New Orange Hills

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to maintain an active care plan addressing the risk for skin impairment for one of three sampled residents (Resident 2). * The facility failed to ensure Resident 2 had a care plan to address the risk for skin breakdown related to history of anal future. This failure posed as a risk of not providing Resident 2 with individualized and person-centered care.

Inspectors wroteBased on interview, medical record review, and facility document review, the facility failed to ensure the necessary care and services were provided to maintain the highest practicable well-being for one of five sampled residents (Resident 1). * The facility failed to ensure the licensed staff assessed, identified, and intervened in a timely manner when Resident 1 did not have a urinary output draining from the suprapubic catheter (a hollow flexible tube used to drain urine from the bladder, inserted into the bladder through a cut in the abdomen, a few inches below the belly button) into a collection bag on 5/25/26 from 0700 to 2300 hours. In addition, Resident 1's physician was not notified until 2345 hours on 5/25/26. [...]

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to develop and/or implement the comprehensive care plans for two of 27 sampled residents (Residents 4 and 99) and three nonsampled residents (Residents 35, 118, and 124). * The facility failed to develop a care plan for Resident 118's use of buspirone HCl (an anxiety medication) and include the specific targeted behaviors in the care plan interventions for Resident 118's use of psychotropic medications. * The facility failed to implement the care plan intervention for Resident 99's bladder incontinence. * The facility failed to develop a care plan interventions to address when Resident 4 and 124 have tremors or was moving while being shaved during showers. * The facility failed to develop a care plan to address Resident 35's toenails. [...]

Inspectors wroteBased on observations, interviews, medical record reviews, and facility P&P review, the facility failed to provide the necessary respiratory care services for three sampled residents (Residents 23, 49, and 55) and two nonsampled resident (Residents 25 and 64) reviewed for respiratory care. * The facility failed to ensure Resident 23 was administered with oxygen as ordered by the physician. * The facility failed to notify the physician and hospice care when Resident 49 was not provided the BiPAP machine nightly as ordered due to a missing piece of the BiPAP mask. * The facility failed to ensure Resident 25's nasal cannula was stored in a sanitary condition when not in use. *The facility failed to ensure Resident 64's nasal cannula was stored in a sanitary condition. [...]

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen. * The facility failed to ensure the kitchen utensils had a smooth cleanable surface and in good condition. * The facility failed to ensure the yellow cutting board used for cutting cooked meat, poultry, and fish was kept in a sanitary condition and with cleanable surface. * The facility failed to ensure the lid for the heavy-duty blenders used for pureed preparation was free from dust. * The facility failed to ensure the storage racks in the dry storage room were free from dust. * The facility failed to ensure the scoops used for food portioning and measuring cups were air dried prior to storing. * The facility failed to ensure the can opener was free from rust-like residue. [...]

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to implement the infection control practices designed to provide the safe and sanitary environment and help prevent the development and transmission of diseases and infections. * The facility failed to implement the infection control surveillance program for the months of July 2025 through January 2026. The facility conducted surveillance of resident infections only when the residents were prescribed antimicrobial medications and/or if the residents were diagnosed with an infection. The facility failed to determine whether the residents who exhibited signs and symptoms of infection and were not prescribed antimicrobial medications or had not been diagnosed with an infection, met the facility's criteria for infection utilizing McGeer's Criteria. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one sampled resident (Resident 81) and two non-sampled residents (Resident 41 and 130) were assessed, had a care plan and a physician's order to self-administer the medications. * A ketoconazole (antifungal medication) cream was observed on top of Resident 81's bedside drawer. There were no assessment, care plan or physician's order to self-administer the medication. * A bottle of Hydrogen Peroxide (antiseptic solution ) topical solution and a jar of Desitin (anti rash medication) maximum strength was observed on top of Resident 41's night stand. There were no assessment, care plan or physician's order to self-administer the medication. * A Debrox earwax removal aid was observed on top of Resident 130's nightstand. [...]

Inspectors wroteBased on observation, interview, facility record review, and facility P&P review, the facility failed to provide privacy to two non- sampled residents (Resident 56 and 129). * The facility failed to ensure the privacy curtain was completely closed while providing care for Residents 56 and 129. These failures posed the risk of exposing the resident's body to other residents, staff and visitors, and had the potential to negatively affect the resident's well-being.

Inspectors wroteBased on observation and interview, the facility failed to provide a homelike environment for two of 27 sampled residents (Residents 55 and 132) and one nonsampled resident (Resident 79). * Stack of mattresses, boxes, and other miscellaneous items were stored outside; however, the items could be seen from Resident 55's window and were visible from the hallway. * Stack of wooden boards and orange traffic cones were stored outside; however, the items could be seen from Resident 79's window and were visible from the hallway. * Resident 132's room was not thoroughly cleaned. These failures had the potential for the residents to not have a home-like environment that could negatively affect the resident's well-being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the residents were free from unnecessary medications for one of five sampled residents (Resident 118) reviewed for unnecessary medications. * The facility failed to ensure Resident 118 had appropriate targeted behaviors and a documented clinical rationale for the continued use PRN Ativan use. In addition, monthly psychotropic medication behavior summaries were incomplete for bupropion HCl, olanzapine, paroxetine HCl, and not completed for Ativan and buspirone HCl. This failure had the potential for the resident to receive unnecessary medication, as well as an undesirable outcome.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to provide foot care for one of non-sampled resident (Resident 35). * Resident 35's toenails were long and had brown discoloration. This failure posed the risk of further deterioration to Resident 35's toenails.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the appropriate care and services for the use of an indwelling urinary catheter for one of three final sampled residents (Resident 15) reviewed for indwelling urinary catheter care. * Resident 15's indwelling urinary catheter was observed to be cloudy and had a lot of sediments in the tubing. In addition, the indwelling urinary catheter had no label when the drainage bag was changed. This failure had the potential for the resident to develop complications associated with the use of indwelling urinary catheter.

Inspectors wroteBased on observation, interview, medical record review, and facility document review, the facility failed to ensure necessary care and services related to GT feeding were provided for two of two final sampled residents (Residents 2 and 144) and one nonsampled resident (Resident 30) reviewed for tube feedings. * The facility failed to ensure Resident 2 was administered the water flush via GT at the correct rate according to the physician's orders. * The facility failed to ensure Resident 30 was administered the enteral feeding via GT at the correct rate according to the physician's orders. * The facility failed to ensure Resident 144's HOB was elevated at least 30 degrees or greater during the enteral feeding to reduce the risk of aspiration. In addition, the failed to failed to ensure the GT residual monitoring was accurately documented. [...]

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure the facility staff (CNAs 7 and 8) were competent in providing the necessary care and services to the residents who needed to be shaved. * The facility failed to ensure CNAs 7 and 8 had completed the skills competencies on how to shave the residents with episodes of spasms. This failure resulted in residents' to have cuts to their chins and posed the risk of further injury to the residents.

Inspectors wroteBased on observation, interview, medical record, facility record review, and facility P&P review, the facility failed to provide the necessary pharmaceutical services for one of six nonsampled residents (Resident 56) observed for medication administration. * The facility failed to ensure Resident 56's baclofen (a muscle relaxant) was administered as per the physician's order. This failure posed a risk for the resident to experience muscle spasms and could negatively affect the resident's well-being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to follow-up on the consultant pharmacist's recommendations for one of five final sampled residents (Resident 118) investigated for unnecessary medications.* The consultant pharmacist's report for December 2025 showed a recommendation to update Resident 118's behaviors for PRN Ativan (a medication for anxiety) to include specific and quantifiable behaviors targeted. This failure resulted in the continued deficient practice of inappropriate behavior being targeted by Resident 118's psychotropic medication use.

Inspectors wroteBased on observation, interview and facility P&P review, the facility failed to ensure proper storage and disposal of medications for one of two medication storage rooms and three of five medication and treatment carts inspected for medication storage and labeling. * The facility failed to ensure medication storage room and carts were in a clean and sanitary condition. * The facility failed to ensure orally administered medications were stored separate from externally used medications. * The facility failed to ensure all medications and biologicals were not expired. These failures had the potential to negatively impact the residents well- being, the potential for the medications to lose stability and effectiveness, and unsafe administration of the medications and treatment.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure food served was palatable, attractive, and at a safe and appetizing temperature for 88 of 88 residents who received food prepared in the kitchen. * The cole slaw for residents on regular and puree diets was observed with ice in it. This failure had the potential for decreased meal intake which could result in weight loss, decreased nutritive value, and negatively impact the residents' quality of life for all 88 residents who received food prepared in the kitchen.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to maintain an effective pest control program to prevent the presence of an insect in Resident 132's room. * An insect was found crawling near Resident 132's bed. This failure had the potential for pests to multiply, and the presence of pest associated germs.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure one of 27 final sampled residents (Resident 1) received services to prevent pressure ulcers. * Resident 1's LAL mattress settings were not set according to Resident 1's weight. This failure posed the risk of Resident 1's pressure ulcers not receiving full treatment to prevent further decline.

Inspectors wroteBased on interview and facility record review, the facility failed to ensure annual performance evaluations were completed for two of three CNA employee files reviewed (CNAs 4 and 5). * CNAs 4 and 5 did not have annual performance evaluations completed since 2024. This failure had the potential to delay identifying areas requiring additional staff training, leading to the residents to not receiving the proper and safe care.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the medical records were complete and accurate for one of three closed record sampled residents (Resident 12). * Resident 12's medical record showed a respiratory therapy note for care provided on 2/3/26 when the resident was transferred to a GACH on 2/2/26. This failure resulted in an inaccurate medical record for Resident 12.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure quality care and services were provided for two of ten sampled residents (Residents 4 and 6). * The facility failed to ensure Resident 4 was monitored for the side effects and the effectiveness of the diabetic medication, and for signs and symptoms of hyperglycemia (high blood glucose). * The facility failed to ensure Resident 6's glucose monitoring was performed as ordered by the physician. These failures had the potential for the residents to not receive the necessary care and services to maintain their highest physical well-being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the medical record was accurate for one of ten sampled residents (Resident 4). * The facility failed to ensure Resident 4's Fall Risk Evaluation was accurate. This failure posed the risk for Resident 4 not to receive the accurate and necessary care.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary care and services to prevent accidents for one of three sampled residents (Resident 1). * The facility failed to ensure Residents 1's bed was in a low position as per the resident's care plan. Resident 1 fell from the bed and sustained a fracture on left lower leg. This failure contributed in Resident 1 sustaining serious injuries from fall and suffering from pain.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the necessary care and services were provided when monitoring the blood pressure for one of six sampled residents (Resident 2). * The facility failed to ensure Resident 2's blood pressure was monitored as per the physician's order. In addition, the facility failed to ensure the staff had used an approved device to monitor Resident 2's blood pressure. This failure posed the risk for the resident to have inaccurate blood pressure readings.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to establish and maintain the infection control program and practices designed to help prevent the development and transmission of diseases and infections for one of three sampled residents (Resident 3). * The facility failed to ensure the EBP was implemented for Resident 3. This failure had the potential risk for transmission of communicable diseases or organisms to residents in the facility.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the licensed nurses had competencies and skill sets needed to care for one of five sampled resident (Resident 1). * LVN 1 reported the abnormal laboratory values to Resident 1's physician without clarifying the physician's orders, which only addressed the resident's fluid status but not the severely low Hgb and Hct, and elevated WBC count. This failure created the potential risk of not providing qualified staff for the resident's care.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to maintain the highest practicable well-being for two of eight sampled residents (Residents 1 and 2). * The facility failed to ensure Resident 1 was seen for the outpatient physician's follow-up appointments. * The facility failed to ensure Resident 2's wound care was followed as ordered by the physician. These failures had the potential to negatively affect the residents' well-being as the necessary care and services were not provided.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to prevent the development or worsening of pressure injuries for one of eight sampled residents (Resident 7). * The facility failed to apply barrier cream to Resident 7's sacrum during the wound care as ordered by the physician. * Resident 7's wound care assessment failed to reflect Resident 7 had underminingto the sacrococcyx pressure injury. * The facility failed to ensure the low air loss mattress settings for Resident 7 were set correctly. These failures had the potential for Resident 7 to not receive the appropriate care and services to promote healing of the pressure injury.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the infection control practices were followed for one of eight sampled residents (Resident 1). * The facility failed to ensure the isolation gown found in the clean linen's drawer outside Resident 1's room was free from the soiled gloves. * The facility failed to change the soiled tracheostomy tie after performing the neck wound care for Resident 1. These failures posed the risk for transmission of infection and the development of disease-causing microorganisms.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to maintain the accurate medical records for one of eight sampled residents(Resident 2). This failure had the potential for the resident's record not maintained to show accurate information.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the necessary wound care and services were provided for three of five sampled residents (Residents 2, 3, and 5). * The facility failed to ensure Resident 2's wound care treatment orders were clarified and communicated when there were two physiciansproviding two different wound care orders. * The facility failed to ensure Resident 3 was provided with the appropriate bed mattress to promote healing of the pressure injury. * The facility failed to ensure the physician's order for the correct sequence of Resident 5's wound care treatment was followed. These failures had the potential for Residents 2, 3, and 5 to not receive the appropriate care and services to promote wound healing.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of five sample residents (Resident 2) remained free from accident hazards. * The facility failed to provide the bilateral floor mats at Resident 2's bedside as ordered by the physician for safety. This failure had the potential to place Resident 2 at risk for serious injury.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to maintain the highest practicable well-being for two of eight sampled residents (Residents 3 and 5). * The facility failed to follow the physician's order to administer the GT feedings at the scheduled times for Residents 3 and 5. This failure had the potential to negatively affect the residents' health conditions and well-being.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen as evidenced by: * The facility failed to ensure the kitchen utensils had a smooth cleanable surface and in good condition. * The facility failed to ensure the kitchen utensils were clean and free of food particle or residue. * The facility failed to ensure the cutting board was kept in a sanitary condition and with cleanable surface. * The facility failed to ensure the heavy-duty blender used for puree preparation was air dried prior to storing. * The facility failed to ensure the microwave utilized to warm up the food was in sanitary condition and free of food residue. * The facility failed to ensure the sanitary condition of the hood over the stove was maintained. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide reasonable accommodations to meet the needs of four of 27 final sampled residents (Residents 96, 108, 775, and 78). * The facility failed to ensure Residents 96, 108, 775, and 78's call lights were within the residents' reach. This failure created the potential to negatively impact the residents' psychosocial well-being or result in a delay to provide care.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to notify the physician timely of the resident's changes in status for two of 27 final sampled residents (Residents 51 and 56). * Resident 51's physician was not notified timely for a change in swallow status. * Resident 56's physician was not notified of the resident's recent episodes of emesis and of the resident's tube feeding being placed on hold. These failures resulted in a delay of physician notification, intervention and/or implementation of the physicians' orders with the potential for an adverse resident outcomes.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to provide a safe and comfortable environment for one nonsampled residents (Resident 35). * The staff went through the resident's belongings without the resident's consent. This failure resulted in the resident being upset staff went through her personal belongings, which had the potential to negatively impact the resident's well-being.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the necessary care and services provided to two of 27 final sampled residents (Residents 33 and 73). * Resident 73's skin and wound consult recommendations were not followed up timely by the facility. * Resident 33 was not monitored every shift for at least 72 hours following the weight loss. These failures resulted in a potential delay of identifying changes in the residents' statuses and/or a delay of implementing the interventions to ensure the quality of care was provided.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the staff reported and addressed a new pressure ulcer timely for one of three final sampled residents (Resident 51) reviewed for pressure ulcers. This failure had the potential to result in a delay of treatment and interventions being put in place to prevent further decline.

Inspectors wroteBased on interview and medical record review, the facility failed to implement two staff assistance for ADL care for one of eight final sampled residents (Resident 51) reviewed for accident harzards. This failure resulted in the resident sustaining another fall, which had the potential to negatively impact the resident's well-being.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the appropriate care and services to prevent UTI for one of two final sampled residents (Resident 30) reviewed for indwelling urinary catheter. * Resident 30's urinary drainage bag and tubing were positioned above the bladder. This failure posed the risk for Resident 30 to develop urinary tract infection and other complications from UTI.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the correct enteral formula was administered to one of two final sampled residents (Resident 56) reviewed for tube feeding * Resident 56 had the incorrect strength of tube feeding administered. This failure resulted for a less than the ordered calories to be administered to the resident, which had the potential to negatively impact the resident's well-being.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary respiratory care and services for four of seven residents (two final sampled residents, Residents 65 and 83; and two nonsampled residents, Residents 725 and 726) reviewed for respiratory care. * The facility failed to ensure Residents 83, 725, and 726's oxygen tubing was dated. * The facility failed to ensure Resident 65 received oxygen as ordered by the physician. These failures had the potential to put the residents at risk for adverse effects of the inaccurate administration of oxygen and improper care of oxygen equipment.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure three of five final sampled residents (Residents 18, 41, and 56) reviewed for side rail use remained free from the accident hazards associated with the use of elevated side rails. * The facility failed to ensure the accurate and complete assessments and evaluations for the side rails use for Resident 18. * The facility failed to ensure documented evidence of the least restrictive measures attempted prior to the side rail use for Resident 41. * Resident 56's siderail order was for an inappropriate use. These failures had the potential to put the residents at risk for entrapment and serious injuries.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary pharmaceutical services when: * The facility failed to ensure all controlled medications were accounted for and documented for one of three inspected medication carts (Medication Cart A) with controlled medications. * The facility failed to ensure accurate and complete documentation of controlled medication administration for two nonsampled residents (Residents 22 and 94). These failures had the potential for the medications to be administered in errors and opportunities for drug diversion.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the orthostatic blood pressure was monitored accurately as ordered by the physician related to the use of an antipsychotic medication for one of five final sampled residents (Resident 42) reviewed for unnecessary medications. This failure had the potential for Resident 42 to have adverse effects from the psychotropic medications and the potential for not providing the correct data to the prescriber to adjust the dose of the psychotropic medication for Resident 42.

Inspectors wroteBased on observation, interview, medical record review, and facility document review, the facility failed to ensure the medication error rate was below 5%. The facility's medication rate was 25% for nine medication errors out of 36 medication administration observations. One nurse (LVN 2) observed administering the medications was found to have errors while administering the medications to one of 27 final sampled residents (Resident 43) and one nonsampled resident (Resident 35). This failure created the risk of the resident developing complications and ineffective therapeutic effects of the medications.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure proper storage of medication and disposal of biologicals. * The facility failed ensure one single-use medication was discarded after use in Medication Cart E. * The facility failed to ensure the sublingual medication was not stored with externally administered medications in Medication Cart D. * The facility failed to ensure the contents of the sharp disposal container remained below the full line for Medication Cart A. [...]

Inspectors wroteBased on interview and medical record review, the facility failed to follow-up with the physician for the abnormal laboratory results for one of five final sampled residents (Resident 70) reviewed for unnecessary medication. This failure had the potential for the resident to have undesirable outcomes.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the medical records were accurately maintained for four of 27 residents (three final sampled residents, Residents 33, 41, and 105; and one nonsampled resident, Resident 49) reviewed for medical records. * The facility failed to ensure Resident 33's intravenous fluid intake was documented. * The facility failed to ensure the RNA documented Resident 33's refusal to be weighed. * The facility failed to ensure Resident 49's MAR was completed. * The facility failed to ensure Resident 105's hospice visitation log was completed. * The facility failed to ensure Resident 41's updated flu vaccination consent was filed in the appropriate medical records folder. These failures had the potential for the residents' care needs not being met as the medical record was incomplete.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the infection control practices designed to provide a safe and sanitary environment and help prevent the development and transmission of infection were implemented as evidenced by: * The facility failed to implement their infection control surveillance program for January 2024 through September 2024. The facility conducted surveillance of resident infections based on whether the residents were prescribed antimicrobials. Residents who were not prescribed antimicrobials were not included in the facility's infection control surveillance program. * The facility failed to implement their infection control surveillance program for July 2024 through September 2024. [...]

Inspectors wroteBased on interview, facility document review, and facility P&P review, the facility failed to implement their Antibiotic Stewardship Program (ASP) when: * The facility failed to conduct an assessment for the McGeer's criteria to determine the true infection for one nonsampled resident (Resident 525). * The facility failed to use the correct Surveillance Data Collection Form for two final sampled residents (Residents 96 and 108) and four nonsampled residents (Residents 4, 8, 86, and 531). * The facility failed to properly use the Surveillance Data Collection Form criteria to indicate a true infection for one final sampled resident (Resident 83) and three nonsampled residents (Residents 2, 19, and 80). These failures had the potential for inaccurately identifying for true infections and potentially inhibited residents from receiving proper treatment and care.

Inspectors wroteBased on interview, medical record review, and facility document review, the facility failed to ensure the resident rights were respected for one nonsampled resident (Resident 35). * CNA 3 was using his personal cell phone while feeding Resident 35. This failure had the potential for Resident 35 to be treated without dignity and respect.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the staff followed the infection control practices during the wound care dressing change for one of two sampled residents (Resident 3). * The licensed nurse did not change gloves and perform hand hygiene in between the wound care dressing change for Resident 3. This failure had the potential for spread of infections in the facility.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the reasonable accommodations to meet the care needs for one of three final sampled residents (Resident 1). * The facility failed to ensure the call light for Resident 1 was within the resident's reach. This failure had the potential for the resident to not be able to call for assistance when needed.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to implement the comprehensive care plan to address the individual care needs for one of six sampled residents (Resident 1). * The facility failed to implement Resident 1's plan of care to monitor and document output as per the facility's protocol. This failure had potential for not providing appropriate, consistent, and individualized care.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of six sampled residents (Resident 1) was free from the unnecessary drugs. * Resident 1 was administered Norco oral tablet 10-325 mg (medication to manage pain) when Resident's A pain level was below the parameters to administer the ordered medication. This failure had the potential for Resident 1 to receive unnecessary medication and experience adverse effects from the medication.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to maintain the infection control practices to help prevent the development and transmission of diseases and infections for one of six sampled residents (Resident 1). * Resident 1 had three personal clothing itemshanging in a bathroom shared with another resident. * A food cart containing the lunch trays to be passed to the residents was in the hallway next to a dirty linen bin. These failures had the potential to cause the transmission and development of disease and infection.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary services to prevent falls for one of four sampled residents (Resident 2). * The facility failed to ensure Resident 2 was provided with two persons assist during the transfers on 2/28/24, as per the MDS assessment and sustained a fall during this transfer. The fall care plan was not revised to include two persons assist as per the PT's recommendation. In addition, Resident 2 was no not monitored every shift for 72 hours after the fall. * CNA 1's competency for using the gait belt was incomplete and a gait belt was not issued to CNA 1 as per the facility's P&P. These failures had the potential for not providing adequate supervision and assistance to prevent accidents or falls for the resident.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of three sampled residents (Resident 1) received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. * The facility failed to monitor Resident 1 after a change of condition. This failure posed the risk of the resident not receiving the necessary care and services.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the medications were administered for one of the three sampled residents (Resident 3) as ordered by the physician. This failure posed the risk to negatively impact Resident 3's medical condition.

Inspectors wroteBased on interview and medical record review, the facility failed to document the administered medications in the MAR for one of three sampled residents (Resident 1). This failure posed the risk of errors in medical care as the documentation was incomplete.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of six sampled residents (Resident 2) remained free from the accidents hazards. * The facility failed to implement the safety interventions as ordered by the physician and care planed for Resident 2 who was at high risk for falls. This failure had the potential to place Resident 2 at risk for serious injury.

Inspectors wroteBased on observation, interview, medical record review, and facility document review, the facility failed to provide the pharmaceutical services to meet the resident ' s needs for one of six sampled residents (Resident 1). * The facility failed to ensure Resident 1 ' s oxycodone HCL (narcotic pain medication) was accurately reconciled. The oxycodone HCL tablets taken out of the bubble pack (a packaged used to dispense medications) documented on the Medication Count Sheet did not match the electronic MAR as administered to Resident 1. This failure had the potential for exposing the resident to ineffective treatment, medication errors, and the potential for diversion of controlled medications.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of two sampled residents (Resident 1) was free from the unnecessary drugs. * Resident 1 was administered amiodarone HCl (medication for heart rhythm problems), carvedilol (medication to treat high blood pressure), spironolactone (medication to treat high blood pressure and fluid retention), and sacubitril-valsartan (medication to treat patient with chronic heart failure) when Resident 1's blood pressures were below the parameters to administer these ordered medications. * The facility failed to notify the physician when amiodarone HCl, carvedilol, spironolactone, and sacubitril-valsartan were held for two consecutive times as ordered by the physician. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the reconciliation of medications was thoroughly performed and documented in the medical record whenthe one of two sampled residents (Resident 1) was discharged from the facility. * The facility failed to ensure Resident 1's medical record contained a list of reconciled pre-discharge and post discharge medications when Resident 1 was discharged home in accordance with the facility's P&P. This posed the risk for not identifying discrepancies or differences in Resident 1's pre-discharge and post discharge medication orders, which had the potential to negatively impact the Resident 1's wellbeing. * The facility failed to document information in Resident 1's medical record specific to the release of controlled medications to Resident 1's family. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the informed consent was obtained for the use of psychotropic medications (any drug prescribed to stabilize or improve mood, mental status, or behavior) for one of 25 final sampled residents (Resident 16). * The informed consent was not obtained from Resident 16 prior to administering mirtazapine (antidepressant medication). This failure had the potential for the resident to be unaware of the risks associated with the medications which may have adverse side effects detrimental to the resident's well-being or choice.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the call light was kept within reach for two of 25 final sampled residents (Residents 56 and 77) and one nonsampled resident (Resident 664). This failure posed the risk for the residents not being able to call for assistance should they require it.

Inspectors wroteBased on interview and medical record review, the facility failed to develop a plan of care to reflect the individual care needs related to the deep tissue injury (DTI) for one of 25 final sampled residents (Resident 10). This posed the risk of not providing appropriate, consistent, and individualized care to Resident 10.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services for two of the 25 final sampled residents (Residents 8 and 40) and two nonsampled residents (Residents 84 and 93) to maintain their highest physical well-being. * The facility failed to complete the CXR, CBC, BMP, and Mg laboratory tests for Resident 8 as per the physician's order. * Residents 84 and 93's medications were not administered in a timely manner. * Resident 40's wound dressing on both legs and feet were loose, soiled, and touching the floor. In addition, Resident 40's wound dressing were not dated to show when it was last changed. These failures had the potential to negatively impact the resident's' well-being.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the necessary care and services were provided to prevent the development or worsening of pressure ulcers for one of 25 final sampled residents (Resident 10). * The facility failed to ensure Resident 10's heels were offloaded which contributed to Resident 10 developing a Stage 2 pressure ulcer on the right lateral (to the side of, or away from the middle of the body) heel. * The facility failed to ensure Resident 10 received wound care for the fluid filled blister (Stage 2 pressure ulcer) on the right medial (toward the middle or center of the body) heel from 5/7 to 5/10/22. * Resident 10 was admitted to the facility with a DTI (deep tissue injury) on the right heel. The facility failed to ensure Resident 10 received the necessary treatment and services for the DTI. [...]

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure one of 25 final sampled residents (Resident 108) remained free from accident hazards. * The facility failed to ensure Resident 108's side rails were padded as care planned. This failure posed the risk for Resident 108 to become injured by the side rails.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and serviced for one nonsampled resident (Resident 25). * Resident 25's indwelling urinary catheter tubing was observed to dragging on the ground as he self-propelled his wheelchair. This failure posed the risk for the resident to develop complications related to urinary catheter use.

Inspectors wroteBased on interview and medical record review, the facility failed to provide the necessary care for one of 25 final sampled residents (Resident 16). * The facility failed to ensure Resident 16 was administered medications as ordered on the days the resident left the facility for dialysis treatment (a treatment to rid the blood of toxins and waste when the kidneys fail to function). This had the potential for Resident 16 not getting the appropriate doses of medications as ordered, resulting in possible medical complications.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure proper storage, labeling and disposal of medications. * The facility failed to ensure the discontinued medication for one of 25 final sampled residents (Resident 40), and medications for seven nonsampled residents (Residents 38, 47, 62, 113, 114 115, and 366) who were transferred, discharged home or expired were removed from the medication cart. These failures had the potential for the medications to be accidentally administered and/or diverted. * The facility failed to ensure the prepared medications for Resident 463 were labeled when stored in the medication cart as the licensed staff await for the resident to be able to take the medications. [...]

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the food safety and sanitation requirements were met in the kitchen as evidenced by: * Open food containers had no open dates. * Expired food was not discarded. These failures had the potential to cause food borne illnesses in a medically vulnerable resident population who consumed food prepared in the kitchen.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to maintain the accurate medical record for one of 25 final sampled residents (Resident 6). * Resident 6's medical record had two different physician orders to address his end of life choice. Resident 6 had physician's orders to administer Full code/full treatment and DNR. This failure posed the risk for the resident receiving emergency measures against his wishes.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to establish and maintain the infection control practices designed to provide a safe and sanitary environment and help prevent the development and transmission of diseases and infections. * CNA 8 failed to remove her gown and gloves and perform hand hygiene before exiting Resident 31's room which was an isolation room due to exposure to COVID 19. This failure had the potential for the spread of infectious diseases in the facility.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to maintain essential equipment in safe operating condition. The facility failed to ensure four glucometers (a device which measures the amount of sugar in the blood) currently used and stored in the medication carts were properly calibrated. The facility failed to ensure the glucometer monitoring log was completed and the quality control record matched the serial numbers of the glucometer and the lot numbers of the control solutions. This posed the risk for inaccurate blood glucose test results and inappropriate treatments, which posed the risk of inaccurate blood glucose readings used to determine the residents' insulin doses.