Motion Picture and T.v. Hosp D/P SNF

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an environment free from accidents and hazards for four of eight sampled residents (Resident 5, 35, 67, 96) reviewed for accidents by failing to: 1. Ensure Resident 5's bilateral (both sides) fall mats (a protective, impact-absorbing cushion placed on the floor alongside a patient's bed) were provided per plan of care and physician's orders when the right-side fall mat was not in place. 2. Ensure floor mats designed to reduce injury from falls, were free from objects over the mats for Residents 67 and Resident 96. These failures had the potential to result in resident falls resulting in injuries like fractures (broken bones) and lacerations for Residents 5, 67, and 96. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who need respiratory care were provided care consistent with professional standards of practice for two of two sampled residents (Resident 8 and 93) reviewed under the Respiratory care area by failing to: 1. Ensure supplemental oxygen (O2) was administered per physician orders, documented when administered, and monitored while in use for Resident 93. 2. Ensure Resident 8's nasal cannula (NC, a small plastic tube, which fits into the nostrils for providing supplemental O2) tubing was identified by CNA 2 when it was on the ground, was not placed by RNA 2 on the resident's bed linens after being removed from the ground and was replaced by LVN 9 after the tubing was on the ground. [...]

Inspectors wroteBased on observation, interview, and review, the facility failed to ensure safe provision of pharmaceutical services by: 1. Failing to label Resident 38's cyclosporine eye drop (a medicine used to help people with chronic dry eye disease by reducing swelling in the eye) with an open date during the inspection of one (1) of three (3) medication carts (Medication Cart 1) reviewed during the Medication Storage and Labeling task. 2. Failing to indicate the open date and discard Resident 56's ipratropium-albuterol sulfate (also known as duoneb, a prescription liquid solution or medicine that people breathe in through a nebulizer [a small machine that turns liquid medicine into a mist so a person can breathe it directly into the lungs] to help the airway open up and make it easier to breathe) two (2) weeks after opening as indicated in the medication label. 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 by: 1. Failing to ensure a bag of shredded lettuce was not sealed and not labeled with an open date. 2. Failing to ensure the test strip used to check the sanitizing solution was not expired. 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 97 out of 97 medically compromised residents who received food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) for one of five sampled residents (Resident 5) for duloxetine (a psychotropic medication [any medication capable of affecting the mind, emotions, and behavior] classified as an anti-depressant [treats persistent feelings of sadness and loss of interest that can interfere with daily living]). This failure had the potential to result in the use of unnecessary psychotropic drugs resulting in adverse effects (an undesired and harmful result of a treatment or intervention, such as a medication or surgery) and a violation of Resident 5's right to make medical decisions regarding the use of psychotropic medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep the call light (an alerting device for residents to call a nursing personnel to assist them when needed) within reach of the resident for two of two sampled residents (Residents 67 and 76). This failure had the potential to place Residents 67 and 76 at risk for delayed assistance, potentially affecting safety and timely care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe and comfortable homelike environment for one of one sampled resident (Resident 96) by not ensuring the floor mat was maintained in good condition or replaced when damaged. This failure had the potential for the damaged floor mat to create a trip hazard, increasing the risk for falls and possible injury for Resident 96.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled residents (Resident 79) was free from the use of chemical restraints (any drug that is used for discipline or staff convenience and not required to treat medical symptoms) by failing to ensure clonazepam (medication used to treat anxiety disorder [a mental health condition that may result in restlessness, irritability, feelings of nervousness, panic, and fear)]) was prescribed, administered, and monitored for specific, measurable behavioral manifestations. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess the risk of entrapment (an event in which a resident is caught, trapped, or entangled in spaces in or about the bed rail, mattress, or hospital bed frame) from bed rails/side rails (safety devices, typically metal or plastic bars, that attach to the sides of a bed to help prevent falls or provide support for residents) for one (1) of two (2) sampled residents (Resident 84) reviewed for physical restraints (are any action or procedure that prevents a person's free body movement to a position of choice and/or normal access to the body by the use of any method, attached or adjacent to a person's body that the person cannot control or remove easily) by failing to complete the bed rail risk assessment prior to use of bilateral bed rails. [...]

Inspectors wroteBased on interview and record review, the facility failed to act upon the pharmacist's recommendation for one of five sampled residents (Resident 22) reviewed for Unnecessary Medications, Psychotropic (medications capable of affecting the mind, emotions, and behavior) Medications, and Medication Regimen Review (MRR-a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) care area by failing to follow-up with Resident 22's physician or medical provider regarding the consultant pharmacist's MRR recommendation. This failure placed Resident 22 at risk for receiving inappropriate medication, which could lower their well-being or increase the likelihood of adverse drug effects.

Inspectors wroteBased on observation, interview, and record review, the facility failed to honor resident dietary preferences for one of six sampled residents (Resident 23) reviewed during the Dining Observation task by failing to ensure the resident was provided milk and a banana for lunch on 7/13/2026. This failure had the potential to result in resident dissatisfaction leading to psychosocial issues resulting in decreased meal intake and unintentional weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly document the medical record for one of three sampled residents (Resident 66) by failing to accurately document resident's weight and documented 220 pounds (lbs., the standard unit of weight to measure how heavy something or someone is) on 3/07/2026. This failure has the potential to result in incomplete, inaccurate, or delayed records that could lead to miscommunication between healthcare providers and resident harm for Resident 66.

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 implement the facility policy and procedure for one randomly observed resident (Resident 37) when Certified Nursing Assistant (CNA) 6 failed to doff (remove) disposable gloves and perform hand hygiene (HH - process of cleaning hands using soap and water or antibacterial hand rub) prior to exiting the resident's room after providing care with lift equipment (device used to assist with resident transfers). This failure had the potential to result in the spread of infectious microorganisms amongst staff, residents, and visitors.

Inspectors wroteBased on interview and record review, the facility failed to complete an inventory of one of one sampled resident's (Resident 1) home medication. This deficient practice resulted in Resident 1's home medication mismanagement; in addition, failure to inventory a patient's home medication upon admission to a facility creates a high risk of lost belongings, medication omissions, and discrepancies in treatment. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident rights for one resident (Resident 1), were upheld and ensured their right to receive care in a safe environment. This failure resulted in physical harm to Resident 1 by a facility staff employee with the potential to have resulted in serious injury to Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to enforce for one resident (Resident 1), their own policy and procedures regarding abuse prevention and reporting. This failure resulted in Resident 1 to be in an unsafe environment due to continued exposure to an alleged perpetrator.

Inspectors wroteBased on interview and record review, the facility failed to report the alleged abuse incident of one resident (Resident 1), in accordance with facility policy. This failure resulted in delayed investigation of the incident by the state agency and law enforcement that may have a negative impact on the care and treatment received by patient.

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents and/or responsible party (RP) were informed in advance, of the risks and benefits of psychoactive medication (a drug that changes brain function and results in alterations in perception, mood, consciousness or behavior) for two of two sampled residents (Residents 21 and 3) reviewed for informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) by failing to ensure: 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (CP - is a tool that ensures residents receive personalized, comprehensive, and goal-oriented care in a nursing home setting): 1. For two of three sampled residents (Residents 21 and 77) reviewed for care plans by failing to ensure identified problems were specific, grouped together, with individual goals and interventions. 2. For one of seven sampled residents (Resident 19) reviewed under the accidents care area by failing to ensure a comprehensive person-centered Care Plan for smoking was developed and implemented when the smoking CP did not include the use of an apron (a safety device that prevent burns from dropped ashes or smoking materials). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care in accordance with professional standards of practice by: 1. Failing to ensure residents' scheduled medications were administered as ordered at the scheduled time for two of five sampled residents (Resident 66 and Resident 19) who were reviewed under the Medication Administration facility task. 2. Failing to check a resident's gastrostomy tube (g-tube- a surgical opening fitted with a device to allow feedings to be administered directly to the stomach for people with swallowing problems) placement and patency before administering medications for one of five sampled residents (Resident 86) reviewed under Medication Administration facility task. 3. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide appropriate treatments and services to prevent a decline in joint range of motion (ROM, full movement potential of a joint) and mobility for four out of nine sampled residents (Residents 73, 19, 23, and 4) who had limited ROM and mobility by failing to: 1a. Ensure Resident 73's Restorative Nursing Aide program (RNA, nursing aide program that help residents to maintain their function and joint mobility) order for ambulation was updated after Physical Therapy (PT, a rehabilitation profession that restores, maintains, and promotes optimal physical function) recommended RNA to ambulate with a platform walker (a type of walking assistive device with forearm supports to provide extra support during walking) for stability. 1b. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents' environment was free of accident hazards for five of seven sampled residents (Residents 21, 338, 77, 20, and 2) reviewed for accidents by failing to ensure: 1. Resident 21, who was on a swallow precaution (steps to help someone swallow without choking or having food/liquid go down the wrong way), was sitting 90 degrees while eating her breakfast and was completely supervised on 4/8/2025. 2. Resident 338's bottle of Daikin's solution (a strong topical antiseptic widely used to clean infected wounds, ulcers, and burns) was not left at the bedside drawer mixed in with food items. 3. Resident 77's call light's (a device used to summon healthcare workers for assistance, typically found near a resident's bed or within reach of a resident) cord was free from exposed/frayed wires. 4. [...]

Inspectors wrote2. During a review of Resident 39's Face Sheet (FS- front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated the facility admitted the resident on 4/18/2018. During a record review of Resident 39's Patient Diagnosis Information, the Patient Diagnosis Information indicated the resident had diagnoses that included neurocognitive disorder with Lewy bodies (a progressive disorder characterized by the gradual decline of thinking and reasoning abilities, often accompanied by movement and sleep disturbances, and visual hallucinations) and PI of the sacral region (lower back at the base of the spine) stage two (partial-thickness loss of skin, presenting as a shallow open sore or wound). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs by failing to: 1. Ensure the antibiotic medications had monitoring for adverse effect (unwanted undesirable effects that are possibly related to a drug) for two of three sampled residents (Residents 21 and 4) reviewed for antibiotic use. 2. Ensure the antiplatelet (medications that prevent blood clots from forming) had monitoring for adverse effect for one of three sampled residents (Resident 338) reviewed for anticoagulant (a substance that is used to prevent and treat blood clots in blood vessels and the heart) use. This deficient practice placed the residents at risk for unnecessary medication and undetected adverse/side effects.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five percent, when seven (7) medication errors out of 28 opportunities contributed to an overall medication error rate of 25%. The medication error rate are as follows: 1. For Residents 66 and 19, Licensed Vocational Nurse (LVN) 1 failed to administer 9 a.m. scheduled medications at the scheduled time. 2. For Resident 86, LVN 1 failed to flush the resident's gastrostomy tube (g-tube- a surgical opening fitted with a device to allow feedings to be administered directly to the stomach for people with swallowing problems) with water in between medications when LVN 1 administered the resident's g-tube medications. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from significant medications errors for one (1) of 1 sampled resident (Resident 10) reviewed for insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) use and for three of five sampled residents (Resident 66, 19, and 86) reviewed under Medication Administration facility task, by: 1. Failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) insulin administration sites for Resident 10. [...]

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. One disposable cup of coffee belonging to a kitchen staff was placed on top of a metal cart outside the dry food storage area. 2. One and a half boxes of open box of dried noodles and not labeled with an open date was stored in the dry storage area 3. One open bottle of instant coffee and not labeled with an open date was stored in the dry storage area. 4. One open box of wonton chips inside an unsealed plastic bag as not labeled with an open date. 5. One container had a label peas, black eyed dried but observed brown colored short grain inside the container. 6. Observed red potatoes inside a bin that was wet. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain timely and accurate resident medical records for two of 21 sampled residents (Residents 4 and 86) when: a. For Resident 4, the Physical Therapy (PT, a rehabilitation profession that restores, maintains, and promotes optimal physical function) Discharge Summary (DC) and Occupational Therapy (OT, rehabilitative profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) Discharge Summary was not completed after PT treatment and OT treatments were completed in 1/2025. b. For Resident 86, the PT Discharge Summary was not completed after PT treatment was completed on 3/26/2025. These deficient practices had the potential for inaccurate medical documentation and cause a delay in provision of appropriate interventions for Residents 4 and 86.

Inspectors wrote2. During a review of Resident 86's Face Sheet (FS), the FS indicated Resident 86 admitted to the facility on [DATE] with diagnoses including but not limited to anoxic brain damage (damage to brain due to lack of oxygen supply to the brain), hemiplegia (weakness to one side of the body) affecting right dominant side, monoplegia (paralysis of one side of the body) of upper limb affecting left nondominant side, and aphagia (a disorder that makes it difficult to speak). During a review of Resident 86's Minimum Data Set (MDS, a resident assessment tool) dated 3/11/2025, the MDS indicated was severely impaired in cognitive skills for daily decision making. The MDS indicated Resident 86 was dependent on staff for oral hygiene, toileting, bathing, dressing, and bed to chair transfers. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician or medical provider and resident's responsible party (RP) were notified for one (1) of 1 sampled resident (Resident 20) reviewed under change of condition when Resident 20 had an episode of hypoxia (low level of oxygen [O2 - a colorless and odorless gas that the body needs to work properly] in the body). This deficient practice violated Resident 20's right (including RP) to be informed and a had the potential to result in the delay of care, services and further decline of Resident 20 by failing to notify the provider.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident received care consistent with professional standards of practice to prevent pressure injury (PI - localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) for one (1) of 1 sampled resident (Resident 9) reviewed for pressure injury by failing to perform an accurate assessment of Resident 9's PI on the right buttock. This deficient practice placed Resident 9 at risk for developing pressure injuries and worsening of the current PI.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a residents with a urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) received appropriate care and services to prevent urinary tract infections (UTI, an infection in the bladder/urinary tract) for one (1) of 1 sampled resident (Resident 40) reviewed for urinary catheter or UTI by failing to ensure Resident 40's urinary catheter tubing was anchored to the statlock (a device that secures the catheter in place preventing it from being pulled out or moving around). This deficient practice had the potential for the resident's urinary catheter to be pulled out or move around which may lead to pain, trauma, and catheter blockage.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medication and biologicals were stored with currently accepted professional standards for one of three sampled residents (Resident 39) reviewed during the Pressure Ulcer / Injury (PI - localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) care area by failing to ensure mupirocin (a topical medication that treats skin infections caused by bacteria) was removed from the One [NAME] Treatment Cart when the medication was discontinued on 2/12/2025. This deficient practice resulted in Licensed Vocational Nurse (LVN) 1 administering the discontinued mupirocin to Resident 39 potentially resulting in a delay or decline in the resident's PI healing process.

Inspectors wroteBased on interview and record review, the facility failed to reduce the risk of adverse events (an undesirable experience or harm that happens to a patient as a result of medical care), including the development of antibiotic-resistant organisms (occurs when bacteria develop defenses against the antibiotics designed to kill them), from unnecessary or inappropriate antibiotic use for one of three sampled residents (Resident 21) reviewed for antibiotic use by failing to clarify with the ordering physician the appropriate indication of Azithromycin (also known as Zithromax, a type of antibiotic) used as a prophylaxis (an attempt to prevent disease) for pneumonia (an infection/inflammation in the lungs). This deficient practice had the potential to cause adverse side effects and risk for resistance associated with the use of inappropriate antibiotic therapy.

Inspectors wroteBased on interview, and record review the facility failed to establish and implement policies and procedures regarding the use of side rails (SR, adjustable rigid plastic bars attached to the bed that may be positioned in various locations on the bed; upper or lower, either or both sides) and 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). This deficient practice had the potential to result in psychosocial harm, decline in physical functioning, physical harm from entrapment (occurs when a resident is caught between the mattress and SR or wall, or within the SR itself), and death of residents affecting 87 of 87 residents residing in the facility. Cross refernce to F604 and 700.

Inspectors wroteBased on observation, interview, and record review the facility failed to keep the call light (an alerting device for nurses or other nursing personnel to assist a patient when in need) within reach of the resident for four out of five sampled residents (Residents 77, 56, 70 and 13) investigated during review of environment facility task. These deficient practices had the potential for delaying care and services requested by the residents and placing the residents at risk for falls and injuries.

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 patient ' s body that he or she cannot easily remove that restricts freedom of movement or normal access to one ' s body) for four of four sampled residents (Residents 8, 77, 56, and 70) investigated during review of use of restraints by failing to: 1. Ensure side rails (SR, adjustable rigid plastic bars attached to the bed that may be positioned in various locations on the bed; [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide care consistent with professional standards of practice to prevent pressure ulcer/pressure 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 (Resident 58 and 45) being investigated under pressure ulcers by failing to: 1. Set Resident 58's low air loss mattress (LALM, designed to distribute the resident's weight over a broad surface area and help prevent skin breakdown) according to resident's weight and apply Heel Protectors 1 (HP 1, have a cushioned bottom that floats the heel off the surface of the mattress, helping to reduce pressure) on both lower extremities of the resident. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services and treatments to monitor and maintain joint range of motion (ROM, full movement potential of a joint) for four of five sampled residents by failing to: 1. Provide Restorative Nursing Aide program (RNA, nursing aide program that help residents to maintain their function and joint mobility) treatments as ordered for two of five sampled residents (Residents 2 and 12) and 2. Provide a baseline upper extremity (UE, shoulder, elbow, wrist, hand) range of motion assessment for two of five sampled residents (Residents 45 and 63) upon admission to monitor ROM decline. These deficient practices had the potential to cause decline in ROM, mobility, and overall quality of life for Resident 2, 12, 45, and 63.

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 bars attached to the bed that may be positioned in various locations on the bed; upper or lower, either or both sides) for three of four sampled residents (Resident 8, 77 and 70) investigated during review of restraints by failing to: 1. 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 side rails. 2. Review the risk and benefits of side rails with the resident or resident representative and obtain informed consent (process in which residents or resident representatives are given important information, including possible risks and benefits, about a procedure or treatment). [...]

Inspectors wroteBased on interview and record review, the facility failed to provide adequate and sufficient nursing staff to provide care for residents requiring Restorative Nursing Aide (RNA, nursing aide program that helps residents to maintain their function and joint mobility) services. This deficient practice had the potential for 70 residents with physician's orders for RNA to experience a decline in range of motion (ROM, full movement potential of a joint), mobility, and activities of daily living (ADL, basic activities such as eating, dressing, toileting) function.

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to ensure proper storage, preparation, and distribution of food in accordance with professional standards for food service safety by failing to: 1. Ensure a sandwich labeled with a use by date (the date a food item should be discarded) of 3/31/2024 was not readily available for consumption in the resident's room for one of two sampled residents (Resident 24) investigated under the food care area. This deficient practice had the potential to place residents at increased risk of experiencing foodborne illness (an illness that comes from eating contaminated food or drinks). 2. Ensure food was served at a warm temperature for one of two sampled residents (Resident 38) investigated under the food care area and for one of nine residents (Resident 4) present during the Resident Council task. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide rehabilitative therapy services, including occupational therapy (OT, rehabilitative profession that provides services to increase and/or maintain a person's capability to participate in everyday life activities) and physical therapy (PT, a rehabilitation profession that restores, maintains, and promotes optimal physical function) services to two of five sampled residents by failing to: 1. Provide OT services to any residents from 10/7/2023 to present, 2. Provide Residents 45 and 63 with an OT evaluation upon admission per the facility's stated standard of care for all admissions, 3. Provide adequate physical therapy treatments and services to meet Resident 45 and Resident 63's PT care plans and goals. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections for two of four sampled residents observed during medication administration (Resident 2 and 87) and one of two residents investigated for respiratory care (Resident 38) when: 1. Licensed Vocational Nurse 3 (LVN 3) failed to perform hand hygiene prior to preparing Resident 2's medications. 2. LVN 4 failed to perform hand hygiene prior to donning (to put on) gloves and administering eye drops to 3. The facility failed to ensure nasal cannulas (NC, flexible plastic tubing with prongs fitted to the nose that is used to deliver supplemental oxygen or increased airflow to a resident in need of respiratory health) was labeled and dated within the last seven days. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care in a manner that maintained or enhance a resident's dignity and respect in full recognition of their individuality during one (Resident 11) of one random observation by failing to ensure the resident's urinary catheter drainage bag (a bag designed to urine drained from the bladder via a catheter) was covered with a privacy bag. This deficient practice had the potential to affect the residents' sense of self-worth and self-esteem.

Inspectors wroteBased on interview and record review, the facility failed to provide the resident and the resident's representative information regarding formulating an advance directive for one of one sampled resident investigated during review of advance directive care area (Resident 38). This deficient practice had the potential for Resident 83 and their responsible person to not be informed of their right to formulate an advance directive and not honor the resident's wishes regarding end-of-life care.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a comprehensive person-centered care plan (CP, a written course of action that helps a patient achieve outcomes that improve their quality of life) reflective of resident preferences and consistent with the resident rights to meet a resident's medical, nursing, mental, and psychosocial needs for four of four sampled residents (Residents 8, 77, 56, and 70) reviewed during investigation of restraint (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the patient's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) use by failing to: 1. Develop and implement a CP for side rail (SR, adjustable rigid plastic bars attached to the bed that may be positioned in various locations on the bed; [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice by failing to follow the physician's order to apply thromboembolic deterrent (TED hose- stockings that help prevent blood clots and swelling in the legs) in two of twenty-two random observations (Residents 77 and 56) during the initial screening. The deficient practice had the potential for residents to have poor circulation to the extremities that could lead to thrombosis (the formation of a blood clot within blood vessels).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an environment free from accidents and hazards by: 1. Failing to ensure Certified Nursing Assistant 5 (CNA 5) did not transfer one out of one sampled resident (Resident 82) from bed to wheelchair while using a Hoyer lift (a patient lift used by caregivers to safely transfer patients) without another staff assistance investigated during a random observation. This deficient practice placed Resident 82 at risk for falls and serious injuries that include possible fractures and bleeding. 2. Failing to ensure residents did not have lidocaine (a topical [placed on the skin] medication used to treat pain) 4 percent (%, concentration of medication in a solution) roll-on bottle at bedside for one of one sampled resident (Resident 24) investigated under the care area Pain Management. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to label the valproic acid (used to treat seizure disorders [a sudden, uncontrolled burst of electrical activity in the brain], mental/mood conditions) 250 milligrams (mg, a unit of mass or weight) / 5 milliliter (ml, a unit of volume) 125 mg (2.5 ml) solution bottle with an expiration date, affecting Resident 70 in one out of three inspected medication carts (Med Cart A). The deficient practice of failing to label the medication with the expiration date increased the risk that Resident 70 could have received medication that had become ineffective or toxic and could result in health complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose of garbage and refuse properly by not covering the garbage container next to the hand washing station in the kitchen during the initial tour of the kitchen conducted on 4/2/2024 between 7:54 a.m. to 9:00 a.m. This deficient practice had the potential for the spread of bacteria and cross-contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) after hand washing.

Inspectors wroteBased on interview and record review, the facility failed to maintain timely resident medical records for one of four (Resident 38) when Resident 38's Physical Therapy (PT, a rehabilitation profession that restores, maintains, and promotes optimal physical function)) Initial Evaluation dated 11/8/2023 was not documented until 4/4/2024. This deficient practice had the potential for inaccurate medical documentation and cause a delay in provision of appropriate interventions for Resident 38.