Normandy Terrace Nursing & Rehabilitation Center

Inspectors wroteBased on interview and record review, the facility failed to provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives for 1 of 3 residents (Resident #2) reviewed for death. The facility failed to provide immediate basic life support interventions for Resident #2 upon finding Resident #2 unresponsive on [DATE], and Resident #2 was declared deceased on [DATE]. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 5:33 PM. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity level of actual harm because Resident #2 expired, and the facility needed to evaluate training outcomes. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to, based on the comprehensive assessment of a resident, ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 4 residents (Resident #1) reviewed for quality of care. The facility failed to identify and address Resident #1's fall with injury appropriately, leaving Resident #1 with a fractured hip for over 24 hours without treatment. An Immediate Jeopardy (IJ) situation was Identified on 07/13/2026. While the IJ was removed on 07/13/2026 the facility remained out of compliance at a scope of isolated with the potential for more than minimal harm, due to the to the facility's need to evaluate the effectiveness of corrective systems. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 2 of 6 residents (Residents #2 and Resident #4), and the facility failed to ensure that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled for 5 of 5 medication carts (B Hall Carts #1, #2, and #3; A Hall Cart, and C Hall Cart) reviewed for pharmacy services. The facility failed to ensure Resident #4 received ordered insulin on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. The facility failed to ensure Resident #2 received ordered medications on [DATE] after admission to the facility on the evening of [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that all alleged violations involving neglect are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation result in serious bodily injury for 1 of 6 residents (Resident #3) reviewed for neglect. The facility failed to report the unexpected death with signs of potential neglect for Resident #3. This failure could lead to lack of oversight and neglect of residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure, in response to allegations neglect, have evidence that all alleged violations are thoroughly investigated for 2 of 6 residents (Residents #2 and #3) reviewed for neglect. The facility failed to have evidence of investigation into the unexpected death with signs of potential neglect for Resident #3. The facility failed to have evidence of thorough investigation of the unexpected death with signs of potential neglect for Resident #2. These failures could lead to lack of oversight and/or neglect of residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable and, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for 2 of 5 medication carts (A Hall cart and C Hall cart) reviewed for storage of drugs and biologicals. The facility failed to ensure the carts for A Hall and C Hall were locked and secured or labeled and dated. This failure could place residents at risk of medication misuse, medication errors, drug diversion or harm due to accidental ingestion of unprescribed medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary services to maintain good grooming, personal hygiene for residents who were unable to carry out activities of daily living for 3 of 5 residents (Residents #1, #2, and #3) reviewed for ADLs. 1. The facility failed to ensure Resident #1 received scheduled showers on 6/13/2026, 6/16/2026, 6/18/2026, 6/20/2026, 6/23/2026, 6/25/2026. 2. The facility failed to ensure Resident #2 received scheduled showers on 6/13/2026, 6/16/2026, 6/18/2026, 6/20/2026, 6/23/2026, 6/25/2026, 6/27/2026, 6/30/2026. 3. The facility failed to ensure Resident #3 received scheduled showers on 6/15/2026, 6/19/2026, 6/22/2026, 6/24/2026, 6/26/2026. These failures could place residents at risk of skin breakdown, infection, and contribute to feelings of poor self-esteem and hopelessness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary services to maintain good grooming, personal hygiene for residents who were unable to carry out activities of daily living for 3 of 6 Residents (Residents #1, #2, and #3) reviewed for quality of life. 1. The facility failed to ensure Resident #1 received scheduled showers on 04/22/2026, 04/27/2026, 05/1/2026, 05/4/2026, 05/6/2026, 05/8/2026, and 05/13/2026. 2. The facility failed to ensure Resident #2 received scheduled showers on 04/25/2026, 04/28/2026, 05/9/2026, and 05/12/2026. 3. The facility failed to ensure Resident #3 received scheduled showers on 04/22/2026, 04/27/2026, 05/8/2026, 05/13/2026, and 5/15/2026. These failures could affect any resident and contribute to feelings of poor self-esteem and hopelessness.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to provide treatment and care in accordance with the comprehensive person-centered care plan and in accordance with professional standards of practice for 1 of 6 residents (Resident #4) reviewed for quality of care. The facility failed to ensure Resident #4 received wound care on 04/01/2026, 04/03/2026, 04/05/2026, 04/06/2026, 04/07/2026, 04/08/2026, 04/09/2026, 04/10/2026, 04/11/2026, 04/12/2026, 04/13/2026, 04/15/2026, 04/16/2026, 04/20/2026, 04/20/2026, 04/24/2026, 04/30/2026, 05/06/2026, 05/08/2026, 05/09/2026, 05/10/2026, 05/13/2026, 05/04/2026, and 05/18/2026. These failures could affect residents who receive wound care treatments by placing them at risk for receiving inadequate treatments resulting in the worsening of the wounds.

Inspectors wroteBased on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that were complete and accurately documented for 2 of 6 residents (Residents #4 and #5) reviewed for accuracy of records: 1. Nursing staff failed to document accurate weekly skin assessments and weekly ulcer assessments for Resident #4 from March to May 2026 when it was documented the resident had no skin breakdown when the resident had a wound to the right heel. 2. Nursing staff failed to document weekly skin assessments for Resident #5 for May 2026. These failures could affect residents whose records were maintained by the facility and could place the residents at risk of errors in care and treatment.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident has the right to be informed of, and participate in, his or her treatment, including; the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers for 2 of 5 residents (Residents #2 and #3) reviewed for the right to be informed of, and participate in treatment.1. The facility failed to obtain signed consents for 2 anti-psychotic medications for Resident #2.2. The facility failed to obtain a signed consent for an anti-psychotic medication for Resident #3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 2 residents (Resident #1) reviewed receiving nebulizer treatments. The facility failed to ensure Resident #1's face mask and tubing were stored properly to prevent contamination when the resident's unprotected face mask and tubing were observed lying on the resident's bedside table next to their bed. This failure could put residents receiving medication via nebulizer and face masks at risk for cross-contamination and respiratory infection.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure the environment was as free of accident hazards as is possible and each resident receives adequate supervision to prevent accidents for 1 of 1 resident (Resident #1) reviewed for accidents hazards and supervision: Resident #1 left the facility without supervision or staff knowledge on 3/19/26 from 11:35 p.m. to 11:57 p.m. Resident #1 was found approximately 0.1 miles away at a local fast-food restaurant. This failure could place residents at risk of accidents that could result in serious injury, harm, impairment, or death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored properly in the cart for 1 of 3 medication carts (300 hallway medication cart) reviewed for storage: he facility failed to ensure Resident #2's insulin Lispro was stored appropriately in a locked medication cart. This failure could place residents at risk of not receiving prescribed medications as ordered and drug diversions.

Inspectors wroteBased on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that were complete and accurately documented for 1 of 6 residents (Resident #3) reviewed for accuracy of records: The facility failed to document wound care treatments on the TAR for Resident #3 on 3/1/25, 3/6/26, 3/7/26, 3/11/26, 3/13/26, 3/14/26, 3/15/26, and 3/16/26. These failures could affect residents whose records were maintained by the facility and could place the residents at risk of errors in care and treatment.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of needs and preferences for three (3) of twelve (12) residents (Resident #1, Resident #2, Resident #3) reviewed for reasonable accommodation of needs. 1. The facility failed to ensure the call light system in Resident #1's room was in a position accessible to the resident on 02/20/2026.2. The facility failed to ensure the call light system in Resident #2's room was in a position accessible to the resident on 02/20/2026.3. The facility failed to ensure the call light system in Resident #3's room was in a position accessible to the resident on 02/23/2026. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments and permit only authorized personnel to have access to the keys for one (1) of twelve (12) residents (Resident #4) reviewed for medication storage. The facility failed to ensure Resident #4 did not have two (2) velphoro oral tablets (a phosphate binder, a medication used to control phosphorus levels in the blood) at the bedside. This deficient practice could place residents at risk of medication misuse or drug diversion.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to maintain a sanitary, orderly, and comfortable interior by housekeeping and maintenance services, which were necessary to maintain a sanitary, orderly, and comfortable interior for 1 of 8 residents (Resident #3) reviewed for homelike environment. The facility failed to maintain Resident #3's bathroom with dry clean drywall without damage and without stains. This failure could place residents at risk for diminished self-worth.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure the resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart, for 1 of 8 residents (Resident #2) reviewed for misappropriation of property, in that: Housekeeper F (HK F) took Resident #2's money to purchase herself meals. This failure could place residents at risk for harm by exploitation which could result in psychosocial harm and mistrust of the staff.

Inspectors wroteBased on interview and record review, the facility failed to ensure the basis for discharge was documented in the resident's medical record for 1 out of 3 residents (Resident #1) reviewed for inappropriate discharges. 1. The facility failed to provide and document sufficient preparation and orientation for Resident #1 to ensure safe and orderly discharge from the facility to another facility. 2. The facility failed to develop and implement an effective discharge planning process and involve Resident #1 and the resident representative in the development of the discharge plan and inform Resident #1 and resident representative of the final plan. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 2 residents (Resident #2 and Resident #3) reviewed for infection control. The facility failed to ensure RN A followed infection control policy/procedures during wound care for Resident #2 and Resident #3. This deficient practice could place residents at risk for infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to respect the residents right to personal privacy for 2 of 2 residents (Resident #2 and Resident #3) reviewed for privacy/dignity. The facility failed to ensure residents' privacy/dignity was maintained during wound care on (2) occasions. This failure could place residents at risk for poor self-esteem, decreased self-worth, and quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents for 1 of 1 residents (Resident #1) reviewed for accidents and supervision in that: The facility failed to supervise Resident #1 who eloped from the facility on 08/16/25 and was gone from the facility for more than nine hours and found in a closed car and had sustained a heat stroke. The non-compliance was identified as PNC. The Immediate Jeopardy (IJ) began on 08/16/2025 and ended on 08/16/2025. The facility had corrected the non-compliance before the survey began on 08/17/2025. This deficient practice could place residents who were elopement risks at-risk of harm, serious injury, or death.

Inspectors wroteBased on interviews and record reviews the facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown sources are reported immediately but not later than 2 hours to the administrator of the facility and to other officials, including to the State Survey Agency in accordance with State law through established procedures, for 1 of 1 Residents (Resident #1) reviewed for Neglect, in that: The facility did not report an allegation of Neglect to the State Survey Agency (HHSC) within the 2 hours time frame of Resident #1's elopement from the facility This deficient practice could affect any resident and could contribute to further neglect.

Inspectors wroteBased on observation and interview, the facility failed to post on a daily basis information that included the facility name, current date, total number and actual hours worked by registered nurses, licensed practical or licensed vocational nurses, certified nurse aides directly responsible for resident care per shift and the resident census for 1 of 3 days (08/13/2025) reviewed for posting of required information. The facility failed to post the required current nurse staffing and census information on 08/13/2025. This failure could place residents at risk of not having access to information regarding staffing data and the facility census.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure the resident had the right to be informed of, and participate in, his or her treatment, including: The right to be informed in advance of the care to be furnished and the type of care giver or professional that will furnish the care, and the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives, or treatment options and to choose the alternative or options he or she preferred, for 1 (Resident #70) of 8 residents reviewed for resident rights. The facility failed to obtain signed consent from Resident #70 to receive care under secured conditions. [...]

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 2 of 6 residents (Residents #66 and #56) reviewed for infection control, in that: 1. While providing incontinent care for Resident #66, CNA E failed to use proper infection control. 2. While providing incontinent care for Resident #56, CNA F failed to use proper infection control. These deficient practices could place residents at-risk for infection due to improper care practices.

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote and maintain the resident's dignity for 1 (Resident #10) of 25 residents reviewed for dignity, in that: Resident #10's wheelchair was visibly soiled with dust and food particles. This deficient practice could result in psychosocial harm due to feelings of embarrassment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents had the right to personal privacy and confidentiality of his or her personal and medical records for one of five residents (Resident # 66) reviewed for privacy. The facility failed to ensure MA C locked the computer, which exposed Resident #66's morning medication list after she walked away and left the computer unattended. This failure could place residents at risk of having medical information exposed to others and cause residents to feel uncomfortable and disrespected.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 2 resident (Resident #66) reviewed for incontinent care, in that: While providing incontinent care for Resident #66, CNA E used a back to front motion to clean Resident #66's buttocks. This deficient practice could place residents at-risk for infection and skin break down due to improper care practices.

Inspectors wroteBased on observations, interviews and record reviews the facility failed to ensure that CNAs were able to demonstrate competency in skills and techniques necessary to care for residents' needs for 1 of 6 residents (Resident #66) by 1 of 6 CNAs (CNA E) reviewed for competent staff, in that: The facility failed to ensure CNA E used the right technique to clean Resident #66 while providing incontinent care. This deficient practice could place residents at-risk for infection and skin break down due to improper care practices.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drugs and biologicals were stored in accordance with currently accepted professional principles for, 1 of 3 (Hall 300 Nurse cart) medication carts observed, in that: The Nurse Medication Cart in the 300-hall contained five loose medication pills. This failure could place residents who receive medications at risk for not receiving the intended therapeutic effects of medications.

Inspectors wroteBased on observation and interview, the facility failed to maintain and ensure safe and sanitary storage of residents' food items for 1 ( Resident # 86 ) of 5 resident refrigerators reviewed in that: The personal refrigerator for Resident # 86 contained food items that were unlabeled and undated. This deficient practice could place residents at risk of foodborne illness due to consuming foods which are spoiled.

Inspectors wroteBased on interview and record review, the facility failed to maintain clinical records that were complete and accurately documented for 1 (Resident #66) of 25 residents reviewed for clinical records, in that: Resident #66's diagnoses of insomnia and aggressiveness /combativeness were not listed in his diagnosis list and Resident #66's physician order for psychotropic medication erroneously read supervised self-administration. This deficient practice could cause miscommunication among the resident's caregivers and result in improper care.

Inspectors wroteBased on observation, interview and record review, the facility failed a to dispose of garbage and refuse properly for 3 of 4 dumpsters (Dumpsters #1, #2 and #3) reviewed for disposal of garbage. The facility failed to ensure:1. Dumpster #1 had a drainage plug that completely covered the drainage hole in the dumpster and the doors were completely shut.2. Dumpster #2 had a drainage plug and the doors were completely shut.3. Dumpster #3 had a drainage plug that completely covered the drainage hole in the dumpster. These deficient practices could place residents at risk for exposure to germs and diseases carried by vermin and rodents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident receives adequate supervision to prevent accidents for 1 of 6 residents (Resident #1), reviewed for quality of care. The facility failed to supervise Resident #1 who eloped out of a side door of the facility on 2/17/25 at approximately 7:12 p.m. without staff knowledge, through a side door that the alarm had been turned off on and was found ambulating down the sidewalk approximately 400 feet from the facility. An Immediate Jeopardy was identified as past noncompliance on 4/23/25. The IJ began on 2/17/25 and ended on 2/18/25. The facility had corrected the noncompliance before the survey began. This failure could put residents at risk of accidents, and could result in serious injury, harm, impairment, and death.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse, to the administrator of the facility and to other officials including to the State Survey Agency where state law provides for jurisdiction in long-term care facilities in accordance with State law through established procedures for 7 of 12 residents (Residents #2, #3, #4, #5, #7, #8, and #9), reviewed for freedom from abuse, neglect, and exploitation. 1. The facility failed to report when Resident #2 physically attacked Resident #3 for 2 days after the incident. 2. Facility failed to report an incident of suspected abuse, from 12/23/2024 when Resident #5 pushed Resident #4 down until 02/24/2025. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents had the right to be free from abuse, neglect and misappropriation of property for 2 of 6 residents (Residents #2 and #3) reviewed for abuse, in that: 1. The facility failed to protect Resident #2 from physical abuse when Resident #1 grabbed, scratched and hit Resident #2 during a smoke break on [DATE]. The facility failed to respond to develop a plan of care, behavior monitoring, interventions or train staff on behaviors to prevent further abuse. 2. The facility failed to protect Resident #3 from physical and psychological abuse when Resident #1 repeatedly hit Resident #3 in the face and head and scratched him on [DATE] which resulted in swelling, redness, bruising to Resident #3's left eye, scratches to his face, neck, chest and arms and trauma. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objective and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 3 of 4 residents (Residents #1, #2, and #3) reviewed for care plans, in that: 1. Facility failed to develop a person-centered care plan with interventions that addressed Resident #1's diagnoses of mental illness including depression, schizophrenia, dementia or antisocial personality disorder, and behaviors which included stealing, agitation, and aggression. 2. [...]

Inspectors wroteBased on interviews and record review, the facility failed to consult with the resident's physician when there is a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 (Resident #2) of 7 residents reviewed for resident rights. The facility failed to notify Resident #2's physician of her change of condition on [DATE]. Resident #2 continued to have these symptoms and was sent out to the hospital on [DATE]. On [DATE] at 4:30 pm an Immediate Jeopardy (IJ) was identified. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide the necessary care and services to a resident who [NAME] unable to carry out activities of daily living for 1 of 7 residents (Resident #2), reviewed for activities of daily living in the area of incontinent care. Resident #2 was not provided with incontinent care by a nursing staff member on 6/7/24 in a timely manner. This failure could result in residents experiencing a diminished quality of life.

Inspectors wroteBased on interviews, and record review, the facility failed to ensure resident medical records were kept in accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are complete and accurately documented for 1 of 7 residents (Resident #2) reviewed for clinical records. The facility failed to ensure Resident #2's vital signs were documented in the EMR on [DATE] and [DATE]. This deficient practice could place residents at risk for improper care due to inaccurate records.

Inspectors wroteBased on interview and record review, the facility failed to promote the residents' right to receive mail, for all facility residents, in that: Facility staff did not distribute mail received on Saturdays to the residents. This deficient practice could result in residents not receiving mail in a timely manner and a diminished quality of life.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities for 3 of 22 residents (Residents #14, #48 and #73) reviewed for activities in that: 1. The facility failed to provide Resident #14 activities designed to meet her interests and promote physical, mental, and psychosocial well-being. 2. The facility failed to provide Resident #48 activities designed to meet his interests and promote physical, mental, and psychosocial well-being. 3. The facility failed to provide Resident #73 activities designed to meet her interests and promote physical, mental, and psychosocial well-being. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 1 of 8 residents ( Resident #21) reviewed for reasonable accommodations, in that: The facility failed to ensure Resident #21's call light was within reach. This failure could place residents at risk of not having their needs met

Inspectors wroteBased on the interview and record review, the facility failed to transmit the resident assessment within the required time frame for 1 of the 2 discharged residents (Resident # 89) reviewed for data encoding and transmission, in that: The facility did not submit a discharge not anticipated MDS for Resident #89. This failure could put residents discharged from the facility at risk of not having their assessments transmitted accurately.

Inspectors wroteBased on interview and record review, the facility failed to ensure all Pre-admission Screening and Resident Review (PASRR) Level I residents with mental illness were provided with a PASRR Evaluation assessment for 1 of 2 residents (Residents #21) reviewed for PASRR screening, in that: Resident #21's PASRR Level 1 assessment did not accurately capture the resident's diagnosis of mental illness. These failures could put residents with inaccurate PASRR Level 1 Evaluations at risk of not receiving care and services to meet their needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received proper treatment and care to maintain mobility and good foot health for 1 of 1 resident (Resident #1) reviewed for foot care. The facility failed to provide Resident #1 with access to a podiatrist. The deficient practice placed residents at risk of discomfort, poor foot hygiene, and a decline in resident's physical condition.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents for 1 of 2 residents (Resident #1) reviewed for accidents and supervision, in that: Resident #1 eloped from the facility on 02/21/2024 and again on 03/04/2024. The facility failed to prevent Resident #1 from eloping on 2/21/24. Resident #1 eloped again when he was not being monitored on 3/4/24. An Immediate Jeopardy (IJ) was identified as past non-compliance on 04/18/2024. The non-compliance began on 02/21/2024 and ended on 03/05/2024. The facility had corrected the non-compliance before the survey began. This deficient practice could place residents who were elopement risks at-risk of harm, serious injury, or death.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a safe, functional, sanitary and comfortable environment for residents, staff, and the public for 6 out of 12 resident rooms (Rooms #203, #207, #211, #213, #225 and #322) and 2 of 4 dining rooms (MC Dining room [ROOM NUMBER] and #3), 1 of 1 nurses' station (200 Wing), and 1 of 3 wings (300 Wing) reviewed for environmental conditions. 1. The ceiling tiles of the 300 Wing contained brown/black colored stains. 2. The floor in Memory Care dining room [ROOM NUMBER] had missing tiles on the floor. 3. The floor in Memory Care dining room [ROOM NUMBER] had debris and food crumbs throughout the floor and the floor was sticky. 4. There were brown colored stains on the ceiling of room [ROOM NUMBER] and #225. 5. [...]

Inspectors wroteBased on observation, record review and interviews, the facility failed to equip corridors with firmly secured handrails for 1 of 4 halls reviewed for environmental conditions. The facility did not ensure a handrail found in the Memory Care unit, across from the dining room was firmly affixed to the wall. This failure could place residents at risk for avoidable accidents and decreased quality of life due to environmental hazards.

Inspectors wroteBased on interview and record review the facility failed to consider the views of a resident group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility for 3 (01/27/23, 02/15/23 and 03/30/23) of 3 Resident Council meetings reviewed for resident group response. The facility failed to have an effective way to resolve the issues with the resident's meals being cold, late and not palatable to meet the resident's dietary needs and preferences. This deficient practice could place residents at risk for weight loss, food borne illnesses and decreased quality of life and psychosocial well- being. Findings Included: Review of the Facility's Meal Service Times revealed, Breakfast 7 am, Lunch 12 pm and Dinner 5 pm. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents for one (Hall 100 memory care unit) of six halls and the dining rooms observed for environment, in that: The facility failed to ensure the shared bathrooms on Halls 100 (memory care unit) were clean, for Rooms 121,123, 122, 124, 128, 125, 110, 112, 115, 113, 106, 108, 102, 104 and the dining rooms. These failures could place residents at risk for diminished quality of life due to the lack of a well-kept environment and equipment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food that was palatable, attractive and at a safe and appetizing temperature for eight (Residents #3, #18, #31, #37, #42, #70, #97, and #101) of nine residents reviewed for Palatable food. 1. The facility failed to provide food to the residents in a timely manner which resulted in the resident's food being cold. 2. The facility failed to ensure the resident's food was cooked thoroughly and not undercooked. These failures could place residents at risk for weight loss, food borne illnesses resulting in gastro-intestinal issues, diminished quality of life and psycho-social well- being.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for four (Residents #1, #36, #39, and #90) of six residents reviewed for infection control. LVN A failed to disinfect the glucometer machine (an instrument for measuring the concentration of glucose in the blood) between resident use, for resident #36 and #90. RN B failed to disinfect the blood pressure cuff in between blood pressure checks for Residents #1, #39, and unknown resident. This failure could place residents at-risk of cross contamination which could result in infections or illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for two (smoke area and 300 hall) of 13 fire extinguishers, one (on 300 hall) of two portable ice machines, one (main) of two dining areas reviewed for environment. 1. The facility failed to ensure one fire extinguisher located in the patio smoke area and one fire extinguisher located at the end of the 300 hall exit were both fastened and mounted securely to their posts. 2. The facility failed to ensure one of their portable ice machines, the table it sat on and the flooring underneath it was clean that was located behind the 300 hall nurse's station. 3. The facility failed to ensure the facility's Auto floor scrubber was not stored in the main dining room, where the resident ate their meals. 4. [...]