Oak Grove Post Acute

Inspectors wroteBased on interview, and record review, the facility failed to provide written notice to the State Agency (SA) at the time of the position change of the Director of Nursing (DON) for a census of 104 residents, when the current DON started the DON position on 6/26/26, and the facility did not report the change of the DON position to the SA as of 7/9/26. This failure delayed the SA from verifying that the DON was qualified to lead clinical services at the skilled nursing facility, which had the potential to compromise resident safety and compliance with federal and state regulation for a census of 104 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe environment free of hazards for two of three sampled residents (Resident 1 and Resident 2) who were at risk for elopement (the act of leaving a facility unsupervised and without prior authorization), when: 1. Resident 1 and Resident 2's physician order for checking placement and function of the wander guard device (an alarm that alerts the facility when a wandering resident tries to leave the facility unattended) was not followed; and, 2. Resident 1 and Resident 2's monitoring of their wander guard placement (where the device is located on the body) and function were not consistently documented for the month of April 2026. These failures placed Resident 1 and Resident 2 at risk for elopement and had the potential to result in an injury.

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 102 residents who ate facility prepared meals when:1) Kitchen walls, ceiling vent area, and floor were observed with chips in the paint, drywall, and tiles;2) The can opener, red cutting board, and 2 fry pans were observed worn and damaged;3) Food items (sausage patties and container of rice) were found stored but exposed to air; and4) The resident refrigerator in the center nursing hallway had five days of temperatures logged above the safe food range without intervention, and the north resident refrigerator was observed with ice buildup covering the freezer. These failures had the potential to put residents at risk for foodborne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a garbage dumpster lid was maintained to properly cover the contents and preventing the harborage and feeding of pests in one of two facility dumpsters. This deficient practice had the potential of disease spreading among residents and visitors by vermin and pest infestation for a census of 109.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement a comprehensive care plan (a list of resident specific problems, goals, and interventions) for five of 32 sampled residents (Resident 1, Resident 15, Resident 54, and Resident 123), when:1. Resident 1's Physician was not notified when Resident 1's arteriovenous (AV) fistula (a surgically created connection of an artery directly to a vein allowing high blood flow during hemodialysis (HD), a life-saving treatment that acts as an artificial kidney that removes waste and extra fluid from the blood and regulates blood pressure) was negative for thrill (vibration) and bruit (buzzing or swoosh sound) indicating a blockage or failure.2. Resident 15 was receiving oxygen without a physician's order.3. Resident 15 and Resident 54 did not receive one to one activities at least once a week.4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate care and services to four of eight sampled residents (Resident 92, Resident 107, Resident 63, and Resident 95) during medication administration when:1. The first drop of blood sample for glucose level reading for Resident 92, Resident 107, and Resident 63 was not discarded before a sample was obtained on 4/6/26;2. Several crushed and liquid medications in plastic medication cups for gastrostomy tube (GT-also referred to as enteral feeding/tube feeding-a tube inserted through the abdomen directly into the stomach to deliver nutrition, fluids, and medications when swallowing is not possible or safe) medication administration for Resident 95 were left at the bedside table unattended and unsupervised on 4/9/26; and,3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two out of 32 sampled residents (Resident 49 and Resident 85) were assisted with nail care as part of the Activities of Daily Living (ADLs- normal daily functions required to meet basic needs) when Resident 49 and Resident 85 had long fingernails. This failure had the potential for Resident 49 and Resident 85 to sustain skin injury and/or to acquire an infection, and not achieve the highest practicable well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe medication storage practices in the medication rooms and medication refrigerators for a resident census of 109, when:1. North station medication room stored four (4) outdated intravenous (IV) fluid bags of antibiotics (medications used to treat infections) in the medication refrigerator together with other active medications;2. An unauthorized facility staff was in the North station medication room unaccompanied by a licensed nurse;3. South station medication room [ROOM NUMBER] stored multiple enteral feedings in bottles and cartoons and five (5) emergency medication kits (e-kits, portable collection of essential prescription medicines designed to provide immediate care during crisis) with no daily log to document and monitor the temperature of the medication room;4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement appropriate infection prevention and control measures for a census of 109, when:1. Resident 50's oxygen tube (a flexible, lightweight, and typically transparent tube used to deliver supplemental oxygen from a source-like a concentrator-directly to a patient's nostrils or mask) was found on the floor without a date and it was not connected to the oxygen concentrator (a medical device that provides purified oxygen to people with breathing disorders by filtering, compressing, and concentrating ambient air into 90%-95% pure oxygen);2. The Glucometer (a small, portable, battery-powered device used to measure the concentration of sugar (glucose) in a small sample of blood) was not cleaned properly and adequately in between Resident 92, Resident 107, and Resident 63 use; and,3. [...]

Inspectors wroteBased on staff interview and clinical record review, the facility failed to ensure that 1 of 32 sampled residents (Resident 8) was provided with education regarding the risks and benefits of prescribed psychotropic medications (medications used to treat mental health diagnosis) when the facility administered ordered psychotropic medications without confirming that consent had been obtained by the prescribing physician. This failure had the potential to cause Resident 8 to experience unnecessary side effects and duplicate therapy based on the number of psychotropic medications that had been ordered.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accommodate the needs of 2 of 32 sampled residents (Resident 85 and Resident 96) when, Resident 85 and Resident 96 had a call light (device used to contact staff for assistance) that was not within Resident 85 and Resident 96's reach. This deficient practice placed Resident 85 and Resident 96 at increased risk for unmet care needs, delayed staff response, falls, and potential injury.

Inspectors wroteBased on interview and record review the facility failed to honor the resident's right to choose for 1 of 32 residents (Resident 27), when the facility failed to honor Resident 27's request for a schedule concerning when their room would be deep cleaned (an intensive, systematic disinfection process-often called terminal cleaning-that goes beyond daily cleaning to eliminate pathogens and prevent Healthcare Associated Infections) and by which housekeeping team member. This failure caused Resident 27 to experience psychosocial distress that included feeling harassed by housekeeping staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe and comfortable homelike environment to 4 of 32 sampled residents (Resident 24, Resident 51, Resident 57, and Resident 98) when: 1. Comfortable sounds were not maintained for Resident 24, Resident 57, and Resident 98 when Resident 55 yelled loud; and,2. Resident 24, Resident 51, and Resident 98's drawers were broken. These failures removed Resident 24, Resident 51, Resident 57, and Resident 98's right to a dignified homelike environment, with the potential to result in psychosocial harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's right to be free from verbal abuse (using negative words and language that cause harm including demeaning, disrespecting, frightening, and threatening words) for one of thirty-two sampled residents (Resident 68) when Licensed Nurse (LN) 3 and Certified Nurse Assistant (CNA) 1 witnessed a contracted staff (staff who are usually not considered official company employee and are not on the traditional payroll but hired by another company for a specific responsibility) from the housekeeping department who made inappropriate and threatening remarks toward Resident 68 on 3/28/26. This failure had the potential to cause emotional distress and could negatively affect Resident 68's psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review the facility failed to assess a change in condition for one of 32 residents (Resident 1) and notify the physician when Resident 1's arteriovenous (AV) fistula (a surgically created connection of an artery directly to a vein allowing high blood flow during hemodialysis (HD), a life-saving treatment that acts as an artificial kidney that removes waste and extra fluid from the blood and regulates blood pressure) was not properly functioning. These failures placed Resident 1 at risk of missing hemodialysis as scheduled.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement an adequate activities program for two of 32 sampled residents, Resident 15 and Resident 54 when:1. Resident 15 was not provided with one-to-one activities from 3/11/26, to 3/17/26, and2. Resident 54 was not provided with one-to-one activities from 3/19/26, to 3/29/26. These failures had the potential to negatively impact the psychosocial wellbeing of Resident 15 and Resident 54.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement appropriate respiratory care when Resident 15 received supplemental oxygen without a physician's order. This failure had the potential for Resident 15 to experience adverse side effects of supplemental oxygen use. A review of Resident 15's admission Record indicated Resident 15 was admitted to the facility with diagnoses that included but not limited to traumatic brain injury, schizophrenia (chronic brain disorder that causes people to lose touch with reality, making it difficult to distinguish what is real from what is not), and insomnia (chronic inability to get enough sleep). [...]

Inspectors wroteBased on interview and record review the facility failed to ensure one of two sampled residents (Resident 1) who required hemodialysis (HD, a medical treatment that acts as an artificial kidney to filter blood by removing waste products, toxins, and excess fluids) received appropriate care when Resident 1's Physician was not notified when Resident 1's arteriovenous (AV) fistula (a surgically created connection of an artery directly to a vein allowing high blood flow during dialysis) was negative for thrill (vibration) and bruit (buzzing or swoosh sound) indicating a blockage or failure. These failures had the potential to result in Resident 1 to miss hemodialysis due to a malfunction of the AV fistula. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure pharmacy services were maintained for a census of 109 when non-narcotic (medications that are not opioids-not addictive) prescription medication destruction records were not co-signed by a licensed nurse in twenty-nine (29) out of twenty-nine (29) pages of destruction records reviewed during a medication room inspection in one of four medication room on 4/6/26. This failure had the potential risk for medication misuse and/or drug diversion (unlawful use of prescription drug by unauthorized individuals) of prescribed medications due to unsafe disposition practices. During a concurrent interview and record review on 4/6/26, at 7:35 a.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from significant medication errors (the observed or identified preparation or administration of medications or biologicals which are not in accordance with the prescriber's order, manufacturer's specifications, and accepted professional standards) for one of eight sampled residents (Resident 92) during medication administration when, Resident 92 was administered an insulin (medication used to manage blood sugar levels in people with diabetes, a chronic condition where the body does not produce or use insulin properly leading to high blood sugar levels) that was prescribed for Resident 89 on 4/8/26. [...]

Inspectors wroteBased on interview and record review, the facility failed to administer the pneumococcal (a serious bacterial infection that can cause respiratory illness) vaccine and the influenza (or the flu, is a contagious viral infection of the respiratory system that can range from mild to severe, causing symptoms like fever, cough, sore throat, muscle aches, and fatigue) vaccine to one out of five sampled residents (Resident 46) when Resident 46 did not receive the pneumococcal and influenza vaccines. These failures had the potential for Resident 46 to go unvaccinated with the risk for serious health related illness and/or death.

Inspectors wroteBased on interviews and record review, the facility failed to administer Covid-19 (an infectious respiratory disease caused by the SARS-CoV-2 virus) vaccine to one out of five sampled residents (Resident 46) when Resident 46 did not receive the Covid-19 vaccine. This failure put Resident 46 at risk for serious health related illness and/or death.

Inspectors wroteBased on interview, and record review, the facility failed to ensure allegations of abuse were reported within two hours for one of four sampled residents (Resident 1) when an allegation of staff to resident abuse on 2/20/26 was reported to the Department on 2/25/26. This failure had the potential for Resident 1 to experience continued abuse and not having an advocate available to protect Resident 1 rights.

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of four certified nursing assistants (CNAs) had the required competencies to work with residents in the facility, when CNA 2 was not provided orientation and did not have an employee file with the facility. This failure placed residents in the facility at risk for receiving care from staff that did not meet the competencies in skills and techniques required to care for resident needs residing in the facility.

Inspectors wroteBased on interview and record review the facility did not maintain complete personnel records when the initial tuberculosis (TB, a contagious lung disease) screening was not done at the time of hire for one of three sampled nursing staff (Nursing Assistant 1). This failure had the potential to expose staff and residents to tuberculosis, negatively impacting their health and well-being. During a concurrent interview and record review on 3/4/26 at 12:16 p.m. with the Payroll Coordinator (PC), Nursing Assistant (NA) 1's employee personnel record (a structured, secure record that details an employee's relationship with the facility from hiring to offboarding) was reviewed. The PC verified NA 1 was hired on 11/25/25 and NA 1's initial TB test screening (a TB skin test or a blood test to detect infection) was not in NA 1's record. During an interview on 3/4/26 at 1:55 p.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide needed care and treatment to three out of six sampled residents (Resident 1, Resident 2, and Resident 3) when:1. Resident 1's clinical record did not indicate ADL (activities of daily living-essential self-care tasks such as bathing, dressing, eating) care was provided 12 out of 19 days during the day shift, 1 out of 19 days during the evening shift, and 5 out of 19 days during the night shift for a period from 2/1/26 through 2/19/26;2a. Resident 2's clinical record did not indicate treatment to a stage 3 pressure ulcer (a serious, full-thickness skin injury extending through the dermis into the subcutaneous fat layer) to coccyx (tailbone) was provided 3 out of 19 days from 2/1/26 through 2/19/26; and,2b. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program when on 2/11/26 an inspection of the facility, the kitchen, and the food storage areas were not maintained per recommendations from the facility's pest control service for a census of 114. This failure had the potential to spread infection and disease. In addition, this failure increased the risk of unsafe and unsanitary living conditions for the residents, staff, and visitors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure activities of daily living (ADL) were provided to maintain good hand and fingernail hygiene for two of four sampled residents (Resident 2 and Resident 4) when on 2/11/26:1. Resident 2 had long fingernails with a brown substance embedded under them; and2. Resident 4 had dirty hands and fingernails with long sharp edges and contained a dark brown substance embedded under them. In addition, Resident 4 was not assisted, asked, or educated on why it was important to perform hand hygiene before eating his lunch meal. These failures had the potential for Resident 2 and Resident 4 to cut their own skin, or the skin of others, which could lead to infection from harboring microorganisms (bacteria, viruses, or fungus) due to poor hand and fingernail hygiene.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide foot care for one of four sampled residents (Resident 4) when Resident 4 had long, overgrown, and discolored toenails with sharp edges on his left foot, and staff did not follow their facility process and doctors order (a specific actionable instruction given by a healthcare provider for a patients treatment or care) to provide nail care. This failure resulted in Resident 4 not being able to wear a sock or shoe on his left foot due to the pain the long toenails caused. This failure had the potential to affect Resident 4's foot health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly dispose of and refuse their garbage for a census of 115 residents when:1. Garbage area was not maintained in a sanitary condition; there was a trash bag filled with residents' personal trash (used diapers and other trash) left on the ground outside of the garbage dumpster container,2. There were used Personal Protective Equipment (PPE- equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses such as gloves and masks) left scattered on the ground in the garbage area outside of the dumpster; and,3. Dumpsters were not covered, and left open with overfilled trash bags. This failure had the potential to harbor feeding of pests, and spread infection amongst residents, threatening their health and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate storage and labeling of medications and biologicals (complex medicines made from living organisms that treat diseases by targeting specific part of the immune system) for a census of 115 residents when the treatment cart was left opened and unattended with residents' identifiable medications and biologicals. This failure had the potential for misuse of prescribed medications, risk for harm or injury to residents due to unsafe med storage practices.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate care and services to promote healing and prevent pressure ulcers (a localized injury to the skin and/or underlying tissue because of pressure) for two of three sampled residents (Resident 1 and Resident 2), when both residents were observed lying on low-air loss mattresses (LAL mattress, a mattress designed to prevent and treat pressure wounds that uses a continuous, gentle flow of air through a surface of tiny holes to reduce pressure helping to prevent and treat skin breakdown and pressure wounds) that were not correctly adjusted according to Resident 1 and Resident 2's individual weights. These failures had the potential to place Resident 1 and Resident 2 at increased risk for developing pressure ulcers and/or skin breakdown.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a care plan to reduce the potential risk of pressure injury for one of three sampled residents (Resident 1) when a low air loss mattress (LAL mattress, a mattress designed to prevent and treat pressure wounds that uses a continuous, gentle flow of air through a surface of tiny holes to reduce pressure helping to prevent and treat skin breakdown and pressure wounds) was not included in Resident 1's care plans. This failure had the potential to place Resident 1 at risk for possible skin complications and not receiving effective and person-centered care.

Inspectors wroteBased on interview and record review, the facility failed to protect the rights of two of 4 sampled residents (Resident 3 and Resident 6) to be free from physical abuse when:1. Resident 1 with a history of multiple resident-to-resident altercations, made racial slurs and pushed Resident 6 on 9/18/25; and,2. Resident 4 hit Resident 3 in the face on 8/30/25. These failures resulted in Resident 3 sustaining an injury to her mouth and Resident 6 falling from his wheelchair.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive care plan for one of three sampled residents (Resident 1) when:1. Resident 1 was readmitted on [DATE] to the facility with new skin issues; and, 2. Resident 1 had known skin scratching behavior. These failures placed Resident 1 at risk for further skin breakdown and potential worsening of the existing skin issues due to the skin scratching behavior.

Inspectors wroteBased on interview, and record review, the facility failed to ensure medical records were complete and accurately documented for one of three sampled residents (Resident 1 and Resident 2) when: 1. Resident 1's Treatment Administration Record (TAR) report for 11/2025 had missing documentation from a licensed nurse on multiple treatment orders; and, 2. Resident 2's TAR report for 11/2025 had missing documentation from a licensed nurse for the stage 3 pressure ulcer treatment to her coccyx (a deep wound on the tailbone area). These failures had the potential for both Resident 1 and Resident 2's medical records to have insufficient information to determine if treatment orders were being carried out as ordered and could place both residents at risk of complications.

Inspectors wroteBased on interview, and record review, the facility failed to ensure one out of three sampled residents (Resident 1) was provided with adequate pain management when Resident 1's new pain medication order was not carried out by the facility for 35 days. This failure contributed to Resident 1 experiencing pain and had the potential to cause unnecessary psychosocial distress. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 1) was free from involuntary seclusion (a type of abuse that includes separation of a resident from other residents or from her/his room or confinement to her/his room) when Certified Nursing Assistant (CNA) 1, placed and sat in a chair in Resident 1's doorway, blocking Resident 1 from exiting her room during the 9/17/25 night shift (NOC shift). This failure had the potential to result in physical injury and psychosocial trauma (lasting emotional and psychological distress caused by a distressing event) for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of abuse directly to the facility administrator and to the Department (a state agency that licenses, regulates, and inspects skilled nursing facilities (SNFs) to ensure they comply with state and federal regulations) within two hours after the suspicion of abuse was recognized on 9/18/25 by facility staff for one of four sampled residents (Resident 1). This failure delayed the facility and the Department's abuse investigation, potentially allowing continued abuse of Resident 1 and other residents, or causing further psychosocial harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision for one of four sampled residents (Resident 1) with known Dementia (generally involves memory loss) and wandering behaviors when Resident 1 wandered into other resident rooms and walked throughout the facility without supervision. This failure placed Resident 1 at risk for elopement (when a resident leaves the facility without authorization, supervision, or a planned discharge), injury, and/or serious physical harm.

Inspectors wroteBased on interview and record review, the facility failed to protect one of three sampled residents (Resident 1) from abuse when Resident 2, who was assigned one-on-one supervision (a single staff member is assigned to be in constant physical proximity to a resident to ensure their safety and provide immediate assistance), was left alone for a period of time and Resident 2 entered Resident 1's room, hitting him with a wheelchair footrest on 8/20/25. These failures had the potential to negatively affect Resident 1's health and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident medical records were complete and accurately documented for one of three sampled residents (Resident 2) when, Resident 2's every 15-minute safety checks were not consistently documented on by staff for the dates of 8/18/25, 8/20/25, and 8/25/25. This failure had the potential to result in information not being available to ensure accuracy or communication across health care professionals and did not provide for an accurate representation of actual events that occurred to ensure Resident 2's care plan goals and interventions were being met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure necessary doctor's orders and equipment monitoring were in place for an implemented pressure ulcer/injury (PU/PI; refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence) intervention for one of three residents (Resident 4) when, Resident 4 did not have an order for a Low Air Loss Mattress (LAL - alternating pressure and air circulation, which improves blood flow) to include equipment settings (typically based on the patient's weight, pressure sore risk, and skin condition) specific to Resident 4 and there was no documented monitoring to ensure the proper overall function and correct settings of the LAL mattress Resident 4 was using. This failure had the potential for Resident 4 to experience further skin breakdown.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate behavioral health treatment and services to meet the psychosocial needs for one of three sampled residents (Resident 1) when: 1. Resident 1 displayed episodes of anger, and repeated resident to resident altercations, and Resident 1's Psychiatric Initial Eval, (a comprehensive evaluation focused on the diagnosis, treatment and prevention of mental, emotional and behavioral disorders) dated 12/10/24, included treatment goals and recommended follow-up psychiatric visits were not provided, nor documented in Resident 1's clinical health record; 2. Resident 1's Physician Progress Notes, dated 3/14/25, 4/1/25, 4/29/25, 5/9/25, and 5/30/25 indicated an assessment and plan for monitor and follow-up with psychiatry, and Resident 1 was not provided psychiatry consultation or visits until 6/9/25; 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to respect the resident's right to personal privacy for one of three sampled residents (Resident 4) when Certified Nursing Assistant (CNA) 1 and CNA 2 performed social media live streaming (the real-time broadcasting of video and audio content over the internet, allowing viewers to interact with the content creator as it is happening) in Resident 4's room during resident care activities. This failure had the potential to result in Resident 4 feeling a lack of privacy and hopelessness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate care and services with the use of enteral feeding (tube feeding, TF - the delivery of nutrients through a tube inserted directly into the stomach) for one resident (Resident 4) when Resident 4's tube feeding bag and tubing (containing nutrients to be delivered by a mechanical pump delivery system at a prescribed rate of flow) did not indicate the date and time it was put into use. This failure had the potential to produce bacterial growth in the tube feeding solution resulting in an infection. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide one to one supervision (a designated staff to provide constant monitoring to prevent or redirect resident from engage in harmful act) to one of three sampled residents (Resident 2, with known behavioral issues), to prevent the physical altercation between Resident 1 and Resident 2 on 6/7/25. This failure resulted in Resident 2 suffering multiple bruises and a laceration to the right side of his face and Resident 1 suffering two fractures in his left hand.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the environment remained free of accidents or hazards for one of five sampled residents (Resident 4) when, remnants of a broken rail on the wall near Resident 4's bed with splintered wood and protruding screws were not removed. This failure had the potential to result in injury to Resident 4, facility staff, and visitors.

Inspectors wroteBased on interview, and record review, the facility failed to maintain acceptable parameters of nutrition for four of four sampled residents (Resident 1, Resident 2, Resident 3, and Resident 4) when:1. Resident 1's order for daily weight checks for one week and then twice a week weight checks for one month was not carried out, and;2. Resident 2, Resident 3, and Resident 4's weekly weight checks were not completed during their first month of admission. These failures had the potential for Resident 1, Resident 2, Resident 3 and Resident 4's weight loss or weight gain to go undetected, which could result in a delay in their treatment/interventions and have a negative effect on their health and functional status.

Inspectors wroteBased on interview, and record review, the facility failed to ensure one out of three sampled residents (Resident 1) was assessed for risk of substance abuse (a condition characterized by use of substances, such as illicit drugs, despite negative consequences) when the electronic medical record did not reflect a history of substance abuse and no nursing plan of care was initiated upon admission. This failed practice may have contributed to health hazards when Resident 1 tested positive for possible illicit drug use as manifested by a sudden change in vital signs, mental status, and a hospital emergency room admission.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect four of nine sampled residents (Resident 1, Resident 2, Resident 3, and Resident 4) to be free from abuse (verbal, mental, or physical abuse) when: 1. Resident 1 struck the left side of Resident 2's face on 3/10/25; 2. Resident 1 open handed slapped Resident 3's forehead on 3/18/25; 3. Resident 1 hit Resident 3's right ear on 3/24/25; and 4. Resident 4 had a verbal altercation with Resident 1 and Resident 4 kicked Resident 1's knee on 4/17/25. These failures removed Resident 1, Resident 2, Resident 3, and Resident 4's right to be free from abuse and had the potential to result in psychosocial outcomes.

Inspectors wroteBased on interview, and record review, the facility failed to ensure residents remained free from neglect when activities of daily living (ADLs, essential self-care tasks related to personal care such as dressing, eating, bathing, grooming, and toileting) were not provided for two of the three sampled residents (Resident 1 and Resident 2) when: 1. Certified Nursing Assistant (CNA) 1 left Resident 1 in a soiled incontinent (involuntary loss of urine or feces) brief (adult diaper, provides maximum absorbency for incontinence) for two hours; and, 2. CNA 1 left Resident 2 without completing incontinent care and CNA 1 slapped/tapped Resident 2's right leg with an open hand after Resident 2 asked CNA 1 to not touch her legs due to pain. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure two out of three sampled residents (Resident 1 and Resident 2) were safe from accidental hazards when Activity Assistant (AA) 1 gave an illegal substance (joint/gummie/marijuana/cannabis) to Resident 1 and Resident 2. This failure posed potential risks to Resident 1 and Resident 2's safety, potential drug interactions with prescribed medications, risk for falls, and changes in level of consciousness for Resident 1 and Resident 2.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to protect resident ' s right to be free from physical abuse by a resident for two of five sampled residents (Resident 1 and Resident 5) when: 1. Resident 2 splashed water on Resident ' s 1 face; and 2. Resident 2 spit on Resident 5. This failure resulted in Resident 1 feeling uncomfortable and had the potential to affect Resident 1 ' s and Resident 5 ' s psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to implement corrective action for one of five sampled residents (Resident 1) when the recommended services following a facility investigation related to a resident to resident physical abuse allegation when, the Interdisciplinary Team (IDT; a group of healthcare professionals) recommended a psychological evaluation (a comprehensive assessment of an individual's mental health and cognitive abilities conducted by a qualified mental health professional like a psychologist or psychiatrist) for Resident 1 following a resident-to-resident altercation that occured on 12/29/24 and Resident 1 had also requested a psychological evaluation, but the psychological evaluation was not initiated. This failure had the potential to negatively affect Resident 1's psychosocial well-being.

Inspectors wroteBased on interview, and record review, the facility failed to protect the rights of two residents (Resident 5 and Resident 6) to be free from unreasonable confinement when Certified Nursing Assistant (CNA 7) tied the room door with a garbage bag to prevent Resident 5 from leaving the room shared with his roommate (Resident 6). This failure had the potential to negatively impact Resident 5's and Resident 6's sense of dignity and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a sanitary and comfortable facility interior for two of two sampled bathrooms when, two jack and [NAME] bathrooms (a bathroom shared between two bedrooms, with doors entering from each room) that were intended for use for eleven residents (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8, Resident 9, Resident 10, and Resident 11) were noted in disrepair with large areas of peeling paint behind the toilet, an open gap behind the toilet, missing baseboards, and a chipped trim counter located at the front of the sink. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement and revise a person-centered care plan for one of two sampled residents (Resident 1) when, Resident 1's fall care plan interventions of a bedrail, call light within reach, and the bed in the low position was not implemented. This failure had the potential to be a safety risk which could result in Resident 1 falling, negatively impacting Resident 1's health and wellbeing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary conditions were maintained for food storage according to standards of practice and facility policy when: 1a. Resident drinking glasses were not clean; 1b. Utensils were stored in dirty utensil bins; 1c. A dirty vent was blowing into the food area; 2. Pantry contained expired foods; 3. Grilled cheese sandwiches were stored in the oven overnight and were available for resident consumption; 4. Food temperatures were not written down accurately on 12/11/24 for the breakfast meal; 5. Kitchen staff did not wear hair nets appropriately; 6. Incorrect portion sizes were plated for two residents (Resident 83 and Resident 22) for lunch on 12/11/24; and, 7. Lunch meal on 12/11/24 did not have safe food temperatures recorded. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure a process was in place to address and follow-up on resident concerns following Resident Council meetings (a gathering of residents who come together to discuss concerns, share information, and make decisions) for a census of 105. This failure resulted in multiple concerns from residents to go unresolved, with the potential to negatively impact their self-worth, self-esteem, and physical health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect resident rights to be free from mental and sexual abuse and misappropriation of property for 3 of 41 sampled residents (Unsampled Resident 2, Unsampled Resident 1, and Resident 17) when: 1. Resident 82, with a history of inappropriate sexual behavior towards male staff and Unsampled Resident 2, was left alone with Unsampled Resident 2 in the dining/activity room on 7/22/24, at approximately 4 a.m., and touched his private area without his consent; 2. Licensed Nurse (LN) 2 videotaped Unsampled Resident 2 with her personal cell phone, without Unsampled Resident 2's consent, and posted the video, along with disparaging comments about Unsampled Resident 2's sexuality on a group text message which included twenty-three facility licensed nurses and two other staff members on 9/11/24 at 4:59 a.m.; and, 3. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure proper hydration (process of providing fluid to the body) for three of 41 sampled residents (Resident 5, Resident 58, and Resident 89), per facility policy and each residents comprehensive plan of care when: 1. Resident 5 did not have available fluids to drink at bedside; and, 2. Resident 58 did not have available fluids to drink at bedside; and, 3. Resident 89 did not have available fluids to drink at bedside. These failures had the potential to result in altered hydration status, and complications associated with fluid imbalance (when the body loses or gains too much water/fluids) for Resident 5, Resident 58, and Resident 89.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure: 1. Controlled substance medications (medication with a high potential for abuse and addiction) were accurately accounted for on the medication administration record (MAR) and the Controlled Drug Record (CDR) for two of two randomly selected residents (Residents 85 and 101); 2. Ensure the availability of routine medication for 1 of 41 sampled residents (Residents 65); and, 3. Hazardous medications (hazardous drugs (or HD), drugs that pose short- or long-term harm upon exposure to humans via skin or inhalation per manufacturer specification) were not labeled and handled safely with appropriate accessory and cautionary instructions. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe medication administration practices when the medication error rate was more than 5% (% or percentage- number or ratio that expressed as a fraction of 100) with a resident census of 105. Medication administration observations were conducted over multiple days, at varied times, in random locations throughout the facility. The facility had a total of five errors out of 33 opportunities which resulted in a facility wide medication error rate of 15.15% in 3 out of 10 residents (Resident 16, Resident 58, and Resident 65) observed for medication administration. These failures may result in unsafe medications use affecting residents' health and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled and stored in accordance with currently accepted professional principles for a resident census of 105 when: 1. Expired and used single-use medications were identified in medication carts and storage rooms; 2. Medications with shorter expiration dates after first use were not labeled with opened dates; 3. Medications requiring refrigeration were stored at room temperature; 4. Prescription medications with incomplete or missing labels were available for use in facility stock; and, 5. A treatment cart was left unlocked in the hallway during wound care. These failures could contribute to unsafe medication use, storage, and result in medication errors that could affect the well-being of the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to practice appropriate infection prevention and control measures for a census of 105, when: 1. Resident 5, Resident 38, Resident 56 and Resident 48 had visibly soiled curtains in their rooms; 2. Resident 50, Resident 55 and Resident 75 had a missing bathroom vent cover (covering holes from the ventilation system); 3. Treatment Nurse (TN) did not perform hand hygiene when gloves were removed after wound care; 4. The facility did not ensure glucometers (device to measure blood sugar) were cleaned and sanitized; 5. The facility did not clean, sanitize, and disinfect an automatic blood pressure machine (a device to measure a person's blood pressure), after resident use; 6. The facility did not clean, sanitize, and disinfect the pill cutter (a device used to split a pill); and, 7. [...]

Inspectors wroteBased on interview, and record review, the facility failed to provide documented evidence of education for immunizations (a process whereby a person is made resistant to a disease by the administration of vaccines (shots)) when five of five sampled residents (Resident 34, Resident 31, Resident 69, Resident 38, and Resident 85) clinical records did not contain documented evidence of education for receiving or refusing the COVID-19 (an infectious disease caused by the SARS-CoV-2 virus) vaccination. This failure had the potential for Resident 34, Resident 31, Resident 69, Resident 38, and Resident 85 to not be aware or informed of the benefits, risks, and potential side effects of the COVID-19 vaccination prior to receiving or declining the vaccination.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure there was a functioning call light system (system/device used by residents to call staff for assistance) for five of 41 sampled residents when: 1. Resident 35 did not have a functioning call light and an alternative means to call for assistance was not provided; and, 2. Resident 36 did not have a functioning call light; and, 3. Resident 5 did not have a functioning call light; and, 4. Resident 50 did not have a functioning call light and an alternative means to call for assistance was not provided; and, 5. Resident 58 did not have a functioning call light. These failures had the potential to result in Resident 35, Resident 36, Resident 5, Resident 50, and Resident 58 being unable to call staff for help when needed, and their physical and emotional needs not being met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have an effective pest control program for six of forty-one sampled residents (Resident 36, Resident 50, Resident 55, Resident 75, Resident 84, Resident 100) when multiple live cockroaches were observed on the counter and floor in the residents' shared bathroom (three residents in each room with a shared bathroom between the rooms). This failure had the potential to spread a variety of diseases and bacteria throughout the facility to its residents, staff, and visitors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1of 41 sampled residents (Resident 26), was treated with dignity and respect when a staff member stood over Resident 26 while assisting Resident 26 with the lunch meal. These failures had the potential to negatively impact feelings of self-worth and self-esteem for Resident 26 and posed a safety issue.

Inspectors wroteBased on interview, and record review, the facility failed to accurately maintain confidential medical information for 1 of 41 sampled residents (Resident 109), when Resident 109's progress notes were uploaded into Resident 110's medical chart. This deficient practice increased the potential for Resident 109's privacy and confidentiality of personal medical information to be violated.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a home-like environment for 1 of 41 sampled residents (Resident 51), when Resident 51's room did not have a curtain to the sliding glass door, and the screen for the sliding glass door was propped outside of the room. This failure resulted in Resident 51 expressing feelings of dissatisfaction with the facility, with the potential to negatively impact feelings of self-worth and self-esteem.

Inspectors wroteBased on interview and record review, the facility failed to report the results of an investigation into an alleged resident-to-resident abuse incident to the Department, within 5 working days for two of 41 sampled residents (Resident 3 and Resident 79). This failure had the potential for the alleged abuse to reoccur and prevented the Department from initiating possible necessary action to protect Resident 3, Resident 79, and other residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to develop a Comprehensive Care Plan (outlines a resident's care goals, interventions, and expected outcomes) for 3 of 41 sampled residents (Resident 52, Resident 89, and Resident 88) when: 1. A safety care plan was not developed for Resident 52 after Resident 52 left the faciity on 8/29/24 with an unauthorized caregiver without the facilities knowledge, was discovered at the hospital on 9/2/24, and was re-admitted to the facility again on 10/2/24; 2. Resident 88 did not have a hospice (special care given at the end of life) care plan in place; and 3. Resident 89 did not have a care plan developed to monitor for side effects and treatment of target behaviors related to the use of a medication called quetiapine (a medication to treat bipolar disorder-a serious mental illness). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure activities of daily living (ADL) were provided to maintain good hygiene for one of 41 sampled residents (Resident 56) when Resident 56's fingernails were long with sharp edges and contained a dark brown and yellow substance under the fingernails. This failure resulted in Resident 56's nails not being groomed, and the potential for injury due to sharp edges, and infection from harboring microorganisms (bacteria, virus, or fungus).

Inspectors wroteBased on observation, interview, record review, the facility failed to provide care and services for 1 of 41 sampled residents (Resident 50), when Resident 50 did not have a means to be mobile within the facility and was not fitted or provided a wheeled device to use. This failure had the potential to limit Resident 50's mobility within the facility, cause physical limitations and decline, and negatively impact his psychosocial (the mental, emotional, social, and spiritual effects of a disease) well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement interventions to manage pressure ulcers (areas of damaged skin caused by staying in one position for too long) for one of forty-one sampled residents (Resident 13), when Resident 13's pressure ulcer intervention of a wedge (a specially shaped pillow used to lift a specific part of the body off the bed to reduce pressure) was not replaced when the wedge was first identified as missing. This failure had the potential to further worsen Resident 13's pressure ulcer on his back.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of forty-one sampled residents (Resident 50 and Resident 100) who had contractures (a permanent shortening of muscle, tendon, or scar tissue producing deformity or distortion) of their hands were wearing their hand splints as ordered by the physician, when, 1. Resident 50 had a physician order for a right hand splint (providing support and stability for the contracture area), dated 1/26/23, but never received it; and, 2. Resident 100 had a physician order for a brace for a hand contracture, dated 7/22/24, but never received it. These deficient practices placed the residents at risk of further loss of function and decline of their hand contractures.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure six of forty-one sampled residents were free from accidents and hazards when: 1. The facility did not provide adequate supervision to prevent an unauthorized care giver from taking Resident 52 without the facility's knowledge after the caregiver attempted twice to take Resident 52 out of the facility on 8/9/24 and 8/12/24; 2. Resident 51 did not have a safe and functioning mobility device installed in the bathroom. 3. The wanderguards (an alarm monitoring system) for four residents (Resident 91, Resident 60, Resident 79, and Resident 104) were not tested per manufacturers specifications. a. Resident 60 b. Resident 79 c. Resident 61 d. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respiratory care provided was consistent with professional standards of practice for 2 of 41 sampled residents (Resident 14, and Resident 69) when an oxygen in use sign was not posted outside of the rooms for Resident 14 and Resident 69. These failures had the potential to result in negative impacts on the residents' health and safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate pain management for one of 41 sampled residents (Resident 56) when Resident 56's pain medication was not given in a timely manner. This failure led to Resident 56 experiencing unnecessary pain and potentially affected his physical and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate behavioral health treatment and services to meet the psychosocial needs for one of forty-one sampled residents (Resident 50), when Resident 50 displayed episodes of anger and was refusing his treatments and medications, including his antipsychotic medication, and the resident's psychological evaluation (a comprehensive evaluation focused on the diagnosis, treatment and prevention of mental, emotional and behavioral disorders) and/or consultation was not provided as ordered by the physician on 10/29/22, 3/8/23, and 10/18/24. This deficient practice had the potential to negatively affect the Resident 50's psychosocial (the mental, emotional, social, and spiritual effects of a disease) well-being.

Inspectors wroteBased on interview, and record review, the facility failed to ensure 1 of 41 sampled residents (Resident 89), was free from unnecessary psychotropic (drugs that affects brain activities associated with mental processes and behavior) medication when Resident 89 received Seroquel (an antipsychotic to treat mental illness) without prescriber-documented rationale, attempted gradual dose reductions (GDR, a tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued), or implementation of non-pharmacological (non-drug) interventions in an effort to lower the dose or discontinue the medication. This failure had the potential to result in unnecessary use of medication.

Inspectors wrote1. Based on interview, and record review, the facility failed to ensure 2 of 11 residents (Resident 33 and Resident 88) who received hospice care (end of life care) had their care coordinated between the facility and the hospice agency. These failures could have resulted in a failure to provide quality care to terminally ill residents (Resident 33 and Resident 88).

Inspectors wroteBased on interview and record review, the facility failed to ensure four of five sampled residents (Resident 34, Resident, 31, Resident 38, and Resident 85) received vaccine (a process whereby a person is made resistant to a disease by the administration of vaccines) education when residents were offered or declined the Pneumococcal (vaccine to prevent pneumonia) and Influenza (a contagious respiratory illness cause by influenza viruses) vaccines, and failed to offer one of five residents (Resident 69) the influenza vaccine, when: 1. The facility did not provide education, regarding the benefits and potential side effects of the Pneumococcal or Influenza vaccines for Resident 34; 2. The facility did not provide education regarding the benefits and potential side effects of the Influenza vaccine for Resident 31; 3. The facility did not offer the Influenza vaccine to Resident 69; 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to practice appropriate infection prevention and control measures for one of four sampled residents (Resident 1), when a staff member did not wear appropriate Personal Protective Equipment (PPE- refers to protective clothing, gloves, face shields, goggles, face masks and/or respirators or other equipment designed to protect from injury or the spread of infection) while providing care to Resident 1 who was on Enhanced Barrier Precautions (EBP- a set of infection control practices that use gowns and gloves to reduce the spread of multidrug-resistant (difficult to treat) organisms). This failure had the potential to spread infections to residents residing in the facility, negatively impacting their health and well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure their staff provided quality care according to standards of practice for one of four sampled residents (Resident 1) when; 1. The facility's health care providers did not ensure the facility received and reviewed Resident 1's discharge summary from [ACUTE CARE HOSPITAL NAME] on 8/29/24, 9/5/24, 9/28/24, 10/1/24, and 10/21/24 and the facility did not inquire if a urine culture and sensitivity (test the urine to see which antibiotic would be useful to fight the specific bacteria) test was completed on 8/29/24 and 10/2/24 while Resident 1 was at [ACUTE CARE HOSPITAL NAME]. 2. The facility's staff did not follow up in a timely manner for Resident 1's Gastroenterology (the study of diseases of the esophagus, stomach, small intestine, colon and rectum, pancreas, gallbladder, bile ducts and liver) consult. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure infection prevention procedures were followed for three of five sampled residents (Resident 1, Resident 2, and Resident 3) when: 1. Resident 3 tested positive for Covid-19 (a potentially serious respiratory illness) on 8/17/24, and was not placed on isolation (precautions taken to prevent spread of disease) until 8/19/24; 2. The facility admitted Resident 2 into Resident 3 ' s room on 8/17/24, and Resident 2 did not have Covid-19; and, 3. The facility did not ensure testing following exposure to Covid-19 was carried out for Resident 1 and Resident 2, who shared a room with Resident 3, and were exposed to the disease for two days. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a change in condition and needs were addressed for one of three sampled residents (Resident 3) when Resident 3 tested positive for COVID-19 (a potentially serious respiratory illness) on 8/17/24, required isolation (precautions taken to prevent spread of disease), and the facility did not develop a care plan. This failure placed Resident 3 at risk for disease progression, spread of infection to other residents in the facility, and reduced care from staff. Findings A review of Residents 3 ' s admission RECORD indicated Resident 3 ' s diagnoses included Palliative Care (care focused on providing comfort) and Dementia (a condition that affects thinking, reasoning, decision making, and emotions). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide written notification of a room change for eleven of eleven sampled residents (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8, Resident 9, Resident 10, and Resident 11), when: 1. Resident 1, Resident 3 and Resident 4 were moved to another room on 7/29/24 without a written notification including the reason for the move and had no documentation of notice of room change in their record, 2. Resident 7's responsible party (RP) was not provided written notification of Resident 7's room change on 7/29/24, and 3. Resident 2, Resident 5, Resident 6, Resident 8, Resident 9, Resident 10, and Resident 11 were moved to another room on 7/29/24 without advanced verbal or written notification of room change to their RPs. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet the needs of one of four sampled residents (Resident 2) when a medication for Resident 2 was not ordered and administered for five days. This failure had the potential to cause a rash to spread further throughout the body.

Inspectors wroteBased on interview, and record review, the facility failed to provide rehabilitation services and treatment for one of four sampled residents (Resident 1) when a speech therapy (ST) evaluation and treatment was not completed as ordered by the doctor. This deficient practice resulted in delayed treatment and services for Resident 1 and placed the resident at higher risk for further decline.

Inspectors wroteF-688 Based on interviews and record reviews, the facility failed to ensure services to prevent loss of mobility ordered by physician, were provided by restorative nursing assistants (RNA) to three of ten residents receiving RNA services (Resident 1, Resident 2, and Resident 3) when there was limited or no documented evidence of RNA services received, and there were insufficient RNA staff to provide the needed services. Based on interview and record review, the facility failed to ensure services to prevent loss of mobility ordered by a physician, were provided by restorative nursing assistants (RNA) to three of ten residents receiving RNA services (Resident 1, Resident 2, and Resident 3) when there was limited or no documented evidence of RNA services received, and there were insufficient RNA staff to provide the needed services. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure appropriate treatment and services were provided to one of three residents (Resident 3), when the restorative nursing assistant (RNA, a program that helps residents improve quality of life by increasing their level of strength and mobility) services were not implemented per the physician's order. This deficient practice had the potential to result in Resident 3's decline in range of motion (ROM-the range of joint movement).

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was treated with dignity and respect when a Certified Nursing Assistant (CNA 6 ) sat on the lap of Resident 1's family member and made inappropriate remarks towards while the family member was visiting Resident 1. This failure had the potential to negatively impact the psychosocial wellbeing of Resident 1 and her family.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's right to be treated with dignity and respect was honored for one of six sampled residents (Resident 2) when a Restorative Nurse Assistant (RNA) answered Resident 2's call light (device used by residents to call for assistance) but did not follow up on her request to the nurse. Resident 2 waited a total of 47 minutes for the nurse to attend to her needs. This failure had the potential to negatively impact Resident 2's psychosocial well-being and physical health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper infection control practices were performed for two residents (Resident 1 and Resident 3) of seven sampled residents when: 1. Resident 1 was observed in the dining room with an exposed urinary catheter drainage bag (a bag that collects urine from the tubing connected to the bladder) filled with yellow fluid and was touching the floor below his wheelchair; 2. Resident 3 ' s room did not have the proper contact-based precaution sign to alert staff and visitors of the required Personal Protective Equipment (PPE) to be used upon entry and provision of care; 3. Certified Nurse Assistant 1 (CNA 1) did not use proper PPE (a gown and gloves) during the transfer of Resident 3 to a wheelchair; and 4. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure an Infection Preventionist (IP) was available to dedicate the time required to meet all the requirements of the position. This failure decreased the facility's potential to prevent the spread of infection among staff and residents. (Cross Reference F880) In an interview on 12/12/23 at 12:04 p.m. with Assistant Director of Nursing (ADON), the ADON stated the facility ' s former IP abruptly resigned yesterday and the Director of Staff Development (DSD), who was hired on 12/11/23 was IP certified. In an interview on 12/12/23 at 12:05 p.m., the DSD stated he was IP certified and had some prior IP experience; however, he was not able to provide a full list of residents currently on isolation at the facility. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a safe, comfortable and sanitary environment for the facility census of 109 when: 1. Multiple restrooms in resident rooms were observed with cracks on the linoleum floor with yellow-black deposits; 2. The south wing shower room had broken, loose, and exposed floor tiles with sharp edges; 3. Resident 4 did not have running hot water in her restroom; and, 4. Resident 5 did not have a fully functioning bed controller. These failures decreased the facility ' s potential to provide residents a homelike environment.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure an electrical breakdown was fixed in a timely manner for 1 of 3 sampled residents (Resident 1) when electrical sparks and smoke from a power source was noted in his room and close to his bed and was not fixed until the following day, 13 hours later. Resident 1 shared the room with Resident 2 and Resident 3. This failure had the risk potential to result in electrical fire. Additionally, Resident 1 remained in a bed that could not be adjusted to his comfort until the power connection was repaired 13 hours later.

Inspectors wroteBased on interview and record review, the facility failed to provide the services of a full time Director of Nursing (DON) to effectively guide and direct nursing care. This failure decreased the facility's potential to provide accurate and safe care per nursing professional standards for a census of 109 residents.

Inspectors wroteBased on interview, and record review, the facility failed to ensure a request for resident records was fulfilled in a timely manner for one of three residents (Resident 3) when an outside agency's written request for medical records on 9/27/23, on behalf of Resident 3, was not fulfilled within two working days. This failure resulted in a delay of receipt of the specified requests for Resident 3 and denied the resident's right to their medical record request being honored in a timely manner.

Inspectors wroteBased on interview, and record review, the facility failed to ensure professional standards of practice were followed for two of three sampled residents (Resident 1 and Resident 2) when: 1. Resident 1's Physician Orders for Life Sustaining Treatment (POLST - a document which directs which type of treatment a patient wants in case of an emergency) was not signed by the resident, the resident representative, or the attending physician; and, 2. Resident 2's POLST was not signed by the resident or the resident representative. These failures had the potential for Resident 1 and Resident 2's wishes and/or preferences to not be followed regarding their option to receive or not receive life sustaining treatment.

Inspectors wroteBased on interview and record review, the facility failed to accurately complete Resident 1's Wandering Assessment (a rating system to assess risk for wandering: low, moderate, or high) for 1 of 17 residents (Resident 1), after Resident 1 eloped (a vulnerable resident who leaves a facility unnoticed) from the facility on 9/16/23. This failure resulted in Resident 1 receiving an inaccurate Wandering Assessment score on 9/16/23 and could have resulted in inadequate supervision which could have led to resident injury or death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate supervision for 1 of 17 residents (Resident 1) at risk for elopement (a vulnerable resident who leaves a facility unnoticed) when, Resident 1 left the faciity on September 16, 2023, through a nonfunctioning alarmed door, without the staff 's knowledge. This failure jeopardized the health and safety of Resident 1, which could have resulted in injury or death.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide adequate supervision to ensure the safety for one of seven residents identified at risk for wandering (Resident 1) when he left the facility unsupervised, wandered to a busy street, was found by a bystander who called the police, and the resident was taken to the hospital. This failure had the risk potential to jeopardize Resident 1's health and safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain its Infection Prevention and Control Program for a census of 116 residents when: 1. Licensed Nurse did not clean and sanitize a glucometer (a device that measures the level of sugar in the blood) after each resident use, based on standards of practice and manufacturer recommendation for Resident 27, and Resident 82. 2. The laundry services staff stored clean clothes and linens in the dirty area of the laundry room; 3. The facility did not develop a water management program used to prevent the build up and spread of waterborne pathogens (bacteria, viruses, microorganisms that can cause diseases); and, 4. [...]

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 116 residents when there was no evidence of a system for documenting and monitoring trends in antibiotic use in the facility in accordance with their Antibiotic Stewardship Program. This failure increased the potential for inappropriate antibiotic therapy resulting in the development of antibiotic resistant bacterial infections.

Inspectors wroteBased on observation, interview and record review, the facility failed to complete a quarterly care conference (a meeting which provides opportunities for the residents and/or their representative, and professional disciplines to revise the residents' care plans) for 2 of 43 sampled residents (Resident 16 and Resident 63). These failures had the potential for unmet care needs for Resident 16 and Resident 63.

Inspectors wroteBased on observation, interview, record, and facility policy review, the facility failed to provide restorative (RNA-nursing intervention to increase or maintain resident's mobility and to prevent further decline in mobility) treatment and services to three of 43 sampled residents (Resident 35, Resident 65, and Resident 102) when: 1. The recommendation from the Occupational Therapy for restorative nursing services was not carried out for Resident 35; and, 2. Restorative nursing care was not implemented in a timely manner for Resident 65 and Resident 102. These failures placed Resident 35, Resident 65, and Resident 102 at risk for not maintaining their highest practicable level of range of motion (ROM-the degree of movement that occurs at a given joint during an exercise) and mobility functioning.

Inspectors wrote2. A review of Resident 20's admission Record indicated Resident 20 was admitted to the facility in the Fall of 2021. A review of Resident 20's medical health record titled, Social History, dated 4/15/22, indicated, .Smoking history .SMOKES CIGARETTES . A review of the facility document titled, [Facility Name] RESIDENT SMOKING LIST, dated 11/28/22, indicated there were eighteen residents who were considered smokers in the facility. Further review of the document indicated, .[Resident 20's name] . During an observation on 12/7/22, at 1:55 p.m., Resident 20 was observed to be smoking a cigarette while seated in her wheelchair outside in the designated smoking area next to a male resident. When asked, Resident 20 stated she did not use a smoking apron. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Address weight loss in a timely manner for two residents, Resident 57 and Resident 77; and, 2. The facility did not ensure the kitchen had a diet supplement order for Resident 77. These failures had the potential to increase the weight loss for Residents 57 and Resident 77, negatively impacting their health and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate care and services for two of seven residents (Resident 3 and Resident 16) 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 3's tube feeding bottle was not changed in 24 hours and the same bottle was used the following day with Resident 3 receiving inadequate caloric intake; 2. Resident 16's tube feeding bottle label did not indicate the name of the resident, room number, date, start time of the feeding and the rate of the feeding; and, 3. Resident 16's head of bed (HOB) was not elevated to an angle of 30 to 45 degrees (unit of measurement) while the resident was receiving their tube feeding. [...]

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 116 when: 1. Oxygen in use signs were not posted outside of the rooms for Resident 19 and Resident 50, 2. Oxygen therapy was provided without a physician order for Resident 50; and, 3. The oxygen flow rate was not followed per physician order for Resident 19. 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 interview and record review, the facility failed to ensure a specific psychiatric diagnosis (mental health illness) and associated behaviors which could endanger a resident or others, were documented in the medical record based on standards of practice and the facility's policy, for three of seven sampled residents (Resident 20, Resident 37, and Resident 39) when: 1. Resident 20's medical record did not have a specific diagnosis for use of mind-altering medication called risperidone (or also known as Risperdal, a medication used for mental health). 2. Resident 37's medical record did not have specific diagnosis for use of mind- altering medication called quetiapine (also known as Seroquel, a medication used to treat mental health) and resistive to care was listed as the targeted behavior for monitoring when it did not pose harm to resident or others. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and prepare foods in accordance with professional standards for food safety for 109 residents who received food from the kitchen when: 1. There was no air gap (a break in the plumbing to prevent unsanitary water from flowing back into the sink) under the food preparation sink, under the ice machine and under the dishwashing sink; 2. Dry food items were found undated, unlabeled and/or expired; and, 3. Kitchen appliances were not cleaned. These failures had the potential to contribute to foodborne illnesses among residents who received meals from the kitchen.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure the call light system (a system that provide direct communication from the resident to the staff to call for staff assistance) was functioning for one of 43 sampled residents (Resident 260) when the light outside the room above the door was not working and no alternative device was provided to call staff for assistance. This failure had the potential for unmet needs and delayed care for Resident 260.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of 43 sampled residents (Resident 261) was treated with respect and dignity, when Resident 261 was uncovered on an unmade mattress on the floor, with the curtain and door left open, and without a means to call for help or communicate his needs for assistance. This failure had the potential to result in psychosocial harm.

Inspectors wroteBased on interview and record review the facility failed to ensure a schizophrenia (a mental disorder in which people interpret reality abnormally and may result in hallucinations, delusions, and extremely disordered thinking and behavior) diagnosis for antipsychotic medication (mind and mood-altering medication) use was accurately documented and/or followed the standards of practice (a professional guide for healthcare) and the facility's policy in one out of 43 sampled residents (Resident 62). This failure could contribute to unsafe medication use and adverse effects of mind-altering medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure adequate treatment and services were provided for one of 43 sampled residents (Resident 13) when: Resident 13 was not monitored for signs and symptoms (s/s) of low or high blood sugar irregularity and how to manage those s/s while on five anti-diabetic medications (drugs to help the body to lower blood glucose [sugar] levels). This failure had the potential to place Resident 13 at risk for hypo/hyperglycemia (blood sugar level lower or higher than the standard range) to be unrecognized and untreated.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure hazardous medication (medications that may pose a health hazard when not handled appropriately) were safely handled by nursing staff during medication administration based on manufacturers specifications and nursing standards of practice. This failure may result in unsafe medication handling and chemical exposure to nursing staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe medication storage practices in one out of three medication storage areas when: 1. The refrigerated Emergency kit (E-Kit, a sealed and labeled medication box for emergency use) contained an outdated vial of Insulin (a medication for high blood sugar) and the E-Kit par level (amount of medication expected to be in the E-Kit) was less than expected and had not been replaced by the provider pharmacy in five months. 2. The medication refrigerator had excessive ice accumulation or frost around the freezer portion of the refrigerator, and it touched the container of Glargine Insulin (a long-acting form of blood sugar medication) which could render the medication ineffective. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a comprehensive facility assessment that included all required elements for a census of 116. This failure had the potential to result in the inability of the facility to provide the necessary care and services required of its resident population.