Olympic View Post Acute

Inspectors wroteBased on interview and record review, the facility failed to ensure specialized rehabilitative services were provided as ordered for 1 of 4 residents (Resident 24) reviewed for rehabilitation services. This failure delayed residents from attaining, maintaining, or restoring their highest practicable level of physical, mental, functional, and psycho-social well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent 3 of 3 residents (Resident 1, Resident 2, and Resident 3) from experiencing neglect from nursing staff. This failure placed residents at risk for injury, unmet care needs, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to make a reasonable effort to uncover information about prospective employees by not completing reference checks for 3 of 3 employees (Staff D, Staff E, and Staff F) reviewed for implementation of abuse and neglect policies. This failure placed residents at risk for unmet care needs and services and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to prevent 4 of 4 residents (Resident 1, Resident 2, Resident 3, and Resident 4) from experiencing sexual abuse and or neglect at the hands of staff and or of other residents. This failure placed residents at risk of injury, psychosocial harm, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to honor food preferences for 2 of 3 residents (Resident 2 and Resident 3) reviewed for dietary services. The facility also failed to provide alternative foods and failed to provide foods that were on the menu. These failures placed residents at risk for an unsatisfactory meal experience and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to prevent, and appropriately intervene for, verbal abuse and neglect received from a staff member for 1 of 3 residents (Resident 1) reviewed for abuse. This failure placed residents at risk for emotional distress, fear, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the hot water used for beverage(s) were at a safe temperature for 1 of 3 residents (Resident 1) reviewed for accidents hazards. Resident 1 experienced harm when staff served them hot water directly from the dispensing machine without checking the temperature; the hot water spilled on the resident that resulted in a burn with blistering to the midline of their abdomen with reported pain and required wound care. This failure placed residents at risk for serious injury related to scalding and burns.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide necessary assistance with personal hygiene in a timely manner and in accordance with resident preferences for 2 of 3 residents (Residents 2 and Resident 3) reviewed for quality of care. This failure placed residents at risk for un-met care needs, feelings of neglect, and discomfort.

Inspectors wroteBased on interview and record review, the facility failed to establish an Infection and Control Program (IPCP) that included: developing an antibiotic stewardship program, to promote appropriate use of antibiotics and reduce the risk of unnecessary antibiotic use, including the development of antibiotic resistance. This failure placed residents at risk for potential adverse outcomes associated with the inappropriate/unnecessary use of antibiotics.

Inspectors wroteBased on interview and record review, the facility failed to ensure there was a designated and qualified Infection Preventionist (IP) responsible for the facility's Infection Control Program. This failure placed residents at risk for unmet infection control issues or care needs. Finings included .On 02/04/2026 at 3:15PM, Staff B, Director of Nursing Services, DNS, said Staff C, Registered Nurse (RN), had been assigned the role of IP since December of 2025. Staff B was unable to provide any information on the facility's Infection Prevention and Control Program. On 02/04/2026 at 3:37PM, Staff C, RN, said they were assigned two roles, Wound Care Nurse and IP. Staff C said they had graduated from nursing school just a few months prior and did not have any infection control experience other than nursing school. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive Infection Prevention and Control Program (IPCP) based on facility specific and community-based risk assessment. The facility failed to timely prevent, identify, and respond when Resident 1 exhibited respiratory symptoms, which significantly contributed to the spread of illness as Residents 2, 3, 4, & 5 subsequently tested positive. This deficient practice placed residents at risk for illness and outbreak transmission.

Inspectors wroteBased on observation and interview, the facility failed to ensure a resident's room was clean, free of potentially infectious bodily fluids, and free of a potential fire hazard for 1 of 3 residents (Resident 1) reviewed for a safe, sanitary, and homelike environment. This failure placed residents at risk for illness, fire and or burns, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents received necessary nursing assessment, monitoring, and/or care when licensed nursing staff were not actively involved in the assessment or management of residents' wounds and a change in condition and unlicensed medication or nurse technicians performed wound care and assessments without nursing oversight, resulting in complications and hospitalizations for 2 of 2 residents (Resident 1 and Resident 2) reviewed for care and services. Resident 1 experienced harm when their bilateral lower extremity wounds became infected, the resident had a change in consciousness and required transfer to the hospital where they were diagnosed with severe sepsis with organ disfunction (life-threatening whole-body response to infection). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure timely pharmacy services by not having a system in place to obtain ordered antibiotics in a timely manner, resulting in a delay in administration of prescribed antibiotics for 1 of 3 residents (Resident 1) reviewed for care and services. This placed resident at risk of prolonged infection, delay in care and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to notify the Power of Attorney and or Legal Guardian of significant changes for 1 of 3 residents (Resident 1) reviewed for significant changes. This failure placed responsible parties at risk for not being able to make informed decisions.

Inspectors wroteBased on observation, interview and record review the facility failed to provide ordered pain-relieving interventions in a timely manner for 1 of 3 residents (Resident 1) reviewed for pain management. This failure placed residents at risk for unmet needs, anxiety, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to involve the resident's representative in the development of the resident's plan of care, inform the representative of changes in the plan of care and review the plan of care for 1 of 3 (Resident 1) residents reviewed. This failure placed residents at risk of lack of advocacy for their healthcare needs, preferences and medical history.

Inspectors wroteBased on interview and record review the facility failed to obtain and monitor laboratory tests timely per physician orders for 1 of 3 residents (Resident 1) reviewed. This failure placed residents at risk of clinical complications, unstable medical conditions and delayed recovery.

Inspectors wroteBased on observation and interview, the facility failed to provide a safe and sanitary environment for residents and staff related to shower rooms, utility rooms, and equipment storage rooms. This failure placed residents and staff at risk for injury, cross contamination (process by which bacteria or other microorganisms are transferred from one subject or object to another), and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident or resident representatives' right to make healthcare choices was upheld. Specifically, the facility did not provide the resident's representative with adequate information or involvement in decision making related to care and treatment for 1 of 3 residents (Resident 1). This failure placed residents and their representatives at risk of not being able to make informed decision regarding care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the appropriate care and services for 2 of 3 residents (Resident 1 and Resident 2) reviewed for indwelling catheter (a flexible tube inserted into the bladder to drain urine) care and maintenance. Resident 1 experienced harm when their indwelling suprapubic urinary catheter was not changed monthly as ordered and required hospitalization due to catheter related complications. This failure placed residents with indwelling catheters at risk of medical complications.

Inspectors wroteBased on interview and record review, the facility failed to report and investigate an incident of potential neglect for 1 of 1 resident (Resident 1) reviewed for hospitalization related to a preventable complication of a suprapubic catheter. This failure limited the opportunity for the facility to identify and correct system failures that contributed to the residents' decline.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure informed consent was obtained prior to administering psychotropic medications, and/or ensure consent forms accurately identified the type of medication (drug class) and associated risks and benefits of use for 3 of 5 residents (Resident 62, 48, & 28) reviewed for unnecessary medications. These failures placed residents and/or their representatives at risk of not being fully informed about the care and treatment related to the risks and benefits associated with end-of-life care and psychotropic medications and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were included in care conferences and discussions on their person-centered plans of care for 7 of 18 sampled residents (Resident 58, 56, 37, 15, 24, 45, & 28). This failure placed residents at risk of having services discontinued or started without being fully informed or involved, not having preferences honored at end of life, and unidentified/unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free of chemical restraints for 5 of 6 residents (Residents 39, 62, 48, 28 and 56) reviewed for unnecessary medications or pain. The failure to ensure psychotropic medications (drugs that affect behavior, mood, thoughts and perception) had adequate indications for use, resident specific target behaviors (TB) were identified and monitored, gradual dose reductions (GDRs) were performed, non-drug interventions were attempted prior to administration of as needed (PRN) psychotropic medications, and PRN psychotropic medication orders did not exceed 14 days unless a documented clinical rationale was provided, placed residents at risk of receiving unnecessary psychotropic medications, experiencing adverse side effects such as sedation, decline in physical function, and other negative health outcomes.

Inspectors wroteBased on interview and record review, the facility failed to provide written bed hold notices at the time of transfer to the hospital for 2 of 4 sampled residents (Residents 19 and 39) and ombudsman notification for 3 of 4 sample residents (Residents 19, 75 & 39) reviewed for hospitalization. This failure placed the residents at risk for lack of knowledge regarding their right to hold their bed while in the hospital, protection of resident rights during transfers, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide residents with care plans that were comprehensive, individualized and person centered, updated, and/or accurate for 11 of 18 sampled residents (Residents 28, 56, 45, 63, 39, 127, 20, 16, 37, 15, & 24) reviewed. This failure placed residents at risk of unidentified and unmet care needs, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were free from unnecessary medications by providing and documenting on non-pharmacological interventions (NPI) for pain management, having parameters for medications, and/or using non-opioid medications for 4 of 6 residents (Residents 56, 37, 40 & 48) reviewed for unnecessary medications or pain. This failure placed residents at risk of medication tolerance, increased pain, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to store food for residents in accordance with professional standards for 2 of 2 nursing station refrigerators (East, West) reviewed for food service safety. The failure to maintain documented refrigerator temperature logs placed residents at risk of foodborne illness (caused by the ingestion of contaminated food or beverages), unsanitary conditions, and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure the binding arbitration agreements (legal document that required the use of a third party to resolve disputes) were reviewed in a manner that explicitly informed the resident or their representative of what they were consenting to, or were understood in their entirety, for 3 of 3 residents (Residents 39, 126, & 127) reviewed for binding arbitration. This failure placed residents at risk for legal complications and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to show evidence of an ongoing, effective, comprehensive, data-driven Quality Assurance and Performance Improvement program (QAPI, a program that focused on the full range of care and services provided by the facility that included clinical care, quality of life and resident choice). The facility failed to provide evidence of documentation that demonstrated the development, implementation, and evaluation of a performance improvement activity for 1 of 1 sampled Process Improvement Projects (PIP) reviewed. The facility failed to provide evidence of the medical director participating in the QAPI program. This failure placed residents at risk for ongoing unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to have a system in place for maintaining documentation of staff screening, education, offering and current COVID-19 (a contagious disease caused by the coronavirus SARS-CoV-2) vaccination status for 12 of 12 months (May 2024 - May 2025) reviewed. These failures placed residents and staff at risk of contracting COVID-19, related complications and a diminished quality of life.

Inspectors wroteBased on interviews and record review, the facility failed to immediately notify the physician and resident representative of significant changes in physical condition, for 2 of 5 residents (Resident 15 & 28) reviewed for nutrition. This failure placed residents at risk for a delay in medical/nutritional treatment and not having their representatives involved in the health care decision making process for timely care and services.

Inspectors wroteBased on interview and record review the facility failed to comprehensively assess for the use of bed rails/mobility bars, the use of a bed against the wall, and a wander guard for 4 of 4 sample residents (Residents 19, 20, 3 and 24) reviewed for physical restraints. This failure placed residents at risk of potential injury, potential restraint, unmet care needs, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Pre-admission Screening and Resident Review (PASRR) assessment accurately reflected residents' mental health diagnoses for 2 of 5 sampled residents (Residents 62 & 48) reviewed for unnecessary medications. This failure placed residents at risk for inappropriate placement and/or not receiving timely and necessary mental health services to meet their mental health needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure services provided met professional standards of practice for 2 of 32 residents (Residents 127 & 20). Facility staff's failure to administer medications in accordance with physician's orders, and to complete assessments and treatments as ordered placed residents at risk for ineffective treatment of disease processes, medication adverse side effects and other potential adverse health outcomes.

Inspectors wroteBased on interview and record review, the facility failed to ensure the bowel protocol was implemented, bowel movements were monitored and/or documented on, for 2 of 6 residents (Residents 56 & 48) reviewed for unnecessary medication and constipation. This failure placed residents at risk of bowel obstructions, pain, and a diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to consistently provide weekly skin assessments and failed to implement supplements as recommended for wound healing for a pressure ulcer (PU, injury to the skin and underlying tissue due to prolonged pressure) for 1 of 2 sampled residents (Resident 24) reviewed for pressure ulcers. These failures placed residents at risk of developing avoidable pressure ulcers and/or delayed healing of pressure ulcers and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure intravenous (IV) services were provided in accordance with professional standards of practice for 1 of 1 resident (Resident 127) reviewed for IV therapy. The facility failed to provide Peripherally Inserted Central Catheter (PICC line, a long, thin tube that's inserted through a vein in the arm and passed through to the larger veins near the heart) care, maintenance and monitoring to include changing needleless injection caps, PICC dressing changes, measuring external length to verify the line had not migrated, and arm circumference to monitor for swelling. deep vein thrombosis. These failures placed residents at risk for loss of vascular access, infection, and other potential negative outcomes.

Inspectors wroteBased on interview and record review, the facility failed to have a system in place that ensured periodic reconciliation and accounting for all controlled medications, for 1 of 1 medication carts (East B cart) reviewed for narcotic records. The failure to consistently reconcile controlled medications at shift change and to co-sign the ledger to show both nurses validated the accuracy of the medication count, placed residents at risk for misappropriation of their medication and detracted from the facility's ability to promptly identify potential diversion.

Inspectors wroteBased on interview and record review, the facility failed to ensure 1 of 1 resident (Resident 127) reviewed for intravenous (IV) therapy, was free of significant medication errors. The failure to administer IV antibiotics at ordered times/intervals, placed residents at risk for ineffective treatment of infection, prolonged antibiotic therapy and associated adverse side effects.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications were stored at proper temperatures, dated when opened when required, and expired medications were discarded in accordance with professional standards of practice for 2 of 2 medication rooms (East and [NAME] Medication rooms) and 1 of 2 medication carts (West A cart) reviewed. This placed residents at risk of taking and/or receiving expired/outdated medications and biologicals.

Inspectors wroteBased on interview and record review, the facility failed to implement an Antibiotic Stewardship Program that ensured accurate and complete information (signs/symptoms) was collected monitored and/or documented on for 2 of 3 monthly infection line listings (a document that tracks resident infections) reviewed (February 2025 & April 2025). The facility also failed to implement a process for documenting on McGeer's Criteria (tool that provided criteria to show if antibiotics were indicated), that included provider notification, intervention implemented (if provider wanted to continue or stop the antibiotic and the reason for it), and an accurate list for tracking residents that did and did not meet criteria, for 1 of 1 residents (Resident 26) reviewed for McGeer's Criteria. [...]

Inspectors wroteBased on interview and record review the facility failed to initiate a resident grievance for 2 of 5 sampled resident (Resident 1 and 2) reviewed for grievances. This failure placed the residents at risk of not receiving a grievance resolution, a denial of personal rights and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure discharge planning included assessment of resident's ability to manage medications, prepare or have access to prepared meals, and to handicap accessible living quarters for 1 of 3 residents (Resident 1) reviewed for discharge planning. This failure placed residents at risk for unmet care needs, psychological distress, re-hospitalization, and a decreased quality of life.

Inspectors wroteBased on interviews, and record review, the facility failed to ensure baseline care plans were developed and implemented within 48 hours of admission and included the minimum information necessary to properly care for 4 of 4 sampled residents (Residents 1, 2, 3, and 4) when reviewed for care plans. This failure placed residents at risk for unidentified and/or unmet care needs, negative health outcomes, and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide care and services adequate to prevent hospitalization for 2 of 3 residents (Residents 1 & 2) reviewed for hospitalization. The facility failed to provide central line maintenance for Resident 1 resulting in hospitalization for a potential central line (also known as a central venous catheter (CVC), is a long, thin tube (catheter) inserted into a large vein to provide long-term access for fluids, medications, blood draws, and monitoring) blood infection and failed to adequately monitor Resident 2 (who was receiving nutrition via a feeding tube), following an episode of emesis, resulting in hospitalization for acute respiratory failure with hypoxia. These failures placed residents at risk for infection, hospitalization, and a diminished quality of life.

Inspectors wroteBased on observations and interview, the facility failed to ensure the resident audible call system was functioning properly and repaired timely for 2 of 4 resident halls reviewed for call light systems. This failure placed residents at risk for delayed staff response to potential emergencies and resident needs, falls, injury and decreased quality of life. An intake reported on 03/04/2025 at 3:32 PM, documented the facility's audible call light system was not working for rooms 1-17 and manual bells were provided for the residents. On 03/07/2025 at 11:35 AM, the call light to room [ROOM NUMBER] was observed and it was noted there was no audible alarm. At 4:15 PM, Staff A, Administrator, said the repair company had been there, and they had to order a part, it had not arrived yet. They had passed out bells to the residents effected. [...]

Inspectors wroteBased on interviews and record review, the facility failed to thoroughly investigate an injury for 1 of 3 residents (Resident 1) reviewed for accidents. Facility failure to complete thorough investigations placed residents at risk for further falls and injuries, potential abuse, and other negative health outcomes.

Inspectors wroteBased on interview and record review, the facility failed to ensure behavioral health care and services were provided for one of six sampled residents (Resident 2) reviewed for behavioral health services. This failure placed residents at risk for increased behaviors, not receiving necessary services to meet their mental health needs and a diminished quality of life.

Inspectors wroteBased on observation and interview the facility failed to maintain a safe, clean and comfortable environment through maintenance of the hallway carpets for 3 of 3 halls (East, Mid, and [NAME] B) observed. This failure has the potential to place residents at risk for not having a clean, homelike environment and a diminished quality of life.

Inspectors wroteBased on interviews and record review, the facility failed to ensure services provided met professional standards of practice for 1 of 4 sampled residents (Resident 1) reviewed for quality of care when facility staff 1. failed to assess, monitor and/or document resident responses to interventions on a daily basis for newly admitted residents receiving skilled services and 2. failed to obtain and document vital signs for residents at risk for sepsis (a life-threatening condition that occurs when the body's immune system has an extreme response to an infection. It can lead to organ failure, shock, and death). These failures placed residents at risk for rehospitalization, health complications, and decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide care in a manner that promoted respect and dignity for 2 of 5 residents (2, 3) reviewed for dignity and respect. This failure placed residents at risk for unmet needs, diminished self-worth, and continued episodes of disrespect.

Inspectors wroteBased on observation, interview and record review, the facility failed to consistently provide care and services as ordered for non-pressure wounds for 1 of 5 residents (1) reviewed for quality of care. This failure placed residents at risk for worsening wounds, infection, and decreased quality of life. Resident 1 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS), an assessment tool, dated 10/19/2024, documented the resident was cognitively intact, medically complex and had an infection and non-pressure wounds of the foot, requiring dressings. The care plan focus for right lower ulcer with gangrene (a serious condition that occurs when body tissue dies due to a lack of blood flow or a bacterial infection), initiated on 10/14/2024, included interventions to treat wound as per MD orders. [...]

Inspectors wroteBased on interview and record review, the facility failed to prevent the development of pressure ulcers (PU - injury to skin and underlying tissue resulting from prolonged pressure), perform/document regular skin assessments, and to consistently complete provider ordered wound care for 4 of 4 sampled residents (Residents 1, 2, 3, & 4) reviewed for pressure ulcers. These failures placed residents at risk for continued deterioration or pressure ulcers/injuries, infection and pain.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident representatives were notified of changes in condition for 2 of 4 sampled residents (1 and 2) reviewed for notification of changes when resident family members were not notified of new pressure wounds. This failure prevented the residents' representative from participating in discussions about resident care decisions and placed the residents at risk for delayed medical treatment, diminished quality of life, and increased pain.

Inspectors wroteBased on interview and record review the facility failed to provide care and services consistent with professional standards for 1 of 4 residents (Resident 2) reviewed for quality of care when the facility staff failed to document assessment and monitoring of the resident for latent injuries, resolution of injuries, and potential adverse side effects of medications for multiple incidents involving the resident. This failure placed all residents at risk for unmet needs, declining health, and decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 1 of 3 residents (Resident 1) reviewed for quality of care, was provided care, in accordance with professional standards of practice. The facility failed to secure an order for administration and monitoring for the continuous positive airway pressure (CPAP: an external device that provides a fixed pressure to keep breathing airways open while you sleep) therapy. This failed practice placed residents at risk for ineffective assisted ventilation, worsening health conditions, and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to obtain informed consents for 2 of 5 sampled residents (Residents 33 and 53) reviewed for psychoactive medications. This failure placed residents and/or legal representatives at risk of not being fully informed to make decisions about their medications prior to administration. Findings Included . <Resident 33> Resident 33 was admitted on [DATE] with diagnoses including anxiety disorder (excessive worrying and feelings of fear, dread, and uneasiness) and depression (feelings of hopelessness and persistent sadness). The 5 day Minimum Data Set (MDS), an assessment tool, dated 05/26/2024, showed the resident was cognitively intact and was independent to needing set up assistance with activities of daily living(ADLs). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to timely initiate and thoroughly investigate allegations of abuse, neglect, and/or misappropriation for 3 of 5 residents (Residents 23, 21 & 27) reviewed for abuse and neglect. The failure to immediately investigate an allegation of staff to resident abuse, identify the alleged perpetrator (AP), and implement interventions to ensure the alleged victims (AV) and other residents' safety, placed residents at risk for continued abuse/neglect, psychosocial harm, and decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) Level 2 comprehensive evaluations (the process to determine what types of mental health services are required after a Level 1 PASRR determined services were necessary) were obtained and/or implemented and incorporated into the care plan for 2 of 5 residents (Resident 17 and 18) reviewed for PASRRs. This failure placed residents at risk for not receiving necessary mental health care and services.

Inspectors wroteBased on observation and interview, the facility failed to ensure medications were stored, labeled, and dated when opened and/or discarded when expired for 1 of 1 medication room (East Medication) and 1 of 2 medication carts (East medication carts) observed. These failures placed residents at risk to receive incorrect and/or expired medications.

Inspectors wroteBased on observation and interview, the facility failed to serve foods that were appetizing, palatable, and served at the proper temperature for 5 of 7 (Residents 23, 18, 39, 116 and 61) sampled residents reviewed for dining. The failure to ensure meals were served at appropriate temperatures, with a good presentation, and that were palatable, placed residents at risk for decreased satisfaction with meals, poor intake, weight loss, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure refrigerator temperatures were maintained within acceptable ranges for 3 of 6 (East Nurse, [NAME] Nurse and Prep)refrigerators reviewed for food service. These failures placed residents at risk for food-borne illness and a diminished quality of life.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to initiate and complete a thorough grievance investigation for 1 of 5 residents (Resident 27) who were reviewed for grievances. The facility failed to ensure there was a resolution for lost property and for concerns related to sitting in soiled briefs. These failures placed the resident at risk for frustration, skin impairment, loss of dignity, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to report resident allegations of abuse to the state agency within 24 hours as required, for 2 of 5 residents (Residents 23 & 21) reviewed for abuse and neglect. These failures resulted in delayed investigations into alleged abuse, and placed residents at risk for abuse, psychosocial harm, and decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide residents a written notice detailing the reasons for discharge/transfer and to provide a copy of the notice to the state Ombudsman office as required for 1 of 3 sampled residents (Resident 32) reviewed for hospitalizations. This failure placed residents at risk for inappropriate transfers and a lack of information regarding their rights and options related to bed-holds.

Inspectors wroteBased on interview and record review, the facility failed to provide the resident and/or resident representative, a written notice of the facility's bed-hold policy at the time of transfer for 1 of 3 sampled residents (Resident 32) reviewed for hospitalizations. This failure placed residents at risk for emotional distress and a diminished quality of life.

Inspectors wroteBased on interviews and record review, the facility failed to ensure the Minimum Data Sets (MDS), an assessment tool, accurately reflected residents' health status and/or care needs for 1 of 35 sampled residents (Residents 32) reviewed for MDS accuracy. The failure to accurately assess residents nutritional needs, placed residents at risk for unidentified and/or unmet care needs and a diminished quality of life.

Inspectors wroteBased on observations, interview, and record review, the facility failed to ensure ongoing communication and collaboration occurred with the dialysis (procedure to clean and filter waste from the blood) center for 1 of 1 sampled resident (Resident 32) reviewed for dialysis. These failures placed residents at risk for unidentified medical complications, adverse health outcomes, and unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess and maintain safety of quarter bed rails for 1 of 4 sampled residents (Resident 3) reviewed for accidents. This failure placed the resident at risk of injury and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to monitor behaviors for 1 of 5 sampled residents (Resident 33) reviewed for Unnecessary Medications. This failure placed residents at risk of experiencing behaviors without appropriate interventions to attain and/or maintain their highest practicable physical, mental and psychosocial well-being and a decreased quality of life. Findings Included . Resident 33 was admitted on [DATE] with diagnoses including anxiety disorder (excessive worrying and feelings of fear, dread, and uneasiness) and depression (feelings of hopelessness and persistent sadness). The 5-day Minimum Data Set (MDS), an assessment tool, dated 05/26/2024, showed the resident was cognitively intact and was independent to needing set up assistance with activities of daily living (ADLs). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide prompt dental services for 1 of 3 sampled residents (Resident 6), reviewed for dental services. This failure placed the resident at risk for unmet dental needs, nutritional compromise, and a diminished quality of life.

Inspectors wroteBased on observation and interview, the facility failed to provide proper infection prevention techniques for 1 of 3 sampled residents (Resident 35) reviewed for pressure ulcer/injury. This failure put residents at risk for infection and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide care in a manner that promoted respect and dignity for 1 of 3 residents (1) reviewed for dignity and respect, when staff failed to provide toileting assistance when requested by the resident, prior to their physical therapy session. This failure placed residents at risk for embarrassment, anxiety, and diminished self-worth.

Inspectors wroteBased on interview and record review, the facility failed to timely and thoroughly investigate an allegation of neglect for 1 of 3 residents reviewed for abuse and neglect. This failure placed residents at risk for unidentified/continued abuse/neglect, not identifying corrective actions to prevent further neglect, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 4 of 4 residents (Residents 1,2,3,4) reviewed for quality of care when staff failed to assess, monitor and/or document resident responses to interventions on a daily basis, for newly admitted residents receiving skilled services. These failures placed residents at risk for unmet needs, declining health, and decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure care plan conferences were held with the resident and/or resident representative for 1 of 4 sampled residents (Resident 4) reviewed for participation in care planning. This failure placed residents and/or resident representatives at risk of not being fully involved and informed of decisions about care and services and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to notify the resident's Power of Attorney (POA) of a change in condition for 1 of 4 sampled residents (Resident 4) reviewed for notification of changes. This failure placed residents at risk for not having the opportunity to have family notified of changes in condition and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who required ileostomy (surgically created opening in the bowel for the discharge of body wastes into a collection bag) care received services consistent with professional standards for 1 of 4 residents (Resident 1) reviewed for quality of care. The failure to obtain orders for frequency of ostomy care, which supplies to use and lack of prompt attention to resident request for ostomy care placed residents at risk for skin breakdown and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents with indwelling urinary catheters (a flexible tube inserted into the bladder through the urethra that drains into a bag) were provided with catheter care and management in a manner that minimized the risk for complications and catheter related urinary tract infections for 2 of 2 residents (Residents 4 and 5) reviewed for urinary catheters. These failures placed residents at risk for catheter associated urinary tract infections, other potential health complications, and decreased quality of life.

Inspectors wroteBased on interview and record review the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 of 5 residents (Resident 3) reviewed for quality of care when staff failed to assess, monitor and/or document respiratory assessments and resident response to intervention. These failures placed residents at risk for unmet needs, declining health, and decreased quality of life.

Inspectors wroteBased on interview and record review the facility failed to intervene timely and/or provide necessary supervision during a resident-to-resident altercation for 2 of 3 residents (Resident 1 & 2) reviewed for accidents and supervision with known histories of agitation and inappropriate behaviors. Resident 1 experienced harm when they developed a subdural hematoma (blood pooling on surface of the brain) during the altercation. The failure to provide adequate interventions and supervision during resident altercations placed all resident at risk for potential injuries or harm.

Inspectors wroteBased on interview, and record review, the facility failed to ensure professional standards of nursing practice were provided when medications were not given as ordered for 1 of 4 sampled residents (Resident 2) reviewed for quality of care. The facility's failure had the potential to cause adverse side effects, declining mental and physical health, and decreased quality of life.

Inspectors wroteBased on interview and record review the facility failed to provide medically related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 of 4 residents (Resident 2) reviewed for behavioral health services. The facility's failure to identify, communicate, and attempt to determine the reasons behind resident's nonadherence to recommendations precluded them from developing and implementing resident specific interventions to mitigate causative factors and increase acceptance of care. This failure placed residents at risk of having unmet social service needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to identify, assess, and monitor a pressure ulcer (PU - an injury to skin and underlying tissue resulting from prolonged pressure on the skin) and to implement orders timely to prevent the PU from deterioration and infection for 1 of 3 sampled residents (1), reviewed for PUs. Resident 1 experienced harm when the facility did not identify, monitor, or implement orders to care for a PU resulting in the resident developing septic shock (a potentially fatal condition when organs fail as a result of an infection) and a Stage 3 PU (full thickness loss of skin exposing subcutaneous tissue). This failure placed residents at risk for wound infection, delayed healing, increased pain, and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to notify the resident's Power of Attorney (POA) of a change in condition for 1 of 3 sampled residents (1) reviewed for notification of changes. This failure placed residents at risk for not having the opportunity to have family notified of changes in condition and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure sufficient staffing was available to provide necessary care, services, and supervision for 9 of 30 days review for sufficient staffing. This failure place resident at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure a comprehensive antibiotic stewardship program was in place for the facility. This failure placed all facility residents at risk for over-use and miss-use of antibiotic.

Inspectors wroteBased on interview and record review, the facility failed to provide a written notice of transfer to the resident and/or the resident's representative and to the Office of the State Long-Term Care Ombudsman describing the reason for transfer for 3 of 3 sampled residents (126, 9 & 20) reviewed for transfer notifications regarding hospitalization. This failure placed residents and/or their representatives at risk of not being informed of the resident's condition, unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure a written bed-hold notice was provided to the resident or resident's representative at the time of transfer to the hospital for 3 of 3 sampled residents (9, 20 & 126) reviewed for bed-hold notification. This failure placed residents and resident representatives at risk of not being informed regarding their right to hold their bed while in the hospital.

Inspectors wroteBased on interview and record review, the facility failed to ensure staff with a medication endorsement were working within their scope of licensure for 4 of 4 Nurse Technicians (Staff L, Q, R & S) and 1 of 1 Certified Nursing Assistant (CNA) (Staff K), failed to ensure medications were passed according to professional standards for 1 of 1 Registered Nurse (Staff B), and failed to ensure provider medication orders were followed for 1 of 5 sampled residents (51) reviewed for services provided meet professional standards regarding medication administration. This failure placed residents at risk for inaccurate assessments, medication errors, and a diminished quality of care.

Inspectors wroteBased on interview and record review, the facility failed to perform ongoing neurological assessments (neuro checks - assesses the nervous system and identifies any abnormalities that affect function and activities of daily living) for residents after an unwitnessed fall for 4 of 4 sampled residents (19, 127, 37 & 1) reviewed for quality of care related to accident hazards. This failure placed residents at risk of having unidentified injuries, a delay in treatment, at risk for worsening conditions, health complications and a diminished quality of life.

Inspectors wroteBased on observation and interview, the facility failed to ensure residents dependent on staff for eating assistance were offered dining assistance in a timely manner for 6 of 10 sampled residents (1, 8, 30, 33, 42 & 127) reviewed for resident rights related to dining services. This failure placed residents at risk for excessive wait times, cold food and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents and/or resident representatives were informed and provided consent before administering a psychotropic (mind altering) medication for 1 of 5 sampled residents (Resident 58) reviewed for right to be informed about treatment decisions. This failure placed residents and/or resident representatives at risk of not being fully informed of the risks and benefits before making decisions about medications and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure a newly admitted resident was informed of their rights and responsibilities as a resident in the facility for 1 of 1 sampled residents (126) reviewed for notice of rights and rules. This failure placed residents at risk of not understanding their rights, a reduced ability to self-advocate, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents' medical information was maintained in a manner to ensure privacy and confidentiality when staff failed to secure the electronic health records (EHR) for 1 of 1 sampled residents (Resident 37) reviewed for privacy and confidentiality. This failure placed residents at risk of having their medical information not kept confidential and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain and provide a safe, sanitary, and homelike environment for 1 of 3 sampled residents (Resident 4) reviewed for homelike environment. This failure placed residents at risk for a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were free from physical restraints for 1 of 1 sampled residents (127) reviewed for physical restraints. This failure placed residents at risk for injury and a decrease quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure allegations of abuse were reported to the State Agency within 24 hours and failed to log the incident in the facility's reporting log for 1 of 2 sampled residents (Resident 58) reviewed for abuse. This failure placed residents at risk of incidents not being reported and at risk for abuse and neglect.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the comprehensive care plan addressed weight loss for 1 of 1 sampled residents (Resident 20) reviewed for comprehensive care plans. This failure placed residents at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to obtain weekly weights per provider order and identify a weight loss for 1 of 1 sampled resident (Resident 20) reviewed for nutrition. This failure placed residents at risk for weight loss, inadequate nutrition, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess residents for risk of entrapment, obtain informed consent and care plan for the use of bed rails for 1 of 1 sampled residents (Resident 1) reviewed for restraints. This failure placed residents at risk of entrapment, injury, and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from unnecessary psychotropic (affecting the mind) medications by failing to monitor for medication side effects and target behaviors for 1 of 5 sampled residents (Resident 58) reviewed for unnecessary psychotropic medications. These failures placed residents at risk for medical complications, receiving unnecessary psychotropic medications and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure daily staff postings were accurate for the type of staff providing care to residents for 30 of 30 daily staff postings reviewed for staffing information. This failure placed residents and visitors at risk of not knowing what type of staff was providing care to residents.