - an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDRO- a germ that is resistant to many antibiotics] in nursing homes).2. Ensure EBP signage was posted outside of Resident 1's room. These failures had the potential to spread and expose other residents, staff, and visitors to infection.

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) for two of three sampled residents (Residents 1, and 2) by failing:1. To ensure Licensed Vocational Nurse 4 (LVN 4) follow physician order to hold (to temporarily pause or skip a dose as instructed by a healthcare professional) losartan (medication used to treat hypertension [HTN- high blood pressure]) for Resident 1's systolic blood pressure (sbp- the top or first number in a blood pressure reading. It measures the maximum pressure the blood exerts against the artery walls when the heart beats and pumps blood throughout the body) below 110 millimeters mercury (mmHg-standard unit of measurement for pressure) on 5/14/2026, at 9 a.m.2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care in a manner that maintained dignity for one of the three sampled residents (Resident 4) by failing to ensure Resident 4 was provided with silverware (eating utensils such as forks, knives, and spoons) with breakfast tray. On 6/8/2026, Licensed Vocational Nurse (LVN) 1 provided disposable utensils to Resident 4. This failure had the potential to negatively affect Resident 4's self-esteem and self-worth.

Inspectors wroteBased on interview and record review, the facility failed to promptly notify one of three sampled residents (Resident 3) Responsible Party (RP) 1 of Resident 3's change in condition on 6/1/2026, before Resident 3 was transferred to the General Acute Care Hospital (GACH). This failure had violated RP's 1's right to be informed and had the potential to increase RP 1's level of anxiety (an intense, persistent, and often overwhelming feeling of worry, dread, or unease).

Inspectors wroteBased on interview and record review the facility failed to notify the resident's Responsible Party (RP - when signing admissions paperwork for a hospital, nursing home, or assisted living facility, the responsible party is the person designated to make medical or administrative decisions for the resident) of the transfer and the reasons for the move in writing for one of three sampled residents (Resident 3). This failure had the potential for incomplete information conveyed to residents or RP 1 and could have violated resident and RP 1's rights to appeal (the process in which cases are reviewed by a higher authority) transfer or discharge.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident received care consistent with professional standards of practice to prevent pressure ulcer (localized damage to the skin and/or underlying tissue usually over a bony prominence) for one of three sampled residents (Resident 4) by failing to ensure the low air loss mattress (LALM-a mattress designed to distribute the patient's body weight over a broad surface area to prevent skin breakdown and treat pressure ulcers) was set according to Resident 4's weight as per physician order and manufacturer's guidelines (the official recommendations and standards set by the company that built a product that outline the proper procedures for installation, operation, maintenance, and troubleshooting, ensuring the product functions safely, efficiently, and within its warranty limits). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that resident's was free of unnecessary medication for one of three sampled residents (Resident 3) by failing to ensure Licensed Vocational Nurse (LVN) 8 and LVN 9 adequately monitor and document for the manifested behavior of restlessness for a resident who received antianxiety medications (medications used to treat symptoms of anxiety, such as excessive worry, panic attacks, fear, and physical tension). This failure had the potential to result in Resident 3 receiving unnecessary medications and not receiving the adequate care and treatment necessary for physical, mental and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to maintain accurate and complete medical records for one of three sampled residents (Resident 2) by failing to ensure dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney[s] have failed) forms were completed prior to transferring Resident 2 to the dialysis center and upon return to the facility. This failure had the potential to cause confusion in the care and the medical records containing inaccurate documentation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its infection control measures for one of three sampled residents (Resident 4), by failing to ensure Licensed Vocational Nurse 1 (LVN 1) wear a gown when assisting Resident 4 who was on enhanced barrier precaution (EBP- an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDRO- a germ that is resistant to many antibiotics] in nursing homes) to turn and sit on the edge of the bed. This failure had the potential to spread and expose other residents, staff, and visitors to infection.

Inspectors wroteBased on interview and record review, the facility failed to implement its policy for antibiotic (medication used to treat infection) stewardship (efforts in doctor's offices, hospitals, long-term care facilities and other health care settings to ensure that antibiotics are used only when necessary and appropriate, means prescribing the right drug at the right dose at the right time for the right duration) for one of three sampled residents (Resident 2) by falling to monitor Resident 2 for the adverse effects (undesired or harmful effects) of levofloxacin (medication used to treat bacterial infections) on 5/10/2026, and 5/11/2026, from 3 pm to 7 a.m. These failures had the potential for antibiotic resistance (do not respond to a drug) and had the potential for Resident 2 to experience an adverse reaction.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) had a safe discharge that included sending the resident to a location that met the resident's needs. This deficient practice resulted in Resident 1 being admitted to General Acute Care Hospital (GACH) 1 on 6/1/2026.

Inspectors wroteBased on interview and record review, the facility failed to follow the Responsible Party's (RPs- the individual legally and financially accountable for paying medical bills) request to be notified prior to any ancillary services (are diagnostic, therapeutic, or custodial support measures that assist primary care providers in treating residents). On 5/18/2026, the Podiatrist (a physician and surgeon who treats the foot, ankle, and related structures of the leg), trimmed one of three sampled residents (Resident 1) toenails without RP's approval. This failure had violated the RPs right to be informed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to notify the Conservator (a court-appointed individual with the legal authority to make personal, medical, and financial decisions for a resident who is no longer capable of making those decisions themselves) of one of three sampled residents (Resident 1) when Resident 1 died on [DATE]. This deficient practice resulted in a violation of Resident 1's rights.

Inspectors wroteBased on interview and record review, the facility failed to inform the attending physician (MD) and responsible party (Conservator - a court-appointed individual with the legal authority to make personal, medical, and financial decisions for a resident who is no longer capable of making those decisions themselves) of two of three sampled residents (Resident 1 and Resident 2). The facility failed to:1. Inform Resident 1's MD and the Conservator, when Resident 1 was found unresponsive and died on [DATE].2. Inform Resident 2's MD when Resident 2 was in pain and medication was unavailable on [DATE]. These deficient practices resulted in violation of Resident 1's rights and the potential for Resident 2 to have unmanaged pain.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 2) who complained of pain received medication according to the physician orders. This failure resulted in Resident 2's pain management to be ineffective resulting in Resident 2 being in pain.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (is a form that summarizes a person's health conditions and current treatments for their care) for one of three sample residents (Resident 1), regarding Resident 1's use of aspirin (a medication used as a blood thinner that prevents blood cells called platelets from sticking together) and Resident 1's behavior of hitting herself. These deficient practices had the potential to negatively affect Resident 1's physical and psychosocial wellbeing.

Inspectors wroteBased on interview and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices for two of three sampled residents (Resident 1 and Resident 3) when:1. The facility failed to ensure Resident 1's Progress Note, dated 4/2/2026, accurately document Resident 1's condition.2. The facility failed to accurately document Resident 3's physician's recommendation on Resident 3's Situational Background Appearance and Review and Notify (SBAR- a structured communication tool used in healthcare to share important patient information quickly and accurately) Communication Form, dated 4/2/2026.3. The facility failed to accurately document Resident 3's care plan (is a form that summarizes a person's health conditions and current treatments for their care) for a witnessed fall. [...]

Inspectors wroteBased on interview and record review, the facility failed to inform and provide written information to adult residents concerning the right to accept and refuse medical and surgical treatment and the residents' option to formulate an advance directive (a legal document including resident preference on end-of-life treatment decisions) for four of six sampled residents (Residents 14, 10, 17, and 150) when the Social Services Director (SSD) failed to provide written information to residents regarding advance directive formulation. These deficient practices violated the residents' rights to be fully informed of the option to formulate their advanced directives, placing the residents at risk of receiving unwanted or inappropriate treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignity including the right to be free from physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the resident's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) for four of five sampled residents (Residents 142, 264, 86 and 80) reviewed for physical restraints by failing to ensure: 1. Resident 42's use of restraint, bed placed against the wall, had a physician's order, informed consent, restraint assessment, and a care plan on its use. 2. Resident 264's use of restraint, bed placed against the wall, had a current physician's order, informed consent, and a specific restraint assessment for bed placed against the wall. 3. [...]

Inspectors wroteBased on interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a plan of care that summarizes a resident's health conditions, specific care and services facility staff need to provide a resident to promote healing and prevent a worsening of a condition, and current treatments) to meet the resident`s needs for one of five sampled residents (Resident 175) reviewed under unnecessary medications care area when: 1. The facility failed to develop a care plan for the use of Lorazepam (a medication that is used to treat anxiety) and monitor its adverse effects (unexpected and harmful reactions caused by a medication taken at normal doses) for Resident 175. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents' environment was free of accident hazards for five (5) of 5 sampled residents (Resident 163, 159, 231, 239, and 255) reviewed for accidents by failing to ensure: 1. Resident 163 did not have any medications or biologicals left at the resident's bedside. 2. Resident 159's bed was kept at the lowest position. 3. Resident 231's call light button did not have frayed/exposed wires on them. 4. Resident 239 did not have a table placed on top of the floor mat (a thick, soft pad placed on the floor beside a resident's bed to cushion them if they fall). 5. Resident 255 did not have a table placed on top of the floor mat. These deficient practices increased the risk of accidents such as falls with injuries, poisoning, and electrocution on residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents with a urinary catheter (also known as Foley catheter - a hollow tube inserted into the bladder to drain or collect urine) and residents who were incontinent of bladder received appropriate care and services to prevent urinary tract infections (UTI - an infection in the bladder/urinary tract) for three of four sampled residents (Resident 168, 3, and 60) reviewed for urinary catheter or UTI care area by, failing to: 1. Ensure Resident 168's urinal bottle (a portable, handheld container designed to collect urine when a person cannot get to the bathroom) was labeled with the name of the resident and the date it was provided. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respiratory care provided to residents was consistent with professional standards of practice for four of four sampled residents (Residents 22, 235, 5, and 212) reviewed for respiratory care by failing to ensure: 1. Resident 22's suction canister (a rigid or semi-rigid medical container used to collect fluids, blood, and mucus removed from a resident's body during surgery or respiratory care) was labeled with the date and time it was provided. 2. Resident 235's oxygen (O2) via nasal cannula (NC - a simple, two-pronged device that delivers extra oxygen to the nose) tubing was not touching the floor. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to safely use bed rails (metal or plastic bars or guards attached to the sides of a bed to act as a barrier or support) for three of four sampled residents (Resident 11, 22 and 163) by failing to ensure: 1. Resident 11's half (1/2) bed rails (a 1/2 (half-length) bed rail is a safety barrier that covers only the top portion of a bed, typically near the user's torso) had a physician's order and a comprehensive person-centered care plan for its use. 2. Resident 22's and 163's 1/2 bed rails had a physician's order, informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered), bedrail assessment, and a care plan on its use. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure residents were free of any significant medication errors (means the observed or identified preparation or administration of medications or biologicals which are not in accordance with the prescriber's order, manufacturer's specifications, and accepted professional standards) for three of three sampled residents (Residents 142, 80, and 1) reviewed for insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) use by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (sq, beneath the skin) insulin administration sites. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to meet the nutritional needs for 38 out of 237 residents who received fortified diet (foods with nutrients added to them) when on 4/20/2026 during lunch service, [NAME] 2 did not follow the menu and used a teaspoon instead of a tablespoon to add melted margarine on the potatoes and vegetables. This deficient practice had the potential to result in an inadequate number of calories and/or protein the residents need which may lead to weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen by: 1. Failing to ensure eight (8) meal trays were stacked and still wet in the drying area section next to the dishwashing area and two (2) clear food storage bins were stacked and still wet in the dried food storage bins area. 2. Failing to discard four (4) sprouted onions, and 4 onions with brown and dark gray discoloration inside a brown box. 3. Failing to discard one (1) dented can of fruit cocktail. 4. Failing to ensure 4 plastic bags of hotdog buns and 2 plastic bags of hamburger buns were labeled with an open date. 5. Failing to indicate an open date for 1 container of soy milk, 1 container of almond milk, and 1 container of liquid non-dairy creamer. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement its antibiotic stewardship program (a coherent set of actions which promote using antimicrobials responsibly) that includes antibiotic (ATB - a medicine that fights bacterial infections by killing bacteria or stopping them from multiplying) use protocols and a system to monitor antibiotic use for three of four sampled residents (Residents 168, 22, 28) reviewed for antibiotic use by failing to ensure: 1. Resident 168's Augmentin (a powerful, prescription-only antibiotic used to treat a wide range of bacterial infections) had a monitoring for adverse effects (a harmful, unwanted, or unexpected reaction caused by a medication, medical treatment, or procedure) of its use. 2a. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the electrical and resident care equipment in safe operating condition for four of six sampled residents (Residents 49, 136, 3, and 41) reviewed under the environmental task by failing to ensure there were no frayed wires on Resident 49,136, and 3's bed remote control and the call light (a button or pull-cord used in nursing homes that allows a resident to instantly alert staff when they need assistance) was properly functioning for Resident 41. These deficient practices had the potential for Residents 49, 136, and 3 to sustain accidents such as electrical shock and physical discomfort and to place Resident 41 at risk for unmet needs and delayed responses to emergencies.

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat residents with dignity and respect for two of two sampled residents (Residents 3 and 287), by failing: 1. To ensure Resident 3 did not sit on his stool (feces) on the resident's incontinence brief while eating his lunch on 4/20/2026, observed during lunch time dining observation. The resident already verbalized to Certified Nursing Assistant (CNA) 6 that he cannot eat with a stool in his bottom. This deficient practice violated Resident 3's dignity and respect by failing to provide a sanitary environment while eating. 2. To ensure Resident 287's privacy curtains were closed by (LVN) 4 while administering medications via gastrostomy tube ([G-tube] - a small tube surgically placed directly into the stomach through the skin of the belly to deliver food, liquids, and medications). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a homelike environment for one of one sampled resident (Resident 2) by not maintaining functional closet drawers. This deficient practice violated Resident 2's rights to a safe, clean, sanitary, and homelike environment.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from unnecessary psychotropic medication (medications that affect the mind, emotions, and behavior) and the use of chemical restraints (any drug that is used for discipline or staff convenience and not required to treat medical symptoms) for one of five sampled residents (Resident 175) reviewed for unnecessary medications by failing to ensure lorazepam (an anti-anxiety medication) was monitored for specific, measurable behavioral manifestations and adverse effects (negative outcomes or effects that result from a particular action or event). This deficient practice had the potential to result in the administration of unnecessary psychotropic medication and placed Resident 175 at increased for adverse effects related to psychotropic medication therapy, such as drowsiness, dizziness, or slurred speech.

Inspectors wroteBased on interview and record review, the facility failed to report an unwitnessed fall with an injury of unknown origin to the State Survey Agency (SA) immediately but no later than two (2) hours of allegation for one (1) of three (3) sampled residents (Resident 23). This failure had the potential to lead to delayed investigation and intervention of possible abuse or neglect, placing the resident at risk of ongoing harm.

Inspectors wroteBased on observation, interview, and record review, the nursing staff failed to revise a care plan to reflect a change in the physician's order for oxygen therapy for one (1) of one (1) sampled residents (Resident 212). This deficient practice has the potential to result in inconsistent care and staff not following the most current physician orders.

Inspectors wroteBased on interview, and record review, the facility's licensed nursing staff failed to provide care in accordance with professional standards of care to two of three sampled residents (Residents 142 and 80) reviewed for insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) use by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (sq, beneath the skin) insulin administration sites. The deficient practice had the potential for adverse effect (unwanted, unintended result) of the same site subcutaneous administration of insulin such as excessive bruising, lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin). Cross reference F760.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that one of three sampled residents (Resident 53) had received proper treatment after the Ophthalmology appointment. This deficient practice had the potential to result in Resident 53's vision to deteriorate and possibly cause an infection.

Inspectors wroteBased on interview and record review, the facility failed to provide services to one of three sampled residents (Resident 93) reviewed under position, mobility care area who had limited range of motion (ROM - full movement potential of a joint) by failing to: 1. Notify Resident 93's physician when Resident 93 had constant refusals for right hand and right elbow splints. 2. Assess Resident 93 after constant refusals with the Restorative Nurse Assistant (RNA) application of right hand and right elbow splints. These deficient practices had the potential to have decline in Resident 93's ROM and mobility due to delayed treatments and a potential for delayed identification of ROM and mobility decline.

Inspectors wroteBased on interview and record review, the facility failed to recognize, evaluate, and address the needs of residents at risk or already experiencing impaired nutrition and hydration for one of two sampled residents (Resident 3) by failing to perform weight loss assessments (a systematic evaluation conducted by health professionals to measure, track, and interpret changes in an individual's body weight over time) as established by the interdisciplinary team (IDT, a coordinated group of health professionals from different specialties who work together to manage a resident's total care) on the first of the month. The deficient practice had predisposed the resident to unrecognized weight loss without intervention leading to poor nutrition of the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow up a resident's request for dentures for one of two sampled residents (Resident 80). Resident 80 was seen by the dentist on 12/12/2025 with treatment recommendations of new dentures/partials, and teeth extractions (removal of a tooth). This deficient practice had the potential to result in the inability to effectively chew foods, weight loss, lack of energy, and loss of muscle mass for Resident 80.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement and maintain an infection control program for one (1) of 1 sampled residents (Resident 153), during a random observation, by failing to ensure Resident 153 did not touch and pour a cup of water from the water pitcher on top of the Medication Cart (Med Cart) 1 used for medication pass in the presence of multiple staff sitting at Station 2 desk. This deficient practice had the potential to spread infections and illnesses among other residents and staff.

Inspectors wroteBased on interview and record review, the facility failed to maintain accurate and complete medical record for one of three sampled residents (Resident 1) by failing to document General Acute Care Hospital's (GACH) Case Manager (CM) inquiry on Resident 1's discharge back to the facility and reason why the facility did not accept Resident 1 back on 3/5/2026. This failure had the potential to result in confusion in care and the medical records containing incomplete documentation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of seven emergency exit doors (Exit Door 1 and Exit Door 2) were free from any obstructions. This deficient practice had the potential to prevent prompt evacuation of residents and staff due to obstruction of egress (designated emergency exit door) access in the event of an emergency.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free from chemical restraint (use of medication to manage a patient's behavior or restrict their freedom of movement, primarily to control agitation [a feeling of irritability, mental distress or severe restlessness] or aggression [any behavior, word, or action that is intended to harm another person, animal, or object]) by:Failing to monitor Resident 1 for the side effect (secondary, usually unwanted, effects of a medication or treatment that occur alongside the intended therapeutic result) of orthostatic blood pressure (a sudden drop in blood pressure occurring within three minutes of standing, that causes symptoms like dizziness, lightheadedness, blurred vision, or fainting) changes on 1/18/2026, and 1/25/2026, while on quetiapine (medication used to treat various [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was medicated for pain as per physician's order. On 1/21/2026, 1/25/2026, 1/26/2026, and 1/29/2026, nurses administered hydrocodone (medication used to treat pain) 5/325 milligram (mg-metric unit of measurement, used for medication dosage and/or amount) to Resident 1 despite a physician order to administer oxycodone (medication used to treat pain) for pain level between seven to ten (zero- no pain and ten- worst pain). These failures had the potential to result in Resident 1's uncontrolled pain.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a person-centered care plan (a tool that ensures residents receive personalized, comprehensive, and goal-oriented care in a nursing home setting) for two of three sampled residents (Residents 1 and 2) by:Failing to develop a care plan on Resident 1's noncompliance with oxygen use. Failing to implement care plan on Resident 2's risk for fall to keep bed in low position. These failures had the potential for delays in the delivery of necessary care and services to Resident 1 causing hypoxia (low levels of oxygen in your body tissues) and could result in Resident 2's fall and injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 2), who was assessed as high risk (a person is significantly more likely to fall due to factors like weak muscles, poor balance, dizziness from medication, or vision problems) for fall, was asleep on a bed in high position. This deficient practice had the potential to place Resident 2's at risk of fall and injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) who had chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing) were provided with respiratory care consistent with professional standards of practice by:Failing to ensure oxygen nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) was connected to Resident 1. Failing to follow a physician order for oxygen administration of two liters per minute via nasal cannula. These failures can negatively impact on Resident 1's health and well-being and can potentially result in excessive oxygen, suppressing (the act of stopping) Resident 1's ability to breathe.

Inspectors wroteBased on interview and record review, the facility failed to maintain accurate and complete medical record for one of three sampled residents (Resident 1) by failing to document the conversation of Family Member 1 (FM 1) with Social Service Assistant 1 (SSA 1) about Resident 1's medication. This failure had the potential to cause confusion in care and the medical records containing inaccurate documentation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control measures for one of three sampled residents (Resident 1) by failing to ensure oxygen tubing was not touching the floor. This failure had the potential for Resident 1 to get infection.

Inspectors wroteBased on interview and record review, the facility failed to have an on-going, effective pest control management program (a program that monitors, identifies, controls, and prevents pest infestations in the facility). This deficient practice had the potential to spread infections and illnesses among residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure the medical records for one of five sampled residents (Resident 1) were maintained in accordance with accepted professional standards and practice, complete, and accurately documented by failing to ensure accurate documentation of Fall Risk Assessment (a tool to identify residents at high risk of falling by evaluating factors such as medical conditions, vision, balance, mobility, medications) form. This deficient practice had the potential for inaccurate medical interventions for Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain complete and accurate medical records for one of three sampled residents (Resident 1), when Licensed Vocational Nurse (LVN) 1 failed to document Resident 1's apixaban (an anticoagulant-medication used to prevent and treat blood clots) administration accurately when the medication was documented as administered instead of not administered on 12/15/2025 at 9 a.m. This deficient practice had the potential for facility staff to not know if the medication was administered or not.

Inspectors wroteBased on interview and record review, the facility failed to review and revise a comprehensive care plan (a plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs) for one of three sampled residents (Resident 1) by failing to ensure Residents 1's care plan was revised to reflect Resident 1's skin problems. This deficient practice had the potential to delay provision of person-centered care for Residents 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: A. Follow its policy and procedure titled, Infection Prevention and Control Program, last reviewed on 11/6/2025, for one of three sampled residents (Resident 1) by failing to: 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure resident safety for three of six sampled residents (Resident 2, Resident 3, and Resident 4) when the ceiling of the residents' room was leaking with rainwater. The facility did not move the residents from the room with leaking rainwater. This deficient practice had the potential for Residents 2, 3, and 4 to be at risk of sustaining injury related to ceiling leaking with rainwater.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe, clean, homelike environment for two of four sampled residents (Residents 7 and 8) by:1. Failing to ensure Resident 7's room was free of leaking ceiling (from rainwater).2. Failing to ensure Resident 8's room had a comfortable room temperature. These failures had the potential for unsafe and unclean environment with the potential to place Residents 7 and 8 at risk for physical discomfort.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a person-centered care plan (a tool that ensures residents receive personalized, comprehensive, and goal-oriented care in a nursing home setting) for one of three sampled residents (Resident 7) by failing to develop a person-centered care plan to address Resident 7's safety secondary to refusal of room change while Resident 7's room had a leaking ceiling from rainwater. This failure had the potential for delays in the delivery of necessary care and services to Resident 7 and placed Resident 7's safety at risk.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide dignity for one of nine sample resident (Resident 7) by failing to ensure that the staff (Licensed Vocational Nurse 5) address Resident 7 by name and not being called honey and to ensure four staff ( three Certified Nursing Assistants and 1 Occupational Therapist) were talking in English all the time in the hallways. These deficient practices had the potential to affect residents' sense of self-worth and self-esteem. A. During a review of Resident 7's admission Record, the admission Record indicated the facility admitted Resident 7 on 9/3/2025 with diagnoses of hypertension (high blood pressure) and difficulty of walking. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a nasal spray (delivers a fine mist of medicine directly into your nose) was not left at a resident's bedside table and the resident was assessed for self-administration of medication for one of three sampled residents (Resident 5). This deficient practice had the potential to place the other residents at risk to misuse the medication.

Inspectors wroteBased on interview and record review, the facility failed to administer an antibiotic as ordered by the physician for one of three sample residents (Resident 1). This deficient practice had the potential for Resident 1's health condition to be untreated that can lead to physical harm.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that one of nine sample resident's (Resident 2) call light was working properly. This deficient practice had the potential to place Resident 2 at risk for an accident like a fall due to not being able to call for help/assistance.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain a written authorization or approval from the Department of Healthcare Access and Information (HCAI, previously known as the Office of Statewide Health Planning and Development of OSHPD) prior to the use of portable air-conditioning (AC- a machine that forces cool air into a building) unit. HCAI is the state agency that reviews and approves plans for construction, repairs, renovations, and remodeling made in healthcare facilities to comply with State Building Codes. In addition, the facility failed to notify the Department (Licensing/Certification), within five days of the commencement of any construction/alterations to the skilled nursing facility. This deficient practice placed residents at risk for any safety issues related to the unauthorized use of the portable AC unit.

Inspectors wroteBased on interview and record review, the facility failed to ensure: A. That one of seven sampled residents (Resident 5), who had a history of multiple falls in the facility (6/24/2025, 6/25/2025, 7/19/2025, 7/20/2025, 7/26/2025, 7/27/2025, 8/3/2025, and 8/10/2025), was assessed as having moderately impaired cognitive function (a decline in a resident's mental abilities, impacting their ability to think, learn, remember, reason, and make decisions), and required moderate assistance (helper does more than half the effort) from staff for toilet transfers and mobility (movement), was free from accidents and was provided with supervision (refers to the ongoing monitoring and guidance provided by staff to ensure the safety and well-being of a resident) by failing to: A1. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow its Policy and Procedures (P&P) titled, Grievances/Complaints, Filing, for one of four residents (Resident 2) when the facility failed to inform Family Member 1 (FM 1) verbally and in writing of the findings of the investigation and the actions that were taken to correct the identified problem. This deficient practice had the potential to violate the rights of Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a person-centered Care Plan (CP - a plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs) for one of three sampled residents (Resident 5) by failing to implement the Medication Regimen Review (a pharmacist's [a healthcare professional who specializes in the preparation and management of medications] systematic check of a resident's entire medication list to identify potential issues such as dangerous side effects or inappropriate doses) per Resident 5's CP. This failure had the potential to delay care for Resident 5 and negatively affect Resident 1's well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the comprehensive care plan (CP, a plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs) was reviewed and revised by an interdisciplinary team (IDT-group of professionals from different disciplines who work together to provide coordinated care for residents) for one of three sampled residents (Residents 5) by failing to: 1. Ensure IDT meeting was held to review Resident 5's CP after Resident 5 sustained a fall on 6/24/2025 and 6/25/2025. 2. Ensure Resident 5's CP was revised after Resident 5 sustained a fall on 7/26/2025 and 7/27/2025. These practices had the potential to delay provision of person-centered care for Resident 5, placing Resident 5 at an increased risk for recurrent falls.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents receiving enteral feeding (also known as tube feeding, the delivery of nutrients through a feeding tube directly into the stomach, duodenum, or jejunum) received appropriate care and services to prevent complications of enteral feeding for one of four sampled residents (Resident 2) when Certified Nursing Assistant (CNA) 1 failed to notify nursing staff to turn off Resident 2's enteral feeding pump (a device that delivers nutrient fluids into a resident's stomach, at a controlled rate) on 8/10/2025. This deficient practice placed Resident 2 at risk for aspiration (accidental inhalation of foreign materials, such as food or liquid, into the lungs).

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of four sampled residents (Resident 1) received medication as prescribed by the physician when the resident did not receive his prescribed as needed (PRN) albuterol (a medicine used to help people with asthma [a lung condition that makes it hard to breathe] and other lung problems breathe better). This deficient practice had the potential for Resident 1 to be negatively affected.

Inspectors wroteBased on interview and record review, the facility failed to ensure the medical records were maintained in accordance with accepted professional standards and practice, complete, and accurately documented for one of three sampled residents (Resident 5) by: 1. Failing to document a summary of observation and evaluation of Resident 5's Change of Condition (COC -major decline or improvement in a resident's status that will not resolve without intervention) form. 2. Failing to document the physician notification on Resident 5's COC form. 3. Failing to ensure accurate documentation on Resident 5's skin evaluation on the COC form. These deficient practices had the potential for inaccurate documentation and inaccurate medical interventions for Resident 5.

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

Inspectors wroteBased on interview and record review, the facility failed to provide an ongoing activity program that is resident-centered for one of three sampled residents (Resident 2). This failure had the potential to affect the Resident 2's sense of self-worth and psychosocial (the interaction between an individual's mental and emotional state [psychological] and their social environment) well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents received care consistent with professional standards of practice for one of three sampled residents (Resident 1) by failing to obtain a physician order for oxygen (air we breathe and is used by our bodies to produce energy) use before oxygen administration. This failure had the potential to place Resident 1 at risk of receiving more oxygen than required and could negatively impact Resident 1's well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its infection control measures for one of three sampled residents (Resident 3) who was on enhanced barrier precaution (EBP- wearing a protective gown and gloves whenever you are doing close-contact care with a patient who might be carrying these germs) by failing to ensure Certified Nursing Assistant 3 (CNA 3) wore protective gown while proving care. This failure had the potential for cross contamination (unintentional transfer of bacteria or germs or other contaminants from one surface to another) of infection among residents and staff.

Inspectors wroteBased on interview and record review the facility failed:1. To supervise the student nurse while providing direct care to one out of three sample residents (Resident 1) during the student's clinical hours. This deficient practice resulted in Resident 1 assisted fall on 6/29/2025 when Student Nurse (SN) 1 assisted Resident 1 on the floor without the facilities knowledge.2. To document and assess Resident 1 after receiving a report from Clinical Instructor Registered Nurse (CIRN) 1 that Resident 1 was assisted in the floor by SN 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) received medication as prescribed. This deficient practice had the potential for Resident 1 to be negatively affected.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary respiratory care and services for one of three sampled residents (Resident 4) by failing to:1. Ensure Resident 4's oxygen tubing and oxygen humidifier (a device that adds moisture to the oxygen a person is breathing in during oxygen therapy) was dated when it was changed.2. Ensure Resident 4's oxygen humidifier bottle had water in it while in use.3. Ensure Resident 4 had an oxygen supplies bag for the oxygen tubing to be kept inside when not in use.4. Ensure Resident 4 had a physician order for oxygen therapy (O2 therapy - a treatment that provides a person with supplemental or extra oxygen) before Resident 4 was provided with oxygen. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the medical records of one of four sampled residents (Resident 1) were maintained in accordance with accepted professional standards and practice, complete, and accurately documented by failing to:1. Ensure Licensed Vocational Nurse (LVN) 4 documented Resident 1's Change in Condition (CIC) monitoring indicating the correct date.2. Ensure Certified Nursing Assistants (CNAs) documented Residents 1's percentage (% - per one hundred) of food eaten every meal (breakfast, lunch, and dinner).3. Ensure CNAs accurately documented Resident 1's bladder (a hallow organ that stores urine in the body) continence. These deficient practices resulted in inaccurate information on Residents 1's medical records and had the potential for delayed and inaccurate medical interventions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents received services with reasonable accommodation of the resident needs for one of four sampled residents (Residents 4). Resident 4, who was at risk for falls, did not have the call light (an alerting device for residents to call for assistance) within the resident's reach. This deficient practice had the potential for not meeting Residents 4's needs for assistance.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident's pain was managed as indicated in the facility's Pain Assessment and Management policy for one of four sampled residents (Resident 2) by failing to ensure Resident 2's pain medication, ibuprofen (medication used to treat moderate pain) 400 milligrams (mg - unit of measurement), scheduled every six hours as needed, was administered according to the physician order. This deficient practice had the potential for Resident 2's unnecessary pain experienced during daily activities and had the potential to lead to a decline in Resident 2's quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide reasonable accommodation of resident needs and preferences to two of four sampled residents (Resident 3 and 4) by failing to ensure: 1. The call light (an alerting device for nurses or other nursing personnel to assist a resident when in need) was within reach for Resident 3. 2. The call light was functional for Resident 4. These failures had the potential to result in the inability of Residents 3 and 4 to call for facility staff assistance and delay in the provision of necessary care and services that could negatively affect the residents' well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice to meet the resident's physical, mental, and psychosocial (relating to the interrelation of social factors and individual thoughts and behavior) needs for one of four sampled residents (Resident 1), by failing to administer medications and treatments as ordered by the physician. These deficient practices had the potential to place Resident 1 at risk for unrelieved shortness of breath, respiratory complications, and negatively affect Resident 1's well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's open area on the right buttocks was assessed comprehensively to include the size and healing progress of wound for one of three sampled residents (Resident 2). This deficient practice could result in Resident 2 not receiving proper treatment.

Inspectors wroteBased on interview and record review the facility failed to ensure one of three sampled residents (Resident 2) was using pressure-reducing mattress every shift to prevent wound development or promote wound healing. This deficient practice had the potential for Resident 2 to develop or worsen wound if the pressure-reducing mattress was not used.

Inspectors wroteBased on interviews and record review, the facility failed to properly manage pain for one of three sampled residents (Resident 1) who was assessed at a higher pain score and pain medication was not administered for treatment. This deficient practice had the potential to ineffectively manage Resident 1's pain.

Inspectors wroteBased on interview and record review, the facility failed to order pain medication and follow up with the physician to sign the narcotic (type of drug that can dull pain) authorization for one of three sample residents (Resident 1). These deficient practices increased the risk that Resident 1 could have with delayed medication treatment leading to untreated pain.

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) for two of three sampled residents (Resident 1 and 2) by failing to ensure the physician's order was followed. 1. Failed to ensure Licensed Vocational Nurse 3 (LVN 3) administered acetaminophen (medication used to treat pain and fever) to Resident 1 on 3/6/2025, with a pain level of four despite physician order to use acetaminophen for pain level between one to three. 2. Failed to ensure clobetasol cream (medication used to treat itching) was administered to Resident 1 as per physician order. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain a safe, clean, homelike environment for two of three sampled residents (Residents 2 and 3). This failure had the potential for unsafe and unclean resident's (Residents 2 and 3) environment with the potential for the spread of infection and place the residents at risk for physical discomfort.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a comprehensive care plan for one of three sampled residents (Resident 1) by failing to ensure a care plan was developed on Resident 1's refusal of his ordered medications. This failure had the potential for complications related to Resident 1 not receiving his ordered medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one of the three sampled residents (Resident 2), who was unable to carry out activities of daily living (ADLs-such as personal hygiene, bathing, bed mobility, dressing and transfers) received the necessary services to maintain good grooming and personal hygiene. This failure had the potential to negatively affect Resident 2' s self-esteem and wellbeing and also placed Resident 2 at risk for infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents received care consistent with professional standards of practice for one of three sampled residents (Resident 2) by failing to ensure Resident 2's blood pressure was monitored every hour as per physician's order after Resident 2 had a change in condition on 4/1/2025 at 8:58 p.m. This failure had the potential for a delay in care in services and unidentified change in condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents received care consistent with professional standards of practice to prevent pressure ulcers (PU-a localized injury to the skin and or underlying tissue usually over a bony prominences as a result of pressure or pressure in combination with shear) for one of three sampled residents (Resident 2) by failing to provide treatment to Resident 2 on 3/2025. This failure had placed Resident 2 at risk for development of pressure ulcers.

Inspectors wroteBased on interview and record review, the facility failed to notify the physician of a change of condition (COC - a major decline in a resident ' s status) for one of nine sampled residents (Resident 1) when on 3/12/2025 at approximately 5 p.m., Resident 1 had a low blood pressure (BP - measurement of the pressure or force of blood inside your arteries [the elastic, muscular tubes or blood vessels responsible for carrying the blood away from the heart and distributing it to several other organs and tissues]) reading of 86/57 millimeters of mercury (mmHg - unit of measurement used to measure BP and is abnormal if less than 90/60 mmHg or greater than 139/89 mmHg) and increased heart rate (HR - the number of heartbeats per unit of time) of 111 beats per minute (bpm - considered abnormal if less than 60 bpm or greater than 100 bpm). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of nine sampled residents (Resident 1) was free from neglect (the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress) when Resident 1 had a change of condition (COC - a major decline in a resident ' s status) on 3/12/2025 at approximately 5 p.m. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide treatment and care in accordance with professional standards of practice for one of nine sampled residents (Resident 1), who had a change of condition (COC - a major decline in a resident ' s status) on 3/12/2025 at approximately 5 p.m., when Resident 1 had a low blood pressure (BP - measurement of the pressure or force of blood inside your arteries [the elastic, muscular tubes or blood vessels responsible for carrying the blood away from the heart and distributing it to several other organs and tissues]) reading of 86/57 millimeters of mercury (mmHg - unit of measurement used to measure BP and is abnormal if less than 90/60 mmHg or greater than 139/89 mmHg) and increased heart rate (HR - the number of heartbeats per unit of time) of 111 beats per minute (bpm - considered abnormal if less than 60 bpm or greater than [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain accurate clinical records in accordance with accepted professional standards and practices for one of nine sampled residents (Resident 1) when Licensed Vocational Nurse (LVN) 1 added documentation entries in Resident 1 ' s medical record to show that Resident 1 was doing a little bit better. Resident 1 had a change of condition (COC - a major decline in a resident ' s status) on 3/12/2025 at approximately 5 p.m. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) received medication as prescribed. This deficient practice had the potential for Resident 1 to be negatively affected.

Inspectors wroteBased on interview and record review, the facility failed to follow its Policy and Procedures (P&P) titled, Grievances/Complaints, Filing, for one of three residents (Resident 1) when the facility failed to inform Family Member 1 (FM 1) verbally and in writing of the findings of the investigation and the actions that were taken to correct the identified problem. This deficient practice had the potential to violate the rights of Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a written or electronic record containing all the information the resident needs to effectively manage their own health) for two of three sampled residents (Resident 1 and Resident 4) by: 1. Failing to ensure Resident 1 had a communication board due to hard of hearing according to Resident 1's care plan intervention. 2. Failing to ensure Resident 4 had a care plan regarding Resident 4's diet and food preferences. These deficient practices had the potential to result in inconsistent implementation of the care plan that may lead to a delay in or lack of delivery of care and services.

Inspectors wroteBased on interview and record review, the facility failed to provide wound care treatment to one of three sampled residents (Resident 4). This deficient practice could lead to worsening and infection of Resident 4's wound.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) received care consistent with professional standards of practice to prevent pressure ulcers/injury (the breakdown of skin integrity due to pressure) by not having Resident 1 wear boots per physician's order. This deficient practice had the potential for Resident 1 to develop pressure ulcers/injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the resident's right to be free from verbal abuse (use of oral, written, or gestured communication, or sounds which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation) for one of three sampled residents (Resident 1). This had the potential to negatively affect Resident 1's psychosocial well-being (refers to a resident's overall mental, emotional, and social health, encompassing aspects like happiness, life satisfaction, self-esteem, social functioning, and a sense of purpose).

Inspectors wroteBased on interview and record review, the facility failed to report an incident of a verbal abuse (use of oral, written, or gestured communication, or sounds which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation) for one of three sampled residents (Resident 1). This deficient practice had the potential to result in unidentified abuse in the facility and failure to protect Resident 1 from further abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 2) had the right to be free from physical abuse (willful infliction of injury resulting physical harm, pain, or mental anguish) on 2/16/2025 at 4:30 p.m. when Resident 1 pulled and hit Resident 2 on the back. This deficient practice resulted in Resident 2 being subjected to physical abuse by Resident 1 while under the care of the facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 3) was provided care and services to maintain good grooming and personal hygiene. Resident 3 was not provided a scheduled shower on 1/29/2025 and 2/22/2025. This deficient practice resulted on Resident 3 ' s feeling dirty and had the potential to result in a negative impact on Resident 3 ' s self-esteem and self-worth.

Inspectors wroteBased on interview and record review, the facility failed to protect a resident's right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) for one of four sampled residents (Resident 1) when on 1/29/2025 at 10:55 a.m., Student Nurse 1 (SN 1) and Student Nurse 2 (SN 2) witnessed Certified Nurse Assistant 1 (CNA 1) hit Resident 1 in the back of the head three times with an open hand (did not indicate which hand). This deficient practice resulted in Resident 1 being subjected to physical abuse by CNA 1 while under the care of the facility. Resident 1 stated he (Resident 1) felt humiliated (ashamed), sad, and complained of pain to the back of the head.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure confidential personal information for one of four sampled residents (Resident 1) was protected. The clinical records of Resident 1 were left unattended on the nurse station 3 computer. This deficient practice had the potential to violate Resident 1's rights for privacy and confidentiality of personal and medical records.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement their policy and procedure on safeguarding of all prescribed medications for one of four sampled residents (Resident 4) by failing to ensure Resident 4's prescribed medication was stored in the medication cart of the nursing station where Resident 4 was located. This deficient practice had the potential for non-authorized access to Resident 4's medications.

Inspectors wroteBased on interview and record review, the facility failed to follow its Policy and Procedures (P&P) titled, Grievances/Complaints, Filing, for one of three residents (Resident 2) when the facility failed to inform Family Member 1 (FM 1) verbally and in writing of the findings of the investigation and the actions that were taken to correct the identified problem. This deficient practice had the potential to violate the rights of Resident 2.

Inspectors wroteBased on interview and record review the facility failed to ensure one of three residents (Resident 4), who was at risk for urinary tract infection (UTI- an infection in the bladder/urinary tract) received the care and services to prevent UTI. This deficient practice had the potential for Resident 4 to develop a UTI.

Inspectors wroteBased on interview and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices for one of three sampled residents (Resident 4) when on 1/26/2025 Licensed Vocational Nurse 1 (LVN 1) inaccurately documented on the Treatment Administration Record (TAR- a report detailing the treatment administered to a patient by a healthcare professional across all types of healthcare facilities) that Resident 4's indwelling catheter (a hollow tube inserted into the bladder to drain or collect urine) drainage bag was changed. This deficient practice had the potential for Resident 4 to develop a urinary tract infection (UTI- an infection in the bladder/urinary tract).

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy and procedure of meeting the staff posting requirements. This deficient practice had the potential to keep residents and visitors unaware of the total number of staff and the actual hours worked by staff in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of six sampled residents (Resident 1 and Resident 3) were free from significant medication errors by failing to ensure the physician orders were followed. The facility failed to: 1. Ensure Resident 3's brimonidine tartrate ophthalmic solution 0.2 percent (a medication used to lower pressure inside the eyes of people with glaucoma) and netarsudil dimesylate ophthalmic solution 0.02 percent (a medication used to treat glaucoma) were administered at the scheduled time on multiple dates. 2. Ensure Resident 1's gabapentin (a medication used to treat nerve pain and seizures) 600 milligrams (mg - unit of measurement) was administered at the scheduled time on multiple dates. These deficient practices placed Resident 3 at risk for inadequate glaucoma management which can cause vision loss. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide safe and comfortable environment for residents, staff, and visitors, as indicated in the facility's policies and procedures by failing to maintain required water temperature range of 105 degrees Fahrenheit (°F - unit of measurement) to 120°F in six of six resident shower rooms (station 1 shower 1B room, station 2 shower 2A and 2B rooms, station 3 shower 4A room, station 4 shower 4 room, and station 5 shower 5 room) and five of five nurse station hand sinks (station 1, station 2, station 3, station 4, and station 5). These deficient practices had the potential for residents, staff, and visitors to be exposed to uncomfortable and unsafe water temperatures.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide reasonable accommodation of resident needs and preferences by failing to provide a call light (an alerting device for nurses or other nursing personnel to assist a resident when in need) to five of nine sampled residents (Resident 249, 159, 48, 49, and 129) reviewed under the Environment task. This deficient practice had the potential to result in the delay of care and services and possible injury to residents when they are unable to summon health care workers.

Inspectors wrote5. During a review of Resident 193's admission Record, the admission Record indicated the facility originally admitted the resident on 11/7/2023, and readmitted the resident in the facility on 7/28/2024, with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on one side of the body) following cerebrovascular disease (stroke, loss of blow to a part of the brain) affecting right dominant side, type 2 diabetes mellitus (a chronic disease that occurs when the body does not produce enough insulin or does not use it properly) with foot ulcer, and generalized weakness. During a review of Resident 193's History and Physical (H&P) dated 7/28/2024, the H&P indicated Resident 193 had fluctuating capacity to understand and make decisions. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for three of 10 sampled residents (Resident 249, 109, and 481) during initial sampling of residents by failing to develop and implement a care plan on: 1. Resident 249's use of Trazadone (a drug used to treat depression [a mental health condition that involves a persistent feeling of sadness and a loss of interest in activities]) and Buspirone (a medication that treats anxiety). 2. Resident 109's use of Zoloft (also known as sertraline, medication that can help treat depression and other mental health conditions). 3. Resident 481's use of indwelling urinary catheter (a hollow tube inserted into the bladder to drain or collect urine). 4. [...]

Inspectors wroteBased on interview and record review, the facility's licensed nursing staff failed to provide care in accordance with professional standards to seven (7) out of 7 sampled residents (Residents 64, 66, 73, 64, 111, 213, 96, 73, and 220) investigated under insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) and anticoagulant (blood thinner - that stops the blood from forming blood clots or making them bigger) use by: 1. Failing to rotate (a method to ensure repeated injections are not administered in the same area) the insulin administration sites for Residents 64 and 66. 2. Failing to rotate subcutaneous (beneath the skin) insulin and heparin administration sites for Residents 111, 213, 96, 73, and 220. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure parenteral fluids (are liquids that are administered intravenously or by injection to bypass the digestive system) were administered consistent with professional standards of practice: 1. For one (1) out of 1 sampled resident (Resident 55) investigated during a random observation when Resident 55's intravenous fluid (IVF) did not indicate the date and time it was started and the licensed nurse's initials on the label. This deficient practice had the potential to place Resident 452 at risk for developing complications such as inflammation of the vein and infection. 2. For 1 of 1 sampled resident (Resident 111) investigated under peripheral intravenous catheter (PIVC, a thin, flexible tube that is inserted into a vein through the skin to administer fluids, medications, or blood products) by failing to: a. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the safe and appropriate use of side rails (SR, adjustable rigid plastic or metal bars attached to the bed that may be positioned in various locations on the bed; upper or lower, either or both sides) for one of nine sampled residents (Resident 39) reviewed under the Restraints care area by failing to: 1. Attempt to use appropriate alternatives prior to installing bilateral lower (at the leg area) SRs. 2. Conduct an assessment including the risk for entrapment (occurs when a resident is caught between the mattress and bed rail or within the bed rail itself) from bilateral lower SRs use. 3. [...]

Inspectors wroteBased on observation interview, and record review, the facility failed provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) for one of one sampled resident (Resident 37) and one of three medication carts (Station 1 Cart B) investigated under the Medication Storage and Labeling task by: 1. Failing to administer Resident 37's Jardiance (hypoglycemic medication-lowers blood sugar levels) and metformin (hypoglycemic medication) medications as ordered by the physician. This deficient practice placed Resident 37 at risk for causing complications and delay in the necessary care and services the resident needs. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to unsure psychotropic drugs (a drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) were given to treat a specific condition as diagnosed and documented in the clinical record to one of 5 sampled residents (Resident 213) investigated under unnecessary medications by failing to act upon the pharmacy consultant's request from the physician to indicate the rationale for contraindication for gradual dose reduction (GDR, stepwise tapering of a dose) of Buspar (a medication that treats anxiety) and Zoloft (an antidepressant ). This deficient practice had the potential for residents receiving unnecessary medication and adverse reactions (undesirable effect).

Inspectors wroteBased on interview and record review the facility failed to ensure residents were free of any significant medication errors to seven (7) out of 7 sampled residents (Residents 64, 66, 73, 64, 111, 213, 96, 73, and 220) investigated under insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) and anticoagulant (blood thinner - that stops the blood from forming blood clots or making them bigger) use by: 1. Failing to rotate (a method to ensure repeated injections are not administered in the same area) the insulin administration sites for Residents 64 and 66. 2. Failing to rotate subcutaneous (beneath the skin) insulin and heparin administration sites for Residents 111, 213, 96, 73, and 220. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Remove Resident 271's discontinued insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) lispro (fast-acting type of insulin) from the medication cart in one of three inspected medication carts (Station 1 Cart B). 2. Dispose Resident 10's hydrocodone-acetaminophen (medication used to relieve severe pain) when the bubble pack (packaging that have a preformed plastic pocket or shell where a product sits securely in place) slot #17 was found with a non-intact seal and covered with tape in one of three inspected medication carts (Station 1 Cart B). 3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure kitchen staff were routinely trained and evaluated for competency skills when staff: a. Unable to verbalize the process of three (3) compartment sink dishwashing and quaternary ammonium compound (QUAT, a chemical that disinfect) sanitizer concentration testing for the red buckets. b. Unable to verbalize which type of dishwashing machine they were using and the process of testing the chlorine solution of the dishwashing machine. These failures had the potential to result in harmful bacterial growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) in 271 of 279 medically compromised residents who received food and ice from the kitchen.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow the menu and did not meet nutritional needs of 108 of 109 residents on soft mechanical diet (diet consisting of soft, and chopped foods), seven of 46 residents on fortified diet (addition of food to increase calories and proteins in the diet), and three of 14 residents on large portions (doubling portion size of foods to increase calories and protein in the diet) diet when: 1. Residents on soft mechanical diet did not receive toasted garlic bread without hard crust. 2. Residents on fortified diet did not receive additional cheese on their pasta. 3. Residents on large portion diets did not receive eight (8) ounces ([oz], a unit of measurement) of milk as indicated on the menu spreadsheet (a sheet that contains each diet and what food and portions each diet would get). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare food by methods that conserved flavor and appearance for lunch when staff served mushy and overcooked broccoli, carrots, and peas. This failure had a potential to result in 137 of 279 residents, including Resident 188, facility residents on regular texture (no restriction) at risk of unplanned weight loss, a consequence of poor food intake, getting food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare foods in a form designed to meet individual needs when: 1. Puree pasta was too sticky and did not pass the spoon tilt test (a test used to determine the stickiness of the food and the ability of the food to hold together) for residents on puree diet (foods that are smooth with pudding-like consistency)/International Dysphagia (difficulty swallowing) Diet Initiative ([IDDSI] a framework for categorizing food textures and drink thickness) level four (4). 2. Residents on soft mechanical diet (diet consisted of soft, chopped foods) received toasted garlic bread with hard crust. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents receive and consume foods in the appropriate nutritive content as prescribed by a physician for regular fortified diet (addition of food to increase calories and proteins in the diet) when staff did not add cheese for seven of 46 sampled residents (Resident 135, Resident 213, Resident 104, Resident 96, Resident 129, Resident 145, and Resident 84) on fortified diet during lunch on 1/14/2025. This deficient practice had the potential to cause weight loss for residents on fortified diets.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: 1. Kitchen equipment and areas were not cleaned and sanitized. a. There was an ice, dirt buildup and dirt debris in the chest freezer. Walk-in freezer roof had ice buildup. b. Walk-in refrigerator floors had dirt buildup and food debris. c. Reach-in refrigerator vents had dust buildup and shelves had dirt and food debris. d. Dry storage room floor had dirt and food debris. e. Ice machine internal parts had reddish dirt and mineral buildup. The ice machine filter was dirty to touch. f. Mixer guard, agitator shaft had dried up food and splatters. g. Residents' refrigerator had dirt buildup. 2. Kitchen equipment and utensils were not smooth, had scratches and cracks. a. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose garbage and refuse (broad, overarching term that applies to anything that is leftover after it is used) properly when the dumpster (large trash container designed to be emptied into a truck) surroundings had liquid and food juices spills on the ground since Monday, 1/13/2025. This failure had a potential to result to attracting birds, flies, insects, pest and possibly spread infection to 266 of 274 facility residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for five of six sampled residents (Residents 73, 47, 129, 72, and 225) by failing to ensure: 1. The oxygen tubing was labeled with the date it was last changed for one of two sampled residents (Resident 73). 2. The urinal bottle (a container for collecting urine that is used by people who are unable to use a bathroom toilet) was labeled with the name and room number of the resident for one of one sampled resident (Resident 47). 3. Failing to ensure Residents 129's and 72's oxygen tubing were labeled with the date they were last changed. 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medication self-administration was clinically appropriate and failed to honor the resident's right to self-administer medications for one of three sampled residents (Resident 179) reviewed under the General-Skin Conditions care area by failing to perform a medication self-administration assessment when staff had knowledge that the resident kept topical medication at the bed side for self-administration. This deficient practice violated the residents' right to self-administer medications and had the potential for the resident to experience adverse effects (an undesired effect of a drug or other type of treatment) of the medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a comfortable and homelike environment to one of two sampled residents (Resident 109) investigated under physical environment by failing to ensure the hot water temperature in the bathroom sink was within acceptable levels per the facility's policy and procedure. This deficient practice violated the resident's rights to a safe, clean, sanitary, and homelike environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide treatment and services to maintain or improve a resident's ability to carry out activities of daily living (ADL - activities such as bathing, dressing, grooming, oral care, mobility, elimination, dining, and communication) for one of one sampled resident (Resident 115) when Resident 115 was not provided nail trimming and cleaning to his fingernails. This deficient practice had the potential in Resident 115 having dirty fingernails, which could lead to scratching himself and cause skin tears or bleeding.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received care consistent with professional standards of practice to prevent pressure injury (the breakdown of skin integrity due to pressure) for one (1) out of two (2) sampled residents (Resident 66) investigated under pressure injury when Resident 66's low air loss mattress (LALM - a mattress that helps prevent and treat pressure wounds by circulating air and relieving pressure on the body) was not turned on and was set according to resident's Body Mass Index (BMI - a tool used to estimate the amount of body fat by using the height and weight measurements). This deficient practice had the potential for the resident's pressure injury to worsen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment was free of accident hazards for eight of 12 sampled residents (Residents 213, 220, 471, 482, 159, 193, 58, 19) investigated under accidents by failing to ensure: 1. Resident 213's fall mat (a cushioned mat that reduces the risk of injury from a fall) did not have a furniture or equipment on top of them. This deficient practice increases the risk of injury when the resident slips, trips, and falls by hitting the hard surface of the equipment or furniture that is on top of the fall mat. 2. Resident 220's Fluocinonide External Ointment (is used to treat the itching, redness, dryness, crusting, scaling, inflammation, and discomfort of various skin conditions) were not left at the bedside. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections (UTI, an infection in the bladder/urinary tract) for one of two sampled residents (Resident 481) being investigated under urinary catheters (a hollow tube inserted into the bladder to drain or collect urine) by failing to keep the urinary catheter tubing off the floor. The deficient practices had the potential for residents to develop catheter associated urinary tract infection (CAUTI, an infection of the urinary tract caused by a tube [urinary catheter] that has been placed to drain urine from the bladder [an organ inside the body that stores urine until it can be excreted]).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents receiving enteral feeding (EF - also known as tube feeding, a method of supplying nutrients directly into the stomach) received appropriate care and services to prevent complications of enteral feeding for one (1) of 1 sampled resident (Resident 66) investigated under the tube feeding care area when the EF bottle did not indicate in the label the resident's name, room number, administration rate, the date and time the bottle was started, and the initials of the nurse. This deficient practice had the potential to result in altered nutritional status such as dehydration and malnutrition and complications associated with enteral feeding such as gastrointestinal (GI) (relating to stomach and intestines) problems such as abdominal pain and diarrhea.

Inspectors wroteBased on interview and record review, the facility failed to accurately code on one (1) of two (2) sampled residents (Resident 164) Preadmission Screening and Resident Review (PASARR - a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) when the PASARR prior to admission did not indicate Resident 103 had schizophrenia (a mental illness that is characterized by disturbances in thought). This deficient practice had the potential to result in the resident's medical and nursing care needs not being met.

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) for one of three sampled residents (Resident 1) by not following the physician's orders. This deficient practice had the potential to result in Resident 1's increase in blood pressure (BP- pressure of circulating blood against the walls of blood vessels).

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection control procedures for one of four sampled residents (Resident 4) by failing to: 1. Ensure Resident 4, who was on enhanced barrier precaution (EBP - an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities), had EBP signage outside the resident's door. 2. Ensure personal protective equipments (PPE - equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) were available to use for Resident 4's care. 3. Ensure Licensed Vocational Nurse 1's (LVN 1) PPE was worn before entering the EBP room. LVN 1 did not wear gloves before touching Resident 4's oxygen nasal cannula (a device used to deliver supplemental oxygen thru the nostril [nose]). 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure care consistent with professional standards of practice to prevent pressure ulcers (PU, a localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure, or pressure in combination with shear) for one of four sampled residents (Resident 4) by failing to: 1. Follow the Physician's Order to place Resident 4 on a Low Air Loss Mattress (LALM, a mattress composed of inflatable air cushions and used to relieve pressure). 2. Follow the manufacturer's instructions to set the firmness of the LALM based on Resident 4's weight. These deficient practices placed the residents at risk for the development and worsening of PUs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 4) had a physician order for oxygen therapy (O2 therapy - a treatment that provides a person with supplemental or extra oxygen) before Resident 4 was provided with oxygen. This deficient practice had the potential to create confusion in the delivery of care and services to Resident 4.

Inspectors wroteBased on interview and record review, the facility failed to implement policy and procedure on safeguarding of all prescribed medications including controlled medications (medications with a high potential for abuse) for one of four sampled residents (Resident 1) by failing to ensure Resident 1's prescribed controlled medications were stored in the medication cart of the nursing station where Resident 1 was located. This deficient practice had the potential for non-authorized access to the resident's medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed the following: 1) Failed to supervise and identify one of six sampled residents (Resident 1's) whereabouts inside and outside of the facility and failed to follow Resident 1's Care Plans (a summary of a person's health condition and current treatment interventions associated with care needs). Resident 1 was found on the floor of the facility's parking lot unattended to and without staff supervision. These deficient practices increased the risks for injuries, pain, and or psychosocial despair to Resident 1 who was dependent on staff for care. 2. Failed to ensure the Fall Risk Evaluation (used to find out if you have a low, moderate, or high risk of falling) was accurate to reflect the correct fall risk score of one of five sampled residents (Resident 3). [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure the physician order of one of five residents (Resident 3) matched the Physician Order for Life-Sustaining Treatment (POLST - a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end-of life). This deficient practice had the potential for Resident 3's wishes regarding their health care to be violated.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, comfortable, and homelike environment for one of five sampled residents (Resident 1) when Resident 1's toilet was observed on 12/19/2024 at 11:29 a.m. overflowing into Resident 1's room. This deficient practice resulted in Resident 1 being unable to use the toilet and placed Resident 1 at risk for fall.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from verbal abuse (the act of harassing, labeling, insulting, scolding, rebuking, or excessive yelling towards an individual) for one of five sampled residents (Resident 5), when on 12/14/2024, Resident 4 called Resident 5 a derogatory word. This deficient practice resulted in Resident 5 being subjected to verbal abuse while under the care of the facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement its abuse prevention policy for one of four sampled residents (Resident 2) by failing to ensure an allegation of sexual abuse (any sexual activity that occurs without consent [permission]) was reported immediately, but not later than two hours after the allegation was made, to the State Survey Agency (SSA). This deficient practice had the potential to result in an unidentified abuse in the facility and had the potential for Resident 2 to experience further abuse.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of resident-to-resident abuse within two hours to the State Survey Agency (SSA) as per its policy on abuse for two of three sampled residents (Resident 1 and Resident 2). This deficient practice had the potential to place Resident 1 and Resident 2 at risk for further abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure medical records were complete and accurately documented for three of five sampled residents (Resident 9, Resident 10, and Resident 11) by failing to ensure licensed nurses documented the level of care provided to Resident 9, Resident 10, and Resident 11 after the residents were exposed to invasive group A streptococcal disease (iGAS - a severe and sometimes life-threatening infection). This deficient practice resulted in inaccurate information on Resident 9, Resident 10, and Resident 11's clinical records and had the potential for delayed and inaccurate medical interventions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe and comfortable environment for one of three sampled residents (Resident 2) by failing to ensure Resident 2's room was comfortable and free from malodor. Resident 1's wound had a malodor (bad odor). This deficient practice had the potential for Resident 2 to be uncomfortable and loss of appetite.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection control procedures for one of three sampled residents (Resident 1) by failing to ensure Resident 1, who had open wounds, was not exposed to the presence of fruit flies. This deficient practice placed Resident 1 at risk for exposure and contracting infections.

Inspectors wroteBased on interview and record review, the facility failed to timely follow its policy and procedure titled, Change in a Resident's Condition of Status, which indicated the facility will notify the resident's attending physician (MD) when there was a significant change (a change in the resident's physical, mental, or psychosocial status that causes either life-threatening conditions or clinical complications) in the resident's condition for one of three sampled residents (Resident 1). Resident 1 had a Change of Condition (COC- a major decline in a resident's status) that started on 7/25/2024 when Resident 1's intake was less than 50 % for three (3) consecutive meals. This deficient practice resulted in a delay of care in Resident 1's nutritional status. Resident 1 lost 20.6 pounds (lbs - a unit of measurement) in a month.

Inspectors wroteBased on interview and record review, the facility failed to administer dextrose (sugar) five (5) percent (%) in water (D5W - a solution of 5% sugar [dextrose]) mixed in water, given when patients need fluids and a small amount of sugar to replenish their body) as prescribed for intravenous (IV - given directly into the blood stream) hydration for one of three sampled residents (Resident 1). This deficient practice had the potential for Resident 1 to develop dehydration (a condition that occurs when the body loses more fluids than it takes in).

Inspectors wroteBased on interview and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices for one of three sampled residents (Resident 1) when: 1. The facility failed to accurately document Resident 1's intake (the amount that you eat, drink, or breathe in). 2. The facility failed to accurately document Resident 1's behavior for poor oral intake. These deficient practices resulted in Resident 1 losing 20.6 pounds (lbs.- a unit of measurement) in a month.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections by failing to: 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician was notified timely for one of three sampled residents (Resident 4) when Resident 4 eloped from the facility on 11/9/2024. This deficient practice resulted in delay of obtaining appropriate instructions from the physician for proper management.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive care plan on wandering (to walk around slowly in a relaxed way or without any clear purpose or direction) and elopement (leaves a healthcare facility without supervision or detection), for one of five sampled residents (Resident 4) when resident eloped from the facility on 11/9/2024. This deficient practice can potentially place Resident 1 at risk for injury.

Inspectors wroteBased on interview and record review, the facility failed to ensure that one of the three sampled residents (Resident 3), who was unable to carry out activities of daily living (ADLs-such as personal hygiene, bathing, bed mobility, dressing and transfers) received the necessary services to maintain good grooming and personal hygiene. This deficient practice had the potential to negatively affect Resident 3's self-esteem and wellbeing and placed Resident 3 at risk of infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident who was a high risk for fall, had history of dementia (a progressive state of decline in mental abilities) and had wandering behavior (to walk around slowly in a relaxed way or without any clear purpose or direction) was provided adequate supervision to prevent an elopement (the act of leaving a facility unsupervised and without prior authorization) for one of three sampled residents (Resident 4). This deficient practice potentially placed Resident 4 at risk for injury.

Inspectors wroteBased on interview and record review, the failed to maintain accurate and complete medical record for two of three sampled residents (Resident 3 and Resident 4). This deficient practice had the potential to cause confusion in care and the medical records containing inaccurate documentation and can result in the delay of delivery of care.

Inspectors wroteBased on interview and record review, the facility failed to ensure that one of the three sampled residents (Resident 2), who was unable to carry out activities of daily living (ADLs-such as personal hygiene, bathing, bed mobility, dressing and transfers) received the necessary services to maintain good grooming and personal hygiene as indicated in Resident 2 ' s care plan. This deficient practice had the potential to negatively affect Resident 2's self-esteem and wellbeing and placed Resident 2 at risk of infection.

Inspectors wroteBased on interview and record review, the facility failed to provide an ongoing activity program that is resident centered for one of three sampled residents (Resident 2). This deficient practice had the potential to affect the Resident 2's sense of self-worth and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) for one of three sampled residents (Resident 1) by failing to follow the physician ' s order. This deficient practice placed Resident 1 at risk of developing dangerous low blood pressure levels and medication error. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow its policy and procedure titled, Change in a Resident ' s Condition or Status, which indicated the facility to promptly notify the resident ' s attending physician (MD) and the resident representative of a change in the resident ' s medical and or mental condition and or status for one of five sampled residents (Resident 2). This deficient practice had a potential to delay the care of Resident 2.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy and procedure when on 9/30/2024 at 10 p.m. a Certified Nursing Assistant 6 (CNA 6) turned off the enteral feeding pump (a device that delivers nutrient fluids into a patient's stomach, at a controlled rate) for one of five sampled residents (Resident 2). This deficient practice placed Resident 2 at risk for complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of seven sampled residents (Resident 2, Resident 3, and Resident 9) received care consistent with professional standards of practice to prevent pressure ulcers (PU, a localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure, or pressure in combination with shear) by failing to: a. Ensure Resident 3's low air-loss mattress (LALM - a mattress composed of inflatable air cushions that is used to relieve pressure on body parts) was set at the appropriate setting per facility policy. b. Ensure treatment was provided to Resident 9 as per physician's order. c. Ensure staff use a single draw sheet on Resident 2's LALM as indicated in the facility's policy. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) for three of five sampled residents (Resident 3, 9, and 10) by: 1. Failing to hold (not administer) Resident 3 ' s hydralazine (medication used to manage elevated blood pressure) for systolic blood pressure (SBP - measures the pressure the blood exerting against the artery walls when the heart beats) less than 110. At 5 p.m., on 8/12/2024, 8/13/2024, and 8/30/2024, Licensed Vocational Nurse 13 (LVN 13) administered hydralazine to Resident 3 when the resident ' s SBP levels were less than 110. 2. Failing to hold Resident 3 ' s diltiazem (medication used to manage elevated blood pressure) for SBP less than 110. On 8/12/2024 at 2 p.m. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure medical records were complete and accurately documented for two of 14 sampled residents (Resident 1 and Resident 3) by failing to: 1. Ensure Licensed Vocational Nurse 8 (LVN 8) and the Social Service Assistant (SSA) documented Resident 1 ' s condition in the resident ' s clinical records before and after the resident's discharge from the facility. 2. Ensure LVN 13 documented Resident 3 ' s Change of Condition (COC) timely in the resident ' s clinical record. Resident 3 had a COC on 9/16/2024 and the COC form was created on 9/17/2024. 3. Ensure facility staff documented the level of care provided to Resident 3 based on the resident ' s level of care assessment. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of 14 sampled residents (Resident 3) was provided dignity when Resident 3 ' s gown was pulled up to her chest, exposing the resident in view of other residents and staff. This deficient practice had the potential to negatively affect the resident ' s psychosocial wellbeing and loss of dignity.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the call light device (also known as a call bell or nurse call button, is a device typically found near a patient's bed or within reach. consists of a button that, when pressed, sends a signal to the nursing station or a centralized system, alerting healthcare providers that assistance is required in the room) was within reach for one of three sampled residents (Resident 14). This deficient practice had the potential to result in the delay of care and services and possible injury to residents when they are unable to call for assistance.

Inspectors wroteBased on interview and record review, the facility failed to notify the resident and the resident's responsible party (RP) of the result of the investigation and resolution of the grievance and failed to document the result of the grievance in the complaint and grievance form for one of three sampled residents (Resident 3). This deficient practice had the potential to violate residents' rights to have grievances addressed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive, person-centered care plan (contains relevant information about a resident ' s health conditions, goals of treatment, specific actions that must be performed, and a plan for evaluation) with measurable objectives and interventions for one of 14 sampled residents (Resident 1) by failing to develop a care plan addressing Resident 1 ' s discharge plans. This deficient practice placed the resident at risk for not receiving the necessary care and services related to the resident ' s discharge goals and needs.

Inspectors wroteBased on interview and record review, the facility failed to provide an ongoing activity program that is resident centered for one of three sampled residents (Resident 3). This deficient practice had the potential to affect the resident's sense of self-worth and psychosocial well-being. During a review of Resident 3 ' s admission Record, the admission Record indicated the facility admitted the resident on 3/14/2012 with diagnoses including Alzheimer ' s disease (a brain disorder that slowly destroys memory, thinking skills, and eventually the ability to carry out the simplest tasks), dementia, and aphasia (a language disorder that affects a person's ability to communicate). During a review of Resident 3 ' s Minimum Data Set (MDS -a federally mandated resident assessment tool), dated 9/12/2024, the MDS indicated the resident ' s cognitive skills was severely impaired. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow professional standards of practice for one of four sampled residents (Resident 3) by failing to: a. Ensure Resident 3 was assessed and monitored after the resident had a change of condition (COC) on 9/16/2024. b. Ensure Resident 3 ' s Attending Physician 1 (MD 1) and resident representative (FM 1) were notified about the resident's COC timely. These deficient practices had the potential to result in inaccurate assessment that can lead to the resident not receiving timely medical interventions.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents who are receiving enteral feeding (also known as tube feeding, a method of supplying nutrients directly into the gastrointestinal tract) received appropriate treatment and services for one of three sampled residents (Resident 3) by: 1. Failing to ensure the physician was notified timely when Resident 3 ' s gastrostomy tube (GT-a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) malfunctioned (fail to operate). 2. Failing to ensure GT residual (the amount of liquid drained from a stomach following administration of enteral feed) was checked and documented before administration of medications, flushing and formula every shift. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 9), who was receiving Lovenox (an anticoagulant that helps prevent the formation of blood clots) was monitored for the side effects of bleeding. This deficient practice had the potential to place Resident 9 at increased risk for side effects including bleeding and bruising.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control procedures for two of six sampled residents (Resident 3 and Resident 11) by: a. Failing to ensure Certified Nursing Assistant 7 (CNA 7) wore gloves while performing oral care (cleaning of the teeth, oral cavity [mouth], and dentures). Resident 3 was on enhanced barrier precaution (EBP - an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities). b. Failing to ensure Resident 11 ' s oxygen tubing was not touching the floor. These deficient practices had the potential for cross contamination (the physical movement or transfer of harmful bacteria from one person, object, or place to another) of the resident ' s care equipment and placed the residents at risk for infection.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide an environment free from accidents and hazards, ensure residents received adequate supervision, and implement and modify interventions to prevent accidents for one of three sampled residents (Resident 1) by failing to ensure Resident 1, who had repeated falls, was appropriately assessed by the interdisciplinary team (IDT, a group of health care professionals with various areas of expertise who work together toward the goals of the resident) after each fall incident. This deficient practice placed the resident at increased risk for falls resulting in injuries.

Inspectors wroteBased on interview and record review, the facility failed to fully inform the Responsible Party (RP- a person delegated to make medical decisions for the resident in the event they are unable to do so) for one of four sampled residents (Resident 1) when heparin (an anticoagulant medication; substance that is used to prevent and treat blood clots in blood vessels and the heart) a new medication to Resident 1 was prescribed on 6/25/2024. This deficient practice violated Resident 1's right to be informed of and participate in the resident's treatment.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) was free of any significant medication error when: 1. Licensed Vocational Nurse 4 (LVN 4) failed to administer diltiazem (a calcium channel blocker [type of drug that keeps calcium from entering the muscle cells of the heart and blood vessels] that treats high blood pressure and angina [chest pain]) and hydralazine (medication that relaxes the blood vessels and increasing the supply of blood and oxygen to the heart while reducing its workload) to Resident 1 as prescribed. This deficient practice had the potential for Resident 1's blood pressure to go down. 2. Licensed Vocational Nurse 1 (LVN 1) and Licensed Vocational Nurse 3 (LVN 3) failed to administer heparin (an anticoagulant medication; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure medical records are complete, accurately documented, readily accessible, and systematically organized for two of nine sampled residents (Resident 1 and Resident 2) by failing to document the resident ' s condition upon leaving the facility and the time the residents were transferred to the General Acute Care Hospital (GACH) emergency room (ER). This deficient practice had the potential for delayed medical interventions for Resident 1 and Resident 2.

Inspectors wroteBased on interview and record review the facility failed to ensure one of four sampled residents (Resident 1) was treated with respect and dignity and care in a manner and in an environment that promotes maintenance or enhancement of their quality of life by failing to ensure only a female Certified Nursing Assistant will be assigned to the resident. On 5/1/2024 Resident 1 was assisted by a male CNA, Certified Nursing Assistant 1 (CNA 1) with perineal care (washing the genital and rectal areas of the body). This deficient practice had the potential to affect the residents ' self-worth and self-esteem.

Inspectors wroteBased on interview and record review, the facility failed to implement its Abuse Prevention and Prohibition Policy and Procedures by failing to conduct pre-employment screening prior to hiring of employees for four out of five sampled staff (CNA 1, 3, 4, and 5). This deficient practice had the potential to place the residents at risk for abuse.

Inspectors wroteBased on interview and record review the facility failed to ensure a Certified Nursing Assistant has a current certification for one of five Certified Nursing Assistant reviewed for certifications (CNA 4). CNA 4 was hired on 4/7/2024. This deficient practice placed the residents at risk for receiving care from CNAs who are not competent and proficient.

Inspectors wroteBased on interview and record review, the facility failed to develop a resident centered care plan addressing oxygen use for one of three sampled residents (Resident 2). This deficient practice had the potential to result in inappropriate care and treatment.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Limit the use of PRN (as needed) Alprazolam (a medication used to treat the inability to sleep) to 14 days in one of five sampled residents (Resident 1). 2. Define and monitor for specific target behaviors tied to the use of psychotropic medications (medications that affect brain activities associated with mental processes and behavior) in one of three sampled residents (Resident 1). These deficient practices increased the risk that Resident 1 may have experienced adverse effects of psychotropic medication therapy leading to an overall negative impact on their physical, mental, and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to create a comprehensive person-centered care plan for one of three sampled residents (Resident 1) by failing to address Resident 1's refusal for Restorative Nursing Assistant (RNA- provide residents routine restorative nursing care and assist residents with exercises to improve or maintain mobility and independence) Program. This deficient practice had the potential for delayed provision of necessary care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure seven of 18 sampled residents (Resident 7, Resident 8, Resident 9, Resident 10, Resident 11, Resident 12, and Resident 17) received the necessary care and preferred services, such as warm showers and bed bath, to attain and maintain the residents' highest practicable physical, mental, and psychosocial well-being. The facility failed to: a. Ensure continuous hot running water were available for Resident 7, Resident 8, Resident 9, Resident 10, Resident 11, Resident 12, and Resident 17. b. Ensure that the water used for Resident 17 who had cognitive (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) impairment, was at comfortable temperature level. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of 18 sampled residents (Resident 8, Resident 9, and Resident 16) were provided bed baths using a safe and comfortable water temperature. The facility staff used the microwave to heat the water for the resident's bed bath. This deficient practice placed the residents at risk for sustaining burns, scalding (injury from hot liquid or steam), and experiencing uncomfortable water temperatures. Cross reference to F675 and F908.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure boiler (a device providing hot water supply) room equipment were in good working condition and provided safe and comfortable environment for the residents, staff, and visitors, as indicated in the facility's policies and procedures. The facility failed to: 1. Maintain boilers in safe operating conditions in one of three boiler rooms. 2. Maintain required water temperature range of 105 degrees Fahrenheit (°F - unit of measurement) to 120°F in five of five resident shower rooms (station 1 shower 1B room, station 2 shower 2A room, station 3 shower 4A room, station 4 shower 4 whirlpool room, and station 5 shower 5 room) and five of five nurse station hand sinks (station 1, station 2, station 3, station 4, and station 5). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 18 sampled residents (Resident 18) was provided a safe and homelike environment. The facility failed to ensure the ceiling in Resident 18 ' s room was free from water leak and water stains. This deficient practice resulted in Resident 18 not having a homelike comfortable and safe environment.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 4) was provided transportation to the facility timely after a medical appointment. On 2/14/2024 at 6 a.m., Resident 4 was transported to Outpatient Rehab Center 1 (ORC 1) for an appointment at 8:40 a.m. Resident 4 did not return to Skilled Nursing Facility 1 (SNF 1) on 2/14/2024. Resident 4 was found in a parking lot near ORC 1 and transferred to General Acute Care Hospital 1 (GACH 1) on 2/16/2024. This deficient practice placed Resident 4 at risk for accidents and injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 3), was provided necessary treatment and services to prevent formation of and promote healing of pressure sore by failing to implement the facility's policy on Braden Skin Risk Assessment Tool (a standardized, eveidence-based assessment tool commonly used in healthcare to assess and document a patient's risk for developing pressure injuries) for Prevention of Pressure Ulcers, by not having an appropriate assessment and that changes in condition are recognized, evaluated, addressed, when a new pressure ulcer developed within the facility. This deficient practice could potentially hinder the healing of Resident 3's pressure ulcers and cause infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Residents 3) received the necessary Restorative Nursing Program [RNP, nursing program that uses restorative nursing aides (RNA are health care professionals who are responsible for providing restorative and rehabilitation care for residents to maintain or regain physical, mental, and emotional well-being. Aides in this capacity are certified nurse assistants (CNAs), with specialized training in restorative care] to help residents improve or maintain one's functional ability and joint mobility by failing to provide RNP services consistently to Resident 3 from 1/2024 to 2/2024 as ordered by the physician and as recommended by the licensed therapist. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate oversight of the Food and Nutrition Services by qualified personnel when the Registered Dietitian did not conduct a comprehensive (complete) nutritional assessment (a detailed evaluation of the resident's nutritional health) by not talking to the resident or resident's family member and physically assessed a resident during the initial admission and quarterly assessment for one of one sampled resident (Resident 3) who had a weight loss. This failure had a potential to result in inaccurate nutrition assessment, ineffective nutrition intervention, and goals.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection control procedures for two of 18 sampled residents (Resident 13 and Resident 16) by failing to: a. Ensure Resident 16's water pitcher was not placed on an area used by other residents. b. Ensure Resident 13's wash basins were not placed on another resident's bathroom sink for hot water. These deficient practices placed Resident 13 and resident 16 at risk for exposure and contracting infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care in a manner that maintained or enhanced a resident's dignity and respect in full recognition of their individuality for two of three sampled residents (Resident 143, 291, and 99) investigated under the dignity investigative care area by: 1. Failing to maintain Resident 143's privacy while addressing their behavior of removing clothes due to itchiness. 2. Failing to ensure Resident 291's shower preference was honored and respected. 3. Failing to ensure Certified Nursing Assistant 4 (CNA 4) asked Resident 99's permission prior to providing care. These deficient practices had the potential to affect the residents' self-worth and self-esteem.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Obtain informed consent (a process during which residents or caregivers are educated regarding the potential risks and benefits of medication therapy) from the resident or their responsible party (a person delegated to make medical decisions for the resident in the event they are unable to do so) prior to treatment with injectable lorazepam (a medication used to treat mental illness) in one of six sampled residents investigated during review of unnecessary medications (Resident 14). 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to offer the resident or their resident representative assistance with formulating an Advance Directive (AD - a legal document telling the doctor one's wishes about their healthcare in the event they cannot make the decision for themselves) upon admission for three (Resident 4, 194, and 222) out of four sampled residents investigated during review of advance directive care area. This deficient practice violated the resident and/or their representative the right to be fully informed of the option to formulate an AD and had the potential to delay emergency treatment or the potential to force emergency, life-sustaining procedures against the resident's personal preferences.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident was free from physical restraint (refers to means of purposely limiting or obstructing the freedom of a person's bodily movement) for one of one sampled resident (Resident 222) investigated during review of physical restraints care area by failing to assess the need for a restraint and by failing to obtain an order from the physician when: 1. Resident 222's right side bed was pushed against the wall to prevent the resident from getting out of bed. 2. A booster pillow was placed on the left side of Resident 222's bed to prevent the resident from getting out of bed. 3. A tab alarm (features a pull-string that attaches magnetically to the alarm with garment clip to the resident) was applied to Resident 222 to notify staff the resident was getting out of bed. [...]

Inspectors wroteBased on interview and record review the facility: 1. Failed to develop a care plan on the use of anticoagulants (a blood thinner that treats and helps prevent blood clots) for two of four sampled residents (Resident 39 and Resident 194) investigated during review of anticoagulant care area by failing to develop a care plan for Resident 39's use of Eliquis (an anticoagulant medication) and by failing to develop a care plan for Resident 194's use of Xarelto (an anticoagulant medication). This deficient practice had the potential for failure to deliver necessary care and services and subjecting residents to adverse effects (a harmful or abnormal result) of significant medications. 2. [...]

Inspectors wroteBased on interview and record review, the facility's licensed nursing staff failed to provide care in accordance with professional standards by: 1. Failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) administration sites of insulin (a hormone that lowers the level of sugar in the blood) to four out of four sampled residents (Residents 73, 97, 1, and 6) investigated for insulin use. 2. Failing to rotate subcutaneous administration sites of heparin (is used to prevent formation of blood clots in the vessels) to one out of four sampled residents (Resident 97) investigated for anticoagulant use. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide needed care and services that are resident centered for two of two sampled residents reviewed under non-pressure skin conditions (Resident 105 and 134) and (Resident 196 Care Area/Universe) when: 1. The facility failed to follow up with Resident 105 regarding the effectiveness of his rash treatments. 2. The facility failed to provide treatment for Resident 134's surgical wound as ordered by the physician. These deficient practices had the potential for Resident 105 and 134's skin conditions to worsen or delay healing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer parenteral fluids (the intravenous administration of medication) consistent with professional standards of practice by failing to: 1. Flush the peripherally inserted central catheter (PICC, a long, thin tube that is inserted through a vein in the arm and passed through the larger veins in the heart) line/central line (a tube that doctors placed in a large vein in the neck, chest, groin, or arm to give fluids, blood, or medications or do medical tests quickly) with 10 milliliters (ml, a unit of volume) of normal saline (NS, a mixture of sodium chloride [salt] and water) prior to administration of intravenous (IV, within a vein) antibiotics to one of one sampled residents (Resident 446) investigated under infection control task. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure effective pain management by failing to identify the resident's pain level after administration of pain medication for one of one sampled resident (Resident 203), who was investigated under the care area of pain management. Resident 203 had no pain level assessments after pain medications were given on: 1/1/2024 at 9:45 a.m.; 1/1/2024 at 2 p.m.; 1/1/2024 at 6 p.m.; 1/3/2024 at 9 a.m.; 1/3/2024 at 5:36 p.m.; 1/4/2024 at 2 p.m.; 1/5/2024 at 2 p.m.; 1/8/2024 at 8:45 a.m.; 1/9/2024 at 3:15 p.m.; 1/10/2024 at 11:30 a.m.; 1/10/2024 at 8:47 p.m.; 1/11/2024 at 9:30 a.m.; 1/11/2024 at 8:10 p.m.; 1/12/2024 at 1 a.m.; 1/14/2024 at 12:15 p.m.; 1/15/2024 at 11 a.m.; 1/16/2024 at 1:20 a.m.; 1/19/2024 at 5:30 a.m.; 1/19/2024 at 11 a.m.; 1/21/2024 at 1 p.m.; and 1/22/2024 at 12:11 p.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary medically related social services to maintain the highest practicable physical, mental, and psychosocial well-being for one of two sampled residents investigated during review of non-pressure skin conditions care area (Resident 105) and one of six sampled residents reviewed under the abuse investigative care area (Resident 203) when: 1. The facility failed to follow up with Resident 105's dermatology (branch of medicine dealing with the skin) consult for itching. 2. The facility failed to identify and assess Resident 203's need for mental and emotional support after a resident-to-resident altercation between Resident 203 and Resident 23 on 1/13/2024. [...]

Inspectors wrote2. A review of Resident 203's admission Record indicated the facility admitted the resident on 12/28/2023 with diagnoses including generalized edema, dependence on supplemental oxygen, muscle weakness, and hypertension (high blood pressure). A review of Resident 203's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 1/3/2024, indicated the resident's cognitive skills (ability to understand and make decisions) were intact (not affected). The MDS indicated Resident 203 required supervision or touching assistance for toileting hygiene, showering/bathe self, lower body dressing, putting on/taking off footwear, and personal hygiene. [...]

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure the consultant pharmacist identified and reported the medication irregularities of failing to monitor for adverse effects and target behaviors related to psychotropic (medications that affect brain activities associated with mental processes and behavior) medication therapy in one of five sampled residents (Resident 14). 2. [...]

Inspectors wrote2. A review of Resident 194's admission Record indicated the facility admitted the resident on 8/18/2023, and readmitted the resident on 10/13/2023, with diagnoses including traumatic brain injury (a form of acquired brain injury caused by sudden trauma), syncope (a loss of consciousness for a short period of time), and history of falling. A review of Resident 194's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 10/28/2023, indicated the resident usually had the ability to make self-understood and understand others. The MDS indicated the resident was receiving high-risk drug class anticoagulant medication (a substance that is used to prevent and treat blood clots in the blood vessels and the heart). A review of Resident 194's Order Summary Report indicated the following orders: [...]

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure a new order for PRN (as needed) injectable lorazepam (a medication used to treat mental illness) was limited to a 14-day duration in one of six sampled residents investigated during review of unnecessary medications (Resident 14.) 2. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure residents were free of any significant medication errors by: 1. Failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) administration sites of insulin (a hormone that lowers the level of sugar in the blood) to four out of four sampled residents (Residents 73, 97, 1, and 6) investigated for insulin use. 2. Failing to rotate subcutaneous administration sites of heparin (is used to prevent formation of blood clots in the vessels) to one out of four sampled residents (Resident 97) investigated for anticoagulant use. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Ensure two unopened vials of latanoprost (a medication used to treat eye conditions) eye drops were stored in the refrigerator according to the manufacturer's requirements affecting Residents 165 and 341 in two of five inspected medication carts (Station 2 Cart B and Station 5 Medication Cart.) 2. Ensure lorazepam oral solution (a medication used to treat mental illness) and injectable lorazepam solution (a medication used to treat mental illness) were stored in the refrigerator per the manufacturer's requirements affecting residents 143 and 211 in one of five inspected medication carts (Station 3 Cart A.) 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: 1. There was no air gap (the unobstructed vertical space designed to prevent any backflow of contaminated water into the [NAME] supply) between the ice machine drainage pipe and the floor drain. 2. There was no thermometer kept inside the walk-in freezer. 3. The paper towel dispenser next to the hand washing station was empty and not replaced immediately after the previous roll was emptied. These deficient practices had the potential to result in harmful bacterial growth and foodborne illnesses (any illness of a toxic or infectious nature contracted through consumption of contaminated water or food).

Inspectors wroteb. A review of Resident 129's admission Record indicated the facility admitted the resident on 12/7/2021 and readmitted the resident on 11/4/2022 with diagnoses including hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (also known as stroke - refers to damage to tissues in the brain due to a loss of oxygen to the area) affecting left dominant side, dysphagia (difficulty swallowing), and encounter for palliative care (specialized medical care that focuses on providing relief from pain and other symptoms of a serious illness). A review of Resident 129's History and Physical (H&P) dated 11/8/2023, indicated that the resident had the capacity to understand and make decisions. [...]

Inspectors wrote5. A review of Resident 203's admission Record indicated the facility admitted the resident on 12/28/2023 with diagnoses including pleural effusion (buildup of fluid between the layers of tissue that line the lungs and chest cavity), dependence on supplemental oxygen, muscle weakness, and hypertension (high blood pressure). A review of Resident 203's MDS, dated [DATE], indicated the resident's cognitive skills (ability to understand and make decisions) were intact. The MDS indicated Resident 203 required supervision or touching assistance for toileting hygiene, showering/bathe self, lower body dressing, putting on/taking off footwear, and personal hygiene. A review of Resident 203's Order Summary Report, dated 12/28/2023, indicated the resident had a physician's order for oxygen at two liters per minute via nasal cannula continuously every shift for shortness of breath (SOB). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the initial care conference meeting was held with the resident or their representative for two of three sampled residents investigated during review of the residents' interdisciplinary team (IDT - a group of health care professionals with various areas of expertise who work together toward the goals of the residents) care plan meeting (Resident 91 and Resident 200). This deficient practice had the potential to violate Resident 91 and Resident 200's right to be an active participants in their care and had the potential for delay in the provision of necessary care and services.

Inspectors wroteBased on observation, interview, and record review the facility failed to keep the call light (an alerting device for nurses or other nursing personnel to assist a resident when in need) within reach of the resident for two out of five sampled residents (Resident 182 and Resident 233) investigated during review of environment facility task. These deficient practices had the potential to result in the resident not being able to call for facility staff assistance and delay in the provision of necessary care and services that can negatively affect the resident's comfort and well-being.

Inspectors wroteBased on interview and record review, the facility failed to protect the residents' right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) for two of six sampled residents (Resident 23 and Resident 203). On 1/13/2024 at 11:30 a.m., in the hallway, Resident 203 threw a fruit cup and spat at Resident 23's face. Then, Resident 23 punched Resident 203 in the face followed by Resident 203 hitting Resident 23 back in the face. This deficient practice resulted in Resident 203 and Resident 23 subjected to physical abuse while under the care of the facility. This deficient practice also caused Resident 203 to report right eye pain and received pain medication.

Inspectors wroteBased on interview and record review, the facility failed to complete a thorough investigation regarding allegations of abuse involving two of six residents (Residents 23 and Resident 203) investigated under the care area of abuse by failing to interview Licensed Vocational Nurse 5 (LVN 5) who witnessed the incident. This deficient practice had the potential to result in unidentified abuse in the facility and failure to protect residents from abuse.

Inspectors wroteBased on interview and record review, the facility failed to send a copy of the notification of a resident's transfer/discharge to the office of the long-term care ombudsman (resident advocate) for one of three sampled residents investigated during review of closed records (Resident 240). The facility did not have documented evidence a copy of Resident 240's Notices of Transfer/Discharge, dated 12/4/2023 and 12/5/2023 was sent to the long-term care ombudsman office. This deficient practice had the potential for Resident 240 to have an unsafe discharge. Cross-reference to F-Tag F661, F625, and F641

Inspectors wroteBased on interview and record review, the facility failed to provide a bed-hold notice to a resident upon transfer to the general acute care hospital (GACH) for one of three sampled investigated during review of closed records (Resident 240). This deficient practice had the potential for Resident 240 to not know if they had a place to return to after hospitalization. Cross-reference F-Tag 661, F623, and F64.

Inspectors wroteBased on interview and record review, the facility failed to develop a baseline care plan (initial written guide that organizes information about the resident's care) within 48 hours of admission for one out of nine sampled residents (Resident 452) investigated under care planning care area. This deficient practice had the potential for Resident 452 not to receive the appropriate care and treatment specific to his needs.

Inspectors wroteBased on interview and record review, the facility failed to indicate and include the interdisciplinary team (IDT - professional disciplines that work together to provide the greatest benefit to the resident) members involved with a resident's plan of care for one of three sampled resident reviewed under care planning (Resident 6) when Resident 6's IDT notes, dated 3/2/2023, did not indicate whether the physician, registered nurse (RN), certified nursing assistant (CNA), and a member of the food and nutrition staff were present during Resident 6's care plan meeting and did not indicate who was present during the IDT meeting conducted on 9/12/2023. This deficient practice had the potential for the facility to be unaware of which disciplines were involved with the resident's plan of care and what their contributions were to the resident's plan of care.

Inspectors wroteBased on interview and record review, the facility failed to complete on a timely basis the resident's discharge plan by failing to follow-up the discharge planning process with the resident and the resident's representative for one of two sampled residents (Resident 107) investigated under the discharge care area. This deficient practice placed the resident at risk for not receiving the necessary care and services related to the resident's discharge goals and needs.

Inspectors wroteBased on interview and record review, the facility failed to implement their policy and procedure on cardiopulmonary resuscitation (CPR, an emergency procedure used to restart a person's heartbeat and breathing after one or both have stopped) by failing to ensure Certified Nursing Assistants maintain current CPR certification two of two Certified Nursing Assistants (CNA 4 and CNA 11) investigated during review of personnel files. These deficient practices had the potential of delayed provisions of emergency care for residents who wishes to have full treatment in a life-threatening situation.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one of three sampled resident (Resident 200) has reading glasses as recommended by the optometrist (health care provider who specializes in eyecare) on 10/20/2023. This deficient practice resulted in Resident 200 not being able to read her books she enjoys.

Inspectors wroteBased on interview and record review the facility failed to provide care consistent with professional standards of practice to prevent pressure ulcer/injury (ulcers that happen on areas of the skin that are under pressure from lying in bed, sitting in a wheelchair, or wearing a cast for a long period) to two out of three sampled residents (Residents 73 and 194) being investigated under pressure ulcer care area, by failing to consistently perform weekly skin assessment to Residents 73 and 194 who had pressure ulcers at stage 4 (the sores extend below the subcutaneous fat into the deep tissues, including muscle, tendons, and ligaments) on the coccyx (the small bone at the end of the spine, also called tailbone). This deficient practice had the potential for development and worsening of pressure ulcers/injuries to the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident received appropriate treatment and services to prevent urinary tract infections (UTI, common infections that happen when bacteria, enter the urethra [duct that transmits urine from the bladder to the exterior of the body during urination], and infect the urinary tract) to one out of two sampled residents (Resident 73) being investigated under catheter care area, by failing to replace worn out Statlock (a device to secure the catheter to prevent tugging and pulling) in order to secure the urinary catheter (a procedure used to drain the bladder and collect urine, through a flexible tube called a catheter) of the resident. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to discard a feeding formula bottle of Jevity (a calorically dense, fiber-fortified therapeutic nutrition that provides complete, balanced nutrition for long- or short-term tube feeding) 1.5 calories (a unit of energy), dated 1/16/2024 (observed on 1/22/2024), via gastrostomy tube (g-tube, a tube inserted through the belly that brings nutrition directly to the stomach) feeding and an undated irrigation syringe (used to administer medication and irrigate the feeding tube) to one out of one sampled resident (Resident 182) being investigated under tube feeding. The deficient practice had the potential for residents to experience gastrointestinal (GI) (relating to stomach and intestines) problems such as abdominal pain and diarrhea.

Inspectors wroteBased on observation, interview and record review, the facility licensed staff failed to ensure a resident who received dialysis (the process of removing waste products and excess fluid from the body using a machine when the kidneys are not able to do so) was assessed after dialysis treatment and failed to document the assessment in the Pre (before)- and Post (after)-Dialysis Communication Form for one of one sampled resident (Resident 63) investigated during review of dialysis care area. This deficient practice had the potential for unidentified complications such as swelling, pain, bleeding, and bruising and had the potential to result in lack of provision of necessary treatment and services after dialysis treatment.

Inspectors wroteBased on interview and record review, the facility failed to promptly provide dental services for two out of three sampled residents (Residents 97 and 39) reviewed under the dental investigative care area by failing to schedule an oral x-ray (use invisible electromagnetic energy beams to produce images of internal tissues, bones, and organs on a film or digital media) per the dentist's treatment recommendation for Resident 97 and Resident 39. This deficient practice had the potential to result in discomfort and the inability to effectively chew foods, weight loss, lack of energy and loss of muscle mass of the residents.

Inspectors wrote2. A review of Resident 70's admission Record indicated the facility admitted Resident 70 on 8/11/2023 with diagnoses including, but not limited to, hyperlipidemia (high cholesterol) and need for assistance with personal care. A review of Resident 70's H&P, dated 8/11/2023, indicated Resident 70 had fluctuating capacity to understand and make decisions. A review of Resident 70's MDS, dated [DATE], indicated Resident 70 had intact cognition and required setup or clean-up assistance with eating, supervision or touching assistance with oral hygiene, partial or moderate assistance with toileting hygiene, showering or bathing himself, upper and lower body dressing, and substantial or maximal assistance with putting on or taking off footwear and personal hygiene. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain medical records in accordance with accepted professional standards by failing to: 1. Accurately document a pertinent individualized care plan for one out of six residents sampled being investigated under abuse (Resident 203) to indicate that abuse occurred between Resident 203 and Resident 23. This deficient practice resulted in Resident 203's medical records being inaccurate and had the potential to result in confusion regarding whether actual abuse took place between Resident 203 and Resident 23. 2. Document the name of the person who pronounced the resident expired (died) at the facility and by the physician failing to create a discharge summary indicating the resident's cause of death to one of three sampled residents (Resident 239) selected for closed record review. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's low air loss mattress (LALM, designed to distribute the patient's body weight over a broad surface area and help prevent skin breakdown) was in good repair at all times for one of five sampled residents (Resident 128) investigated under the Environment facility task. This deficient practice had the potential to place the resident at risk for pressure ulcers (also called pressure injuries and decubitus ulcers - injuries to skin and underlying tissue resulting from prolonged pressure on the skin) due to inadequate pressure redistribution.

Inspectors wroteBased on interview, and record review, the facility failed to follow the facility's policy and procedure titled Resident Assessment to create a Minimum Data Set (MDS, a standardized assessment and care screening tool) significant change in status assessment when there was a decline in residents' activity of daily living (ADL) and skin condition, for one of the three sampled residents (Resident 20). This failure placed Resident 20 at risk for not receiving the necessary care and services related to health care needs.

Inspectors wroteBased on interview and record review, the facility failed to transmit the Minimum Data Set (MDS, a standardized assessment and care screening tool) timely for one of three sampled residents (Resident 101) investigated under the Resident Assessment facility task. These deficient practices had the potential to result in care that does not address the resident's specific care needs.

Inspectors wroteBased on interview and record review, the facility failed to conduct accurate assessments for one of three sampled residents investigated during review of closed records (Resident 240) by failing to accurately code in the Minimum Data Set (MDS, - a standardized assessment and care screening tool) the resident's discharge status. The MDS dated [DATE], indicated Resident 240 was discharged to the general acute care hospital (GACH) when Resident 240 was discharged to a board and care (B&C - a residential care option catering to individuals requiring assistance with daily living activities). This deficient practice had the potential for facility staff to be unable to track where the resident was discharged and ensure the resident was discharged to an appropriate setting. Cross-reference F-Tag F661, F623, and F625

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents received care consistent with professional standards of practice to prevent pressure ulcers (PU, a localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure, or pressure in combination with shear) for two of six residents (Resident 1 and Resident 4) by failing to: 1. Ensure the air pressure redistribution mattress (APM - a mattress composed of inflatable air cushions that is used to relieve pressure on body parts) for Resident 1 was turned on and functioning. 2. Ensure there were appropriate number of linens between Resident 1 and the mattress per manufacturer ' s recommendation. 3. Ensure there was a physician order for the APM setting for Resident 1 and Resident 4. 4. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biological) for three of five sampled residents (Resident 8, 9, 1and 1) by: 1. Failing to ensure Resident 8 was not administered neutral protamine [NAME] (NPH- intermediate acting [works throughout the day and night to provide you with low levels of insulin all the time]) with regular (short acting-starts to work quickly) when the resident ' s blood sugar was below 150 milligrams per deciliter (area of measurement) as ordered by the physician. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled residents (Resident 7) receive treatment and care in accordance with professional standards of practice by failing to check for Resident 7's identification and physician's order prior to transporting Resident 7 to a medical appointment intended for Resident 11 on 12/20/2023. Resident 11 was discharged to General Acute Care Hospital 1 (GACH) on 12/15/2023. As a result Resident 7 was brought by a transportation service arranged by the facility to a medical appointment intended for Resident 11. This deficient practice had the potential to create confusion in the delivery of care and services to Resident 7.

Inspectors wroteBased on interview and record review the failed to maintain accurate and complete medical record for one of five sampled residents (Resident 7) by failing to ensure the facility documented information of Resident 7's transport to a medical appointment intended for Resident 11. This deficient practice had the potential to cause confusion in care and the medical records containing inaccurate documentation and can result in the delay of delivery of care.

Inspectors wroteBased on interview and record review, the facility failed to employ a qualified social service on a full-time basis that met the qualifications as indicated in the facility ' s job description for Social Service Director (SSD). This deficient practice had a potential for the residents residing in the facility not being assisted with obtaining medically related necessary care to attain their highest practicable well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two of five sampled staff (admission Assistant 1 [AA 1] and Payroll Staff [PS 1]) wore surgical mask (a respiratory protective device that provides barrier protection against large particles droplets) during an outbreak (a sudden increase in occurrences of a disease when cases are in excess of normal expectancy) of Coronavirus Disease 2019 (COVID-19- highly contagious respiratory disease is thought to spread from person to person through droplets released when an infected person coughs, sneezes or talks) in the facility. This deficient practice has the potential to result in the spread of COVID-19 to all staff and residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection control procedures for two of seven sampled residents (Resident 6 and Resident 7) by failing to ensure Licensed Vocational Nurse 2 (LVN 2): 1. Performed hand hygiene (hand washing with soap and water and use of alcohol-based hand sanitizer) before and after gloves use while administering medications to Resident 7. 2. Performed hand hygiene before and after touching Resident 6 and Resident 7 and the resident ' s surroundings without wearing gloves. 3. Disinfected the glucometer (a medical device for determining the approximate concentration of blood sugar) before it was returned in the medication cart drawer. These deficient practices placed Resident 6 and Resident 7 at risk for exposure and contracting infections.

Inspectors wroteBased on interview and record review, the facility failed to report the allegation of resident-to-resident abuse to the State Survey Agency (SSA) for two of seven sampled residents (Resident 1 and Resident 2). On 11/16/2023 at 9:30 a.m., Resident 2 reported an allegation of abuse by Resident 1 to Charge Nurse 1 (CN 1). On 11/16/2023 at 6:10 p.m., the Abuse Coordinator reported the allegation to the SSA, 8 hours and 40 minutes after the allegation of abuse was made. This deficient practice had the potential to result in unidentified abuse and failure to protect other residents from abuse.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive, person-centered care plan with measurable objectives and interventions for one of seven sampled residents (Resident 1). The facility failed to develop and implement individualized care plans and interventions addressing Resident 1 ' s aggressive behavior. This deficient practice had placed Resident 1 for not receiving the necessary services and assistance that can result in injury to other residents, visitors, and facility staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy and procedure on meeting the staff posting requirements. The facility also failed to provide the Direct Care Service Hours Per Patient Day (DHPPD refers to the actual hours of work performed per patient day by a direct caregiver) for one of seven sampled residents (Resident 3) after the resident ' s verbal request. This deficient practice had the potential to keep residents and visitors unaware of the total number of staff and the actual hours worked by staff in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow menu for residents when: - Ninety (90) out of two hundred forty-seven (247) residents on soft mechanical chopped meats diet got of big pieces of chicken that measured one and a half inches (1 ½) to two (2) inches in size. - Ten (10) out of 247 residents on regular diet got 2 oz of chicken with rosemary sauce instead of 3 oz and 1 oz of boiled potatoes instead of 4 oz. These deficient practices had the potential to decreased nutritional value for carbohydrate, and protein content not consistent to the physician ' s diet order. Furthermore, soft mechanical chopped diet receiving 1 ½ to 2 of meat may result to difficulty eating, swallowing, and choking (blocked airway causing difficulty in breathing) which decreased food intake resulting to weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare food by methods that conserved flavor and appearance. In addition, food portions were not correct. This deficient practice placed two hundred one (201) of two hundred forty-seven (247) facility residents at risk of unplanned weight loss, a consequence of poor food intake.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide the necessary services for one of 15 sampled residents (Resident 15) who was unable to carry out activities of daily living received the necessary services to maintain good grooming when Resident 15 was observed with long curled nails. This deficient practice had the potential for Resident 15 to have discomfort.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate nutritional and hydration care and services to residents when: 1. The facility failed to provide physician ordered high calorie (Kcal, a unit of energy used to express the nutritional value of foods), high protein (a type of nutrient a person needed for growth and development of muscles) nutritional supplement (product used to add kcal and protein in the diet) of preference. 2. The facility failed to prepare foods by methods that conserved flavor and appearance for Resident 1 causing varied oral intake (PO intake). These deficient practiced caused 14.4% severe unplanned weight loss in six (6) months of one (1) of three (3) sampled residents (Resident 1).

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 15 sampled residents (Resident 1) was free from significant medication error by failing to ensured licensed staff did not administer oxycodone (a pain-relief medicine used to treat severe pain) with Gabapentin (medication used to treat epilepsy [a disorder of the brain characterized by repeated seizures] also taken for nerve pain) to Resident 15. This deficient practice placed Resident 15 at risk for respiratory depression, coma, and death.

Inspectors wroteBased on interview and record review, the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for three of three sampled residents (Resident 1, Resident 2, and Resident 3) by: 1. Facility failed to ensure Registered Nurse 1 (RN 1) documented head to toe body assessment after Resident 3 grabbed the back collar and pushed Resident 2 while seated on a wheelchair away from Resident 3 ' s door on 10/25/2023. 2. Facility failed to ensure RN 1 documented administration of amlodipine (medication used to treat high blood pressure) accurately and per physician ' s order for Resident 1 on 10/2023 Medication Administration Record (MAR-record of medications received by the resident). 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 2) was free from physical abuse inflicted by Resident 3. On 10/25/2023 at 3:05 p.m., Resident 3 grabbed the back collar of Resident 2 ' s shirt and pushed her away from Resident 3 ' s door. This deficient practice resulted to Resident 2 being subjected to physical abuse while under the care of the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure that licensed nurses followed the physician's order for one of three sampled residents (Resident 1) by: 1. Failing to ensure resident was given propranolol (medication used to treat high blood pressure) despite physician ' s order to hold medication if systolic blood pressure (sbp- pressure in the arteries when the heart beats) was below 110 millimeters of mercury (mmHg- unit of measurement) as indicated in residents 10/2023 Medication Administration Record (MAR- record of medications received by the resident). 2. Failing to ensure resident was given amlodipine (medication used to treat high blood pressure) despite physician ' s order to hold medication if sbp was below 110 as indicated in residents 10/2023 MAR. These deficient practices can potentially lower Resident 1's blood pressure.

Inspectors wroteBased on interview and record review the facility failed to inform the resident ' s responsible party when the resident had laboratory results with out of range values for one of six sampled residents (Resident 1). This deficient practice violated the resident ' s rights and/or the representative ' s right to be fully informed of Resident 1 ' s change of condition. Findings A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 3/14/2012 ,with diagnoses including encounter for attention to gastrostomy (a feeding tube surgically inserted on the abdomen directly to stomach to provide nutritional needs), type ll diabetes mellitus (characterized by having high amounts of sugar in the blood), and Alzheimer ' s disease (brain disorder that worsens over time causing memory loss and mental decline). [...]

Inspectors wroteBased on interview and record review, the facility failed to promptly notify the resident's physician of laboratory results that fall outside of clincal reference ranges for one of six sampled residents (Resident 1). This deficient practice had the potential for a delay in treatment and delivery of care and services for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to notify residents, resident ' s representatives, and families of suspected or confirmed COVID-19 (a viral infection, highly contagious, that easily transmits from person to person, causing respiratory problems and may cause death) cases in the facility along with mitigating actions in a timely manner. This deficient practice resulted in residents, their representatives, and their families not receiving notifications regarding the status and impact of COVID-19 in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an odor free and sanitary environment for one of three sampled residents (Resident 1). This deficient practice placed Resident 1 at risk for increased level of discomfort and had the potential to negatively impact the resident's quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure prompt attempts were made to resolve the grievance (an official statement of a complaint over something believed to be wrong or unfair) for one of three sampled residents (Resident 1). This deficient practice violated Resident 1's right to have his grievance addressed.

Inspectors wroteBased on interview and record review the facility failed to ensure the resident 's safety for one out of three sampled residents (Resident 1) by failing to provide transportation to a medical appointment. The facility staff transported Resident 1 via wheel chair to the local General Acute Care Hospital (GACH 1). This deficient practice placed the resident at risk for injuries resulting from an accident. A review of Resident 1 ' s admission Records indicated the facility admitted the resident on 9/1/2023 with diagnosis that included sepsis (the body's extreme response to an infection) unspecified organism, type 2 diabetes mellitus (a disease that occurs when your blood glucose, also called blood sugar, is too high) with other diabetic kidney complications, and acquired absence of left leg below knee. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its infection prevention and control program by: 1. Failing to ensure a resident's oxygen tubing (used for oxygen delivery) was not touching the floor for one of eight (Resident 5) sampled residents. 2. Failing to ensure the Screener (SC) screened visitors for signs and symptoms of Coronavirus Disease 2019 (COVID-19, a highly contagious disease spread from person to person through droplets released when an infected person coughs, sneezes, or talks) prior to entering the facility. 3. Failing to ensure ice scoopers in Station 3 and Station 4 were kept in a closed container. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an updated staffing information was posted daily. As a result, the total number of staff and the actual hours worked by the staff was not readily accessible to residents and visitors.