Noble Care Center

Inspectors wroteBased on interview, and record review, the facility failed to implement comprehensive care plan (a dynamic, individualized, and multidisciplinary document outlining a resident's medical, functional, and psychosocial needs) interventions for 1 of 3 sampled residents (Resident 1) by not consistently providing oral care to Resident 1. This deficient practice had the potential to place Resident 1 at risk for not receiving effective, individualized care that could negatively affect the resident's oral health, comfort, safety, and overall well-being.

Inspectors wroteBased on interview, and record review, the facility failed to ensure 1 of 3 sampled residents (Resident 1), who was dependent on staff for activities of daily living (ADL, basic activities required to care for oneself such as eating and bathing), received the necessary care and services to maintain oral hygiene when oral care was not consistently provided to Resident 1. This deficient practice had the potential to negatively affect Resident 1's oral health, comfort, self-esteem, and overall well-being.

Inspectors wroteBased on interview and record review, the facility failed to report the findings of two of three abuse allegation investigations to the State Survey Agency (the Department), within 5 working days of the incident occurring, when:1. The results of the investigation into the alleged allegation of abuse that occurred on 4/11/26 between Resident 64 and Resident 8 was not reported to the Department; and 2. The results of the investigation into the alleged allegation of abuse that occurred on 5/31/26 between Resident 79 and Resident 92 was not reported to the Department. These failures had the potential to compromise the facility's ability to ensure that appropriate corrective actions were taken as a result of the investigations and could have compromised Resident 64, Resident 8, Resident 79, and Resident 92's safety.

Inspectors wroteBased on interview, and record review, the facility failed to maintain an accurate medical record for two of three sampled residents (Resident 2 and Resident 3) when:Wound care treatments were not documented daily as ordered by the physician for Resident 2 in February 2026 and March 2026; and,Wound care treatments, skin assessments, and skin treatments were not documented daily as ordered by the physician for Resident 3 in February 2026 and March 2026. These failures resulted in an inaccurate representation of the residents' progress in their plan of care and had the potential to result in a decreased well-being for Resident 2 and Resident 3.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe infection prevention practices were used for a census of 96 when a staff member changed bed linens in the room of a resident on Enhanced Barrier Precautions (EBP, infection control interventions designed to reduce the spread of multidrug resistant organisms [MDRO, germs that are more difficult to kill with antibiotics] in nursing homes) on 4/15/26. This failed practice could contribute to the spread of infection by cross-contamination (physical movement or transfer of harmful germs from one person, object, or place to another) in the facility.

Inspectors wroteBased on interview and record review the facility failed to protect one of three sampled residents (Resident 2) from physical abuse by another resident when Resident 1 allegedly pushed his wheelchair into Resident 2's knees on 3/17/26 and punched her in the abdomen on 3/19/26. This failure resulted in Resident 2 being physically assaulted by Resident 1 on two occasions and had the potential to negatively affect her psychosocial well-being.

Inspectors wroteBased on interview and record review the facility failed to ensure an allegation of potential abuse was reported in a timely manner for one of three sampled residents (Resident 2). This failure resulted in a delay in the abuse investigation and decreased the facility's potential to protect residents from physical and psychosocial harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect a resident's right to be free from physical abuse for one of two sampled residents (Resident 1) when the facility did not address Resident 2's escalating behaviors and noncompliance of his medications which resulted in Resident 2 hitting Resident 1 multiple times in the face on 12/4/25. This failure resulted in Resident 1 sustaining multiple injuries to his face and required him to be transferred to an acute care hospital on [DATE] for immediate treatment. This failure also has the potential for psychosocial harm to Resident 1.

Inspectors wroteBased on interview, and record review, the facility failed to ensure that the Medical Director (MD) was notified and made aware of potential health changes for one of two sampled residents (Resident 1) when Resident 1 refused to eat, take his medications, and exhibited aggressive behavior. This deficient practice resulted in the MD not being able to assess Resident 1's health status with the potential delay in treatment.

Inspectors wroteBased on interview, and record review, the facility failed to ensure that a safe discharge plan was in place for one of two sampled residents (Resident 1) when:1. The facility did not notify and document that the Ombudsman (acts as an independent and impartial resource to help individuals and groups resolve issues and complaints, often within a larger organization or government agency), Adult Protective Services (APS- programs that promote the safety, independence, and quality-of-life for vulnerable adults who are, or are in danger of, being abused, neglected by self or others, or financially exploited, and who are unable to protect themselves), the police department, and Resident 1's Responsible Party (RP) were contacted upon his Discharge Against Medical Advice ([NAME]- when a patient leaves a hospital or healthcare facility before their doctor recommends they be discharged ) from the [...]

Inspectors wroteBased on interview and record review, the facility failed to provide physical therapy services for one of three sample residents (Resident 1) as ordered by the physician and as outlined in the plan of care when Resident 1 was ordered to receive physical therapy five times per week beginning on 7/4/25 but documentation showed multiple missed therapy sessions. This failure placed Resident 1 at risk for decline in functional abilities and unmet care plan goals.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) had a safe discharge plan in place when Resident 1 expressed wanting to leave the facility against medical advice (AMA - a situation where a resident left a facility without following the physician's recommendation for treatment). This failure resulted in Resident 1 leaving the facility AMA when he was not equipped to meet his healthcare needs and was found lying in an unknown person ' s front yard 3.4 miles from the facility confused and gravely disabled (a person who was unable to provide for their basic needs [food, clothing, shelter, gravely disabled personal safety, or necessary medical care]).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a clean and safe environment for residents when two of two garbage dumpsters located outside the kitchen service entrance did not have the lids down to cover the trash. This failure had the potential for an unsafe environment for the residents due to possible insect and rodent infestation and spread of disease in the facility.

Inspectors wroteBased on observation and interview, the facility failed to ensure a clean, comfortable homelike environment for a census of 91 when: 1. room [ROOM NUMBER], occupied by three residents, had patched wall work done unevenly in white spackle (a compound used to fill cracks and holes in walls) that did not match the paint on the wall, and several spots of different colored paint; and, 2. A Shared [NAME] and [NAME] (shared bathroom between two rooms that have an entrance from each room) style bathroom between room [ROOM NUMBER] and room [ROOM NUMBER] had a sink pulling out from the wall with cracked caulking (a waterproof filler and sealant), a large circular area on the wall near the handrail had missing paint, and a broken raised toilet seat; and, 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe medication storage for a census of 91 when: 1. Two over-the-counter (medication that can be obtained without a doctors order) medication bottles were stored in open view on the bedside table of Resident 90, in a multi-resident room; 2. An Emergency Kit (E-kit -a locked and secure box containing an available collection of medications and supplies designed to address immediate needs when the pharmacy is unavailable) was opened and a medication was used without the proper documentation per facility policy; and, 3. An opened and used multi-dose vial of Heparin (an injectable medication given to prevent blood clots) was not dated with an opened or use by date per standards of practice. These failures may pose unsafe medication use in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents receiving pureed chicken and pureed noodles received the appropriate nutritive content as prescribed by a physician when serving sizes were smaller than ordered for the 14 residents receiving a Pureed (soft, pudding-like consistency) diet, and the 10 residents receiving the pureed meat on the Dysphagia Mechanical diet (texture- modified diet designed to make foods easier to chew and swallow). This failure had the potential of leading to malnutrition and weight loss for the 14 residents receiving a Pureed diet, and the 10 residents receiving the pureed meat on the Dysphagia Mechanical diet.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food storage and preparation, as well as maintain kitchen equipment and food contact surfaces in accordance with professional standards for food safety for the 87 residents who ate facility prepared meals when: 1. Two food labels were unreadable, two labels did not include the year, and several bottles of seasoning did not have a use by date; 2. Dry storage walls were not smooth and cleanable, floor of the dry storage was uneven, the refrigerator door appeared discolored, and the kitchen floor had missing and cracked tiles; 3. One container of baking powder was left open and unsealed; 4. Dry storage floor was discolored and sticky, oven doors, microwave, and toaster had food residue on surfaces, and the shelf under the dishwashing machine appeared discolored and rough to the touch; 5. [...]

Inspectors wroteBased on interview and record review, the facility's Quality Assessment Performance Improvement (QAPI, a systematic, interdisciplinary, comprehensive, and data-driven approach to maintaining and improving safety and quality in nursing homes) committee failed to develop and implement action plans, for a problem identified in June 2024, when three of eight sampled employee files (Certified Nurse Assistant (CNA) 1, CNA 2, and Licensed Nurse (LN) 8) did not contain background checks until 22-24 months after their hire dates. These failures had the potential to expose residents to physical and psychosocial harm.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of twenty sampled residents (Resident 39) had their rights related to treatment choices known and protected when, a copy of Resident 39's Advance Directive (a legal document indicating resident preference on end-of-life treatment decisions) was not available in the medical record. This failure had the potential to result in Resident 39's preferences for treatment to not be followed.

Inspectors wroteBased on interview and record review, the facility failed to resubmit the Pre-admission Screening and Resident Review (PASRR - a required assessment for individuals with mental illness, intellectual or developmental disabilities, or related conditions, so that a determination of need, appropriate setting, and a set of recommendations for services to be included in the individual's plan of care is provided) for one of twenty sampled residents (Resident 71) when, Resident 71's PASRR was not submitted by the facility on the 31st day after admission to the facility. This failure had the potential for Resident 71 to not receive the necessary services to meet their mental and psychosocial (the link between social factors and individual thought and behavior) needs.

Inspectors wroteBased on interview and record review, the facility failed to develop a baseline care plan within 48 hours of admission as required to address resident-specific care needs for one of twenty sampled residents (Resident 249) when, Resident 249's admission document identified a communication need that was not addressed on his baseline care plan. This failure had the potential for Resident 249 to not receive person-centered care.

Inspectors wroteBased on interview and record review the facility failed to develop and implement a resident-specific care plan intervention for 1 of 20 sampled residents (Resident 66) when, Resident 66 had no care plan addressing his anticoagulant care needs. This failure placed Resident 66 at risk for a decline in their health and well-being.

Inspectors wroteBased on interview and record review, the facility failed to conduct an IDT (Interdisciplinary Team: group of healthcare professionals from various disciplines that works together to develop and implement individualized resident care plans) meetings for one of twenty sampled residents (Resident 31), when Resident 31 ' s quarterly IDT care conferences were not conducted as scheduled for April 2024 and October 2024. This failure had potential to result in Resident 31's changing care needs not being accurately reflected in the care plan and the current care interventions not being readily available to implement and evaluate for their effectiveness and relevance.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate treatment and services were provided for one of twenty sampled residents (Resident 96) when Resident 96's STAT order (should be prioritized first as it is needed urgently) left hand x-ray was delayed and the delay in the order being carried out was not reported to the physician in a timely manner. This failure placed Resident 96's at risk of worsening and prolonged pain while awaiting for diagnosis of the left hand injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe environment for 1 of 20 sampled residents (Resident 65) when, Resident 65's footboard (part of the bed frame located at the foot of the bed) was broken and splintered. This failure had the potential to cause harm to Resident 65.

Inspectors wroteBased on interview and record review, the facility failed to ensure pharmaceutical services were provided to meet the needs for two of twenty sampled residents (Resident 66 and Resident 300) when: 1. Resident 66's antibiotic (a medication that kills germs) doses were not documented accurately in the medical record; and, 2. Resident 300's nicotine patch (a nicotine medicated patch worn on the skin to help reduce cravings of cigarettes) was not available for use for 6 days. These failures had the potential for Resident 66's infection (invasion and growth of germs in the body) to not be fully treated, resulting in a decline of his health and well-being and, resulted in Resident 300 feeling anxious without the nicotine patch and did not allow Resident 300 to achieve his highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of six sampled patients (Patient 68) was free from unnecessary medication when Patient 68 was receiving antidepressant medication with no monitoring for side effects or behavior manifestations of depression and the pharmacist's recommendation for a review of the medication use was not acknowledged by the physician in a timely manner. These failures had the potential for Patient 68 to receive unnecessary medication and the potential for medication side effects to go unnoticed, negatively impacting Patient 68's health and well - being.

Inspectors wroteBased on interview and record review, the facility failed to ensure safe monitoring and assessment of blood pressure (BP-the force of your blood pushing against the walls of your arteries as your heart pumps blood and was measured as two numbers: systolic (when the heart beats) and diastolic (when the heart rests between beats)) and heart rate (HR-frequency of your heart beats per minute) for medications to treat high (hypertension (HTN)) and low (hypotension) BP for 1 of 20 sampled residents (Resident 35) when: 1. Resident 35's physician's prescribed hold parameters (a set of numbers that guide the nursing staff when to not give medication for safety reasons) for midodrine (medication used to treat low BP) was not followed; 2. Resident 35's physician's prescribed hold parameters for labetalol (a medication used to treat HTN) were not followed; 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure standardized recipes were utilized for food preparation to ensure foods were prepared by methods that conserve nutritive value and flavor when vegetables were placed into the steam table approximately three hours before meal service, and measurement tools were not used during meal preparation for the 87 residents receiving kitchen prepared meals. These deficient practices placed residents at an increased risk for nutritional impairment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the alternative meal option of a grilled cheese sandwich had a similar protein content to the main entrée for the 87 residents receiving kitchen prepared meals. This had the potential of leading to inadequate protein intake/malnutrition for those residents choosing the sandwich in place of the main entrée.

Inspectors wroteBased on interview and record review, the facility failed to maintain the confidentiality of 1 of 20 sampled residents (Resident 31) when portions of Resident 31's medical records were discovered in Resident 98's medical record during a closed record review (examining a residents medical records after their care has concluded (for example; discharge, death). This failure had the potential for exposure of Resident 31's private and confidential information to unauthorized individuals.

Inspectors wroteBased on observation, interview, and record review, the facility failed to practice appropriate infection prevention and control measures for a census of 91 when: 1. Licensed Nurse (LN) 1 did not clean, sanitize, and disinfect the glucometer (a device that measures blood sugar levels) per manufacturer's guidelines; and 2. A partially full urinal was sitting on the bedside table with Resident 300's water. These failures had the potential to spread infection and cause health problems to the residents for a census of 91.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Antibiotic Stewardship Program (ASP- a federally mandated program with goals of monitoring, optimizing antibiotic use, and reducing misuse of antibiotics) was followed for one of two residents on antibiotics (Resident 90) in a sample of 20 based on facility policy and national standards when: 1. McGeer Criteria (a set of guidelines for identifying infections in long-term care facilities) was not followed for prescribing antibiotics as indicated in the facility policy and procedure for Resident 90; and, 2. An antibiotic time-out (an active reassessment of an antibiotic prescription 48-72 hours after the medication's first dose) for Resident 90 was done within 24 hours and did not follow the facility's policy and procedure of the ASP; and, 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure shared resident bedrooms measured at least 80 square feet (sq. ft.) per resident in a total of thirty-three resident rooms. This failure had the potential for an inadequacy of space for provision of care and to limit space for residents' personal belongings.

Inspectors wroteBased on interview, and record review, the facility failed to develop a care plan for one of two sampled residents (Resident 1) when Resident 1's care needs for alcohol withdrawal and elopement prevention were not addressed on admission. This deficient practice resulted in Resident 1 ' s elopement from the facility on 12/6/24 and 12/13/24.

Inspectors wroteBased on interviews and record reviews, the facility failed to provide a copy of medical records to Resident 1 within 2 days after a written request was made by Resident 1 on 11/14/24. This failure delayed Resident 1's right to obtain his medical records in a timely manner.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet the needs of one of two sampled residents (Resident 1) when a medication used to control pain was not ordered and delivered. This failure had the potential for Resident 1 to experience nerve pain.

Inspectors wroteBased on interview, and record review, the facility failed to provide the office of the local Long-Term Care (LTC) Ombudsman (OMB, an official advocate who represents the interests of the residents residing in a LTC facility) a copy of the Notice of Transfer/ Discharge for Resident 1 prior to Resident 1's discharge from the facility. This failure placed Resident 1 at risk of not receiving the necessary protections and support of the LTC Ombudsman office.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one of five sampled residents' (Resident 1) smoking safety evaluation records were completed in a timely manner. This deficient practice had the potential to cause inaccurate documentation in Resident 1's clinical record and had the potential to cause injury from smoking.

Inspectors wroteBased on interview and record review, the facility failed to protect one of three sampled resident's (Resident 1) right to be free from physical abuse by facility staff, when Resident 1 was grabbed and was hit in the face by Certified Nursing Assistant (CNA) 1. This failure resulted in Resident 1 crying and sustaining bleeding and discoloration to her lip.

Inspectors wroteBased on interview and record review the facility failed to develop a comprehensive care plan for two of seven sampled residents (Resident 1 and Resident 6) when Resident 1 and Resident 6 were involved in resident-to-resident altercations and post incident care plans were not developed. These failures had the potential for Resident 1 and Resident 6 to not receive adequate care and to have unmet psychosocial needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure professional standards of care were provided for one of seven sampled residents (Resident 7) when Resident 7 sustained a cervical (neck) fracture on 4/8/24 and her medical provider was not informed until 4/26/24. This failure resulted in a delay of treatment, and placed Resident 7 at risk of improper healing and worsening of her injury.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were free from verbal and physical abuse for 2 of 5 sampled residents (Resident 3 and Resident 5), when Resident 3 hit resident 5 on her face and shoulder after Resident 5 shouted and cursed at him to stop staring at her. This failure resulted in physical pain for Resident 5 and the altercation had the potential to diminish the psychosocial well-being of both residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of five sampled residents' (Resident 1) needs were accommodated promptly, when Resident 1's call light was not within his reach. This failure had the potential of Resident 1's needs not being met and to cause psychosocial and/or physical harm for Resident 1 when unable to contact staff when needed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have an adequate system for periodically reconciling controlled drugs (substances that have an accepted medical use and have a potential for abuse and may also lead to physical or psychological dependence), and properly administering medications to meet the needs of the residents for a census 93 when: 1. The facility did not clarify midodrine (medication for hypotension) order parameters and administer midodrine to Residents 45 and 199; and, 2. The facility did not have an adequate system for the Director of Nursing (DON) to accurately periodically reconcile controlled drugs received from the pharmacy by nursing staff to prevent drug diversion (the illegal distribution or abuse of prescription drugs or their use for purposes not intended by the prescriber). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet food storage and food service standards when: 1. The walk-in freezer door was left open and ice build-up was found at the bottom of the door. 2. Various dry food items were not labeled with the use by date, 3. Various opened spices were not labeled with an open date, 4. Bowls of ready to eat green salads were not covered appropriately, 5. Fruits were not washed prior to peeling, 6a. Dishwasher temperature and the sanitizer readings were not done as scheduled; and, 6b. The red bucket sanitizer readings were not completed as scheduled. These deficient practices had the potential of leading to food-borne illness for the 90 out of 93 residents eating facility prepared foods.

Inspectors wroteBased on interview and record review, the facility failed to coordinate assessments with the Preadmission Screening and Resident Review (PASARR, a federal requirement to screen all potential nursing home residents for mental illness and intellectual disability, to help ensure that individuals are not inappropriately placed in a nursing home, and to ensure they receive any specialized services that are required) Program for 3 of 21 sampled residents (Resident 13, Resident 41, and Resident 56) when: 1. Resident 13's PASARR Level II recommendations were not implemented, 2. Resident 41's PASARR level I did not include her mental illness diagnosis of schizoaffective disorder (a mental health disorder characterized by abnormal thought processes and an unstable mood); and, 3. [...]

Inspectors wroteBased on interview and record review, the Consultant Pharmacist (CP) failed to identify and report to the facility an irregularity related to: 1. Resident 18 was administered valproic acid (suspension for seizure) with no resident diagnosis of seizure, therapy duplication for valproic acid suspension and Depakote DR tablet (antiseizure medications also used to treat mood disorders), a gradual dose reduction (GDR- stepwise tapering of a dose to determine if symptoms, conditions or risks can be managed by a lower dose or if the dose or the medication can be discontinued) was not attempted for Depakote DR tablets, follow up on Resident 18's triglyceride (a type of fat found in blood) critical levels, Zyprexa (antipsychotic medication that alternates brain chemistry to help reduce psychotic symptoms), and nortriptyline were administered unnecessarily; and, 2. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure two out of three residents (Resident 18 and Resident 41) were free from unnecessary psychotropic (drugs that affect brain activities associated with mental processes and behavior) medications when: 1. Resident 18 was administered Zyprexa (antipsychotic medication that alternates brain chemistry to help reduce psychotic symptoms), nortriptyline (medication used to treat depression), and valproic acid suspension/Depakote Delayed Release (DR)tablet (an antiseizure medication also used to treat mood disorders) and the facility did not implement resident specific non-pharmacological interventions. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the facility medication error rate did not exceed five percent or greater when observation of 25 opportunities during the medication pass resulted in four errors. The calculated medication error rate was 16%. This failure resulted in: 1. Placing Resident 1 at risk of constipation and nicotine withdrawal when Licensed Nurse (LN) 20 did not administer nicotine patch (patch to help quit smoking) and Miralax (medication for constipation). 2. Placing Resident 202 at risk of low levels of magnesium and folic acid when LN 20 did not administer magnesium and folic acid.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all medications used in the facility were properly labeled and discarded after the expiration date or discontinued date when: 1. In the [NAME] Wing medication cart, Resident 64's discontinued hydrocodone/acetaminophen (medication used to treat pain) 5-325 mg (milligrams- unit of measure); Resident 16's two latanoprost (medication for high blood pressure in the eyes) bottles, one expired and one with no open or expiration dates; Resident 21's two expired latanoprost bottles; Resident 78's two expired latanoprost and two expired Rhopressa (medication for high blood pressure in the eyes) 0.02% ophthalmic bottles; Resident 33's Lantus (medication for high blood glucose) pen with no open or expiration date; [...]

Inspectors wroteBased on interview and record review, the facility failed to provide sufficient oversight of the daily food service operations for 90 residents who received food from the kitchen out of a census of 93 when the facility did not employ a full-time Registered Dietitian (RD) or a Certified Dietary Manager/Supervisor (CDS). This failure resulted in inadequate supervision of the dietary department and had the potential for unsafe food practices and food-borne illness for residents who received facility-prepared foods.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control practices for a census of 93 residents when: 1. The facility failed to implement their water management program for monitoring legionella's disease (an illness caused by bacteria which grow in moist areas) and other water borne illnesses when the processes for water treatment were not documented since August 2023. This failure had the potential to allow for water borne illnesses. 2. Licensed Nurse (LN) 20, 24, and 28 failed to appropriately disinfect (to clean and make free of disease-causing organisms) shared glucometers before and after resident care, according to manufacturer's specifications. This failure had the potential to spread infection to other residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure resident preferences regarding life sustaining treatment were accurately reflected in the electronic health record (EHR) for 1 of 21 sampled residents (Resident 48) when Resident 48's code status order (an order whether or not to perform resuscitation in an emergency) in the EHR did not match the code status listed on the Physician Orders for Life-Sustaining Treatment (POLST- care directives during life threatening situations). This failure had the potential risk of Resident 48's wishes for life sustaining treatment to not be followed.

Inspectors wroteBased on interview, and record review, the facility failed to ensure 2 of 3 sampled residents (Resident 47 and Resident 84) were provided timely and specific notification of how their discharge from Medicare Part A skilled services (specialized services provided in a skilled nursing facility) would affect their continued stay at the facility when the Skilled Nursing Facility Advanced Beneficiary Notice of Non - coverage (SNF ABN, a form which lists the items or services that Medicare may not pay for, the reason why, and the estimated cost to the resident) was not provided prior to their Medicare A services end date. This failure had the potential for Resident 47 and Resident 84 to be unaware of their potential liability for payment of services not covered under Medicare A and their rights to appeal the decision.

Inspectors wroteBased on interview, and record review, the facility failed to ensure an allegation of verbal abuse was reported for 1 of 21 sampled residents (Resident 33) when licensed nurse (LN) 1 did not report to facility administration about Resident 33's allegation of verbal abuse. This failure resulted in a delay of an investigation of the alleged abuse and had a potential to affect Resident 33's psychological well-being.

Inspectors wroteBased on interview, and record review, the facility failed to develop and implement a resident specific care plan (provides direction on the type of nursing care the resident may need based on their health, medication, mental, and or psychosocial needs) for 2 of 21 sampled residents (Resident 90 and Resident 197) when: 1. Resident 90 did not have a care plan developed for the dialysis (procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) services she was receiving; and, 2. Resident 197 did not have a care plan developed for the hospice (specialized in end-of-life care for all residents with an advanced, life-limiting illness) services she was receiving. These failures placed Resident 90 and Resident 197 at risk to not have appropriate, consistent, and individualized care to meet their needs.

Inspectors wroteBased on interview, and record review, the facility failed to consistently complete quarterly Interdisciplinary Team (IDT, care team consisting of different disciplines who assess and coordinate care), care plan conferences (a meeting which provides opportunities for the resident's and/or their representative, and each discipline to revise the residents care plans) for 2 of 21 sampled residents (Resident 13 and Resident 41). These failures had the potential for unmet care needs for Resident 13 and Resident 41.

Inspectors wroteBased on interview and record review, the facility failed to provide treatment in accordance with current professional standards for 1 of 5 sampled residents (Resident 18) when Resident 18 received duplicate medication therapy with the administration of valproic acid suspension (medication for seizure that is also used for mood disorders) for seizures with no diagnosis for seizures, and was also administered Depakote (antiseizure medication also used to treat mood disorders) DR (delayed release) tablets. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pureed food (pudding-like texture that is smooth and blended) was prepared in a manner that preserved the nutritional value for thirteen residents who received pureed food from the kitchen when, [NAME] 2 did not follow the recipe for pureed pasta. This failure had the potential to decrease the nutritive value of the pureed food being served.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure trash was properly disposed of for a census of 93, when the facility's dumpster lids were left open. This failure had the potential to attract unwanted pests.

Inspectors wroteBased on interview and record review, the facility failed to inform residents and/or their representatives of the nature and implications of any proposed binding arbitration agreement (a contract between two or more parties that requires them to resolve disputes before an arbitrator, neutral third party, rather than the court system) when the agreements and the right to rescind within 30 days, were not clearly explained to 2 out of 3 sampled residents (Resident 4 and Resident 298). This failure resulted in Resident 4 and Resident 298 or their responsible party (RP) signing the binding arbitration agreement without fully understanding that they were giving up their right to litigation in a court proceeding should a dispute arise and that they had the right to revoke the agreement within 30 days of signing.

Inspectors wroteBased on interview, and record review, the facility failed to ensure hospice services (specializes in end-of-life care for all residents with an advanced, life-limiting illness) were coordinated for one of six residents receiving hospice (Resident 197)when, 1. The facility did not secure a written agreement describing the responsibilities between the hospice agency and the facility prior to initiating care for Resident 197; and, 2. The hospice agency's nurse progress notes and visit information were not in Resident 197's hospice clinical record. These failures had the potential for Resident 197 to not receive proper and appropriate hospice care and services from the facility and the hospice agency; and had the potential for Resident 197's medical record to have insufficient information to reflect the condition, care, and services provided.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure shared resident bedrooms measured at least 80 square feet (sq. ft.) per resident in a total of thirty-three resident rooms. This failure had the potential for an inadequacy of space for provision of care and to limit space for residents' personal belongings.

Inspectors wroteBased on interview, and record review, the facility failed to provide emergency electrical power on 1/10/24 when the electricity went out and failed to ensure the generator (machine for converting mechanical energy into electricity) safety checks were completed per the facility's policy and procedure (P&P). These failures resulted in the facility being without emergency electrical power for 15-20 minutes and could have resulted in harm to 94 residents who reside at the facility.

Inspectors wroteBased on interview and record review, the facility failed to implement their policy and procedure on abuse prevention when one of three sampled staff members' employee files (Staff 1) did not contain a background check. This failure allowed for an incomplete employee file and exposed residents of the facility to a staff member who was working and interacting with the vulnerable population without a criminal history background check on file at the facility.

Inspectors wroteBased on observation and interview the facility failed to ensure a clean, comfortable, and homelike environment for three out three rooms sampled (Room A, Room B, and Room C) when: 1. Room A, occupied by three residents, had a broken light fixture, a broken foot board, a broken bedside cabinet, a broken closet door handle, and a broken bathroom window screen. Room A had three soiled divider curtains between the three beds. Room A had red stains on the floor and glass sliding door, the ceiling vent had an accumulation of dust and spider webs, and bed 3 had dried brown stains on the bed frame. 2. Room B, occupied by three residents, had three soiled divider curtains between the three beds. Room B had black grime on the floor behind the bathroom and entry doors. 3. Room C, occupied by three residents, had two broken closet storage drawer handles, and broken tiles under bed 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate infection prevention and control measures were practiced for a census of 91 when: 1. Isolation precautions (measures taken to prevent the spread of germs/infections from one person to another) signs were not posted outside COVID positive residents' rooms and isolation precautions were not taken for all COVID positive residents, 2. A staff member did not wear an N95 (type of mask that offers the highest level of respiratory protection) mask in the Alzheimer's Care Unit (ACU) where the facility had COVID positive residents, and staff did not change facemasks after exiting the ACU unit and before entering the non-COVID unit, and 3. Staff were not fit tested (done to ensure a good fit for N95 masks) for N95's. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a qualified Dietary Services Manager (DSM) was employed in the absence of a full-time Registered Dietitian (DC) for 94 residents who received food from the kitchen. This failure had the potential for the residents' nutritional needs not to be met; and dietary staff were not supervised by a qualified person.

Inspectors wroteBased on interview and record review, the facility failed to ensure four of 35 sampled residents (Resident 71, Resident 91, Resident 54, and Resident 13) rights related to treatment choices were known and protected when: 1. There was no evidence an Advance Directive (legal documentation consistent with a person's medical preference when they were no longer able to make decisions for themselves) was discussed and/or offered to Resident 71, Resident 91, and Resident 54; and, 2. Resident 13's code status order (to provide or not provide life saving measures in the event of an emergency) in the electronic medical record did not match the code status listed on the POLST (Physician Orders for Life Sustaining Treatment: care directives during life threatening situations), and nursing staff were unaware of how to proceed when a discrepancy was identified. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete three quarterly care conferences (a meeting which provides opportunities for the residents and/or their representative, and each professional discipline to revise the residents' care plans) for one of 35 sampled residents (Resident 23). These failures had the potential for unmet care needs for Resident 23.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of 35 sampled residents (Resident 147 and Resident 395) received adequate supervision to prevent an avoidable accident when: 1. A safe environment was not provided for Resident 147; and, 2. A smoking assessment and smoking care plan were not completed for Resident 395. These failures had the potential to result in an avoidable injury to Resident 147 and Resident 395.

Inspectors wroteBased on interview and record review, the facility failed to evaluate acceptable parameters of nutritional status for two of thirty-five sampled residents (Resident 27 and Resident 71) when Resident 27 and Resident 71 were not weighed at least weekly. This failure had the potential for weight loss or weight gain to go undetected which could result in a delay of treatment/interventions and have a negative effect on the health of Resident 27 and Resident 71.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respiratory care was provided in accordance with professional standards of practice for a census of 96 when: 1. An Oxygen in use sign was not posted outside of the room for Resident 399, 2. The oxygen flow rate was not followed per physician order for Resident 399 and Resident 3, 3a. Resident 399's oxygen tubing was not dated when last changed; 3b. Resident 3's oxygen tubing was not dated and the oxygen humidifier bottle was empty without a date when changed; and, 3c. Resident 14, Resident 40, and Resident 42's oxygen tubing and/or nebulizer masks were not changed per facility policy. These failures had the potential to result in negative impacts on the residents' health and safety including risks for ineffective oxygen therapy, and respiratory distress.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe medication handling, use, and disposition with census of 96 when: 1. There was a discrepancy between the Controlled Drug Record (CDR, an accountability record for opioid use) removal and the respective Medication Administration Record (MAR, referred to as a drug chart that serves as a legal record of the drugs administered to a resident) documentation for three residents (Resident 17, Resident 72, and Resident 349). 2. Hazardous medications (medications that may pose harm to individuals handling them based on manufacturer and government guidelines) stored in the facility's [NAME] side medication cart, were not tagged in the MAR as hazardous for nursing staff to wear gloves when handling during administration or dispensing. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to carry out a doctor's order for blood thinner medications (a type of medication that prevents blood clot harming the resident) and notify the medical doctor of recurrent missed antibiotic use for one of 96 residents (Resident 88) when: 1. Resident 88's order for enoxaparin (or Lovenox, a blood thinner in the form of a shot or injection) and Resident 88's order for warfarin (a blood thinner given by tablet) for treatment of blood clot, was not carried out as ordered; and, 2. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure safe medication storage for a census of 96 when: 1. Undated and expired medications (spoiled medications that no longer should be used) were stored in the refrigerator in the main medication room (a locked room for storage of medications and supplies). 2. Expired and unlabeled medication stored in the [NAME] side medication cart (a mobile cart containing medications used on daily basis for administration to residents). 3. Expired and unlabeled medications and supplies were stored in two out of two treatment carts (a mobile cart containing medication and supplies for wound and skin diseases). 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain food safety requirements when: 1. Refrigerated food items were stored in an area that contained a pipe wrapped in tape with a liquid dripping from it into a metal tray in the vicinity of stored food, and contained a brownish slimy fluid with residue; 2. Clean cooking equipment was stored on a surface containing food debris and other unidentifiable debris, and cooking utensils were in containers that had dust and food debris on the outside and on the inside; 3. Kitchen ovens contained loose food debris and burnt in food debris; 4. The kitchen did not have air gaps (a break in the plumbing to prevent unsanitary water from flowing back into the sink) in the food preparation sink and the dishwasher; 5. Kitchen floors contained visible dirt, food products and build up; and, 6. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection prevention and control practices for a census of 96 residents when: 1. The laundry services staff did not seperate clean and soiled items in the laundry area, and a ceiling vent fan was dirty and filled with lint; 2. Resident 71 was found with his indwelling urinary catheter (a tube inserted into the bladder to drain or collect urine) bag in contact with the floor; and, 3. Resident 88's peripherally inserted central catheter (PICC, a type of long catheter that is inserted through a peripheral vein, often in the arm, passed through to larger veins near the heart and used to give fluids, nutrition, drugs, or other treatments) line dressing was not changed at least weekly. These failures increased the risk of infectious diseases for residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of thirty-five sampled residents (Resident 4 and Resident 5) were treated with dignity, respect, and in a manner which promoted independence during dining when staff stood over Resident 4 and Resident 5 while assisting them to eat. This failure had the potential to negatively affect Resident 4 and Resident 5's quality of life during mealtime, with a potential for decreased social interaction and loss of appetite.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of thirty five sampled residents (Resident 71, Resident 68, and Resident 79) were provided with reasonable accommodations of needs when; 1. Resident 68 was not provided with a wheelchair; 2. Resident 79 was not provided a tray table to eat meals from; and, 3. Resident 71's call light was not within reach. These failures resulted in Resident 68 and Resident 79's needs not being met, did not provide a homelike environment, removed the possibility for independent functioning, and had the potential to impact their psychosocial well-being. Resident 71 was not able to use the call light when desired which had the potential to result in physical and/or psychosocial harm.

Inspectors wroteBased on interview and record review, the facility failed to obtain acknowledgement that the beneficiary notification forms were given to two of three sampled residents (Resident 47 and Resident 59), when the Notice of Medicare Non-Coverage (NOMNC - a form which indicates that Medicare covered services are ending and how to appeal) and the Advanced Beneficiary Notice of Non-coverage (ABN, a form which gave the choice to continue services under private pay if Medicare did not provide payment) was not mailed to the responsible party (RP) of Resident 47 and proof of sending the forms to Resident 59's RP was not obtained. This failure resulted in Resident 47's RP and Resident 59's RP not having the information available on how to appeal the decision, or have knowledge of the costs to continue treatment in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident's rights to file a grievance was honored for a census of 96 residents, when grievance forms were not available for residents to use. This failure had the potential for a grievance to not be addressed and removed the right for a resident to file an anonymous grievance at any given time.

Inspectors wroteBased on interview and record review, the facility failed to ensure a mental health diagnosis was accurately reflected in the medical records for one resident (Resident 147) out of 35 sampled residents when: Resident 147 was prescribed a mind-altering medication called quetiapine (also called Seroquel, a medication to treat mental illness) for schizoaffective disorder (a type of mental health with mood swings) and valproic acid (a medication for seizure and mental health) for aggressive behavior, while the documented diagnosis by the Mental Health Doctor (specialist doctor in mental health) was advanced dementia (profound memory loss and/or disorientation) in the medical records. Improperly documented diagnoses may result in unsafe medication use in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate treatment and services were provided for one of 35 sampled residents (Resident 64) when Resident 64's elevated blood sugar levels were not reported to the physician in a timely manner. This failure placed Resident 64 at risk for hyperglycemia (blood sugar level higher than the standard range) to be unrecognized and untreated.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate care and services for two of two residents (Resident 20 and Resident 86) requiring tube feeding (method of providing nutrients via a tube directly into the stomach or intestine when a person is unable to eat by mouth) when: 1. Resident 20's tube feeding container was not changed as indicated, 2. Resident 86's tube feeding container label did not indicate the time the feeding was started; and, 3. Resident 86's physician order for tube feeding was not followed. These failures had the potential for the residents to have complications related to tube feedings and/or risk for infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure kitchen staff accurately measured food portions when 3 residents, Resident 59, Resident 31, and Resident 60 did not receive the amount of food required by their diets. This failure had the potential to result in excessive or reduced caloric intake required by the individual resident, negatively impacting the residents' nutritional status, health and well-being.

Inspectors wroteBased on interview, and record review, the facility failed to implement their Antibiotic Stewardship Program (a program designed for the safe use of antibiotics) for a census of 96 residents when Resident 87 was prescribed an antibiotic treatment without a proper indication. This failure increased the potential for inappropriate antibiotic therapy resulting in the development of antibiotic resistant bacterial infections in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure shared resident bedrooms measured at least 80 square feet (sq. ft.) per resident in a total of thirty-three resident rooms. This failure had the potential to limit personal belongings of each resident and inadequacy of space for provision of care to residents.