Park Regency Care Center

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of three sampled residents (Resident 1) received the necessary care and services to prevent accident hazards. * The facility failed to ensure Resident 1 was transported in the shower chair safely, resulting in the resident to sliding off the chair and falling. This failure placed the resident at risk for injury.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to provide the necessary care and services for one of five sampled residents (Resident 1). * The facility failed to assess and implement interventions to ensure Resident 1 received necessary care and services to prevent avoidable pain during transport to a medical appointment. This failure resulted in Resident 1 experiencing unnecessary pain and discomfort.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable well-being for one of three sampled residents (Resident 1). * The facility failed to complete an assessment for the change in condition, notification of physician and responsible party, and documentation of administration of oxygen and its effectiveness for Resident 1. The facility failed to monitor resident's change of condition after the episodes of low oxygen levels. In addition, there was no care plan developed for the oxygen use. These failures posed the risk of the resident not receiving the appropriate care and the potential for a delay in providing care to the resident.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services for four of five final sampled residents (Resident 8, 12, 38, and 55) reviewed for the use of the side rails. * The facility failed to obtain the physician's order, to provide the least restrictive alternatives, and to conduct a bed rail assessment for Resident 12's use of the side rails. * The facility failed to provide documented evidence the manufacturers' recommendations and specifications for installing and maintaining bed rails were conducted for Resident 8, 38, and 55 bed rails. In addition, the facility failed to conduct a bed rail assessment for Resident 38's bed rails. These failures had the potential to place the residents at risk for entrapment and serious injuries.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure the sanitary requirements were met in the kitchen. * Boxed food items in the walk-in refrigerator and freezer were observed placed within two to three inches from the ceiling, blocking the spray of the fire sprinklers. * A floor tile next to the facility's ice machine was observed missing a piece of the tile. * Station 2 Residents' refrigerator did not have a thermometer inside the freezer, and half-a-gallon ice cream was observed with ice build along the top outer edges of the ice cream's lid. * A ceiling tile inside the facility's dining room was observed with a hole in it. These failures posed the risks of the fire sprinklers not releasing their full spray in the event of an emergency, posed the risk of harboring the growth of microorganism; [...]

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the infection control practices designed to provide a safe and sanitary environment and help prevent the development and transmission of infections were implemented. * The facility failed to initiate an infection tracking surveillance for the residents with signs and symptoms of infection who were not prescribed with antibiotic treatment. * CNA 7 was observed with artificial nails, extending beyond her fingertips. * Resident 76's drape was observed with a black substance along the bottom of the drape. These failures posed the risk of not preventing the spread of infection in the facility, posed the risk of causing an injury to residents' skin, and posed the risk of unsanitary environment.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of four final sampled residents reviewed for side rails (Resident 12) and one of one final sampled resident reviewed for physical restraint (Resident 76) were provided the right to self-determination regarding the use of side rails and physical restraints. * The facility failed to ensure the informed consent was obtained prior to the use of side rails for Resident 12. * The facility failed to obtain the informed consent prior to having Resident 76's bed against the wall. These failures posed the risk of the residents and their responsible party not understanding the risks and benefits regarding the use of side rails, physical restraints, and having the resident's bed against the wall.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to determine if it was safe to self-administer the medications left at the bedside for one of 19 final sampled residents (Resident 54). * Resident 54 was observed with a bottle of Systane (artificial tears) eyedrops at the bedside, and an orange bottle containing two nebules of Systane eyedrops. However, Resident 54 was not assessed to determine if she could self-administer medications. In addition, there were no physician's orders for the Systane eyedrops, and to self-administer medication, and no care plan problem addressing the resident's self-administration of the medication. These failures had the potential for Resident 54 to administer the medications inaccurately and could affect their well-being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to offer information on how to formulate an advanced directive (a legal document stating a person's wishes about receiving medical care if the person is no longer able to make medical decisions) and/or maintain a copy of the advanced directive for two of nine final sampled residents reviewed for advanced directives (Resident 50). * Resident 50 was not offered information on how to formulate an advanced directive. * The facility failed to obtain a copy of Resident 54's advanced directive. These failures had the potential for Resident 50 and 54's decisions regarding their healthcare and treatment options not communicated to the healthcare staff and honored.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of one final sampled resident reviewed for physical restraints (Resident 76) remained free of the physical restraints. * The facility failed to ensure Resident 76's bed was not against the wall per the facility's P&P. This failure had the potential for Resident 76 not being able to get out of bed on both sides and the potential for Resident 76 to sustain injury.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of five final sampled residents reviewed for unnecessary medications (Resident 2) and two final sampled residents (Residents 5 and 54) were free from the unnecessary psychotropic drugs (any drug that affects brain activity associated with mental processes and behavior). * The facility failed to ensure Resident 2's orthostatic blood pressure (measure the blood pressure while laying, sitting and standing) was monitored as ordered by the physician related to the use of the antipsychotic medication. * Resident 5's mirtazapine (antipsychotic medication) medication dose was increased. [...]

Inspectors wroteBased on interview, medical record review, and the facility P&P review, the facility failed to develop the comprehensive plans of care to reflect the individual care needs for two of 19 final sampled residents (Residents 35 and 76) and one nonsampled resident (Resident 81). * The facility failed to develop a comprehensive care plan to address Resident 35's fall on 12/9/25, to include interventions aimed to prevent future incident of falls. * The facility failed to develop a comprehensive care plan problem to address Resident 76's bed against the wall. * The facility failed to develop a comprehensive care plan problem to address Resident 81's fluid restrictions. These failures posed the risk of not providing appropriate, consistent, and individualized care to these residents.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the nutritional interventions were followed for one nonsampled resident (Resident 81) reviewed for nutrition. * The facility failed to ensure the physician's order for fluid restriction was followed and documented properly for Resident 81. This failure had the potential to negatively affect the resident's health and well-being.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure two final sampled residents (Residents 38 and 78) investigated for respiratory status were provided with the appropriate respiratory care and services. * The facility failed to ensure Resident 38 had a physician's order for the resident's oxygen use. * Resident 78's nasal cannula was observed on the floor, and undated. In addition, the resident's nebulizer mask and tubing were observed on top of the drawer, uncovered. These failures had the potential to affect the respiratory health and well-being of the residents in the facility.

Inspectors wroteBased on observation, interview, medication label review, facility P&P review, and medical record review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 7.69%. Two of three licensed nurses (LVNs 1 and 3) who were observed during medication administration were found to have errors. * LVN 1 failed to ensure Macrobid (urinary antibiotic) medication was administered to Resident 77 with food and not crushed. * LVN 3 failed to ensure ursodiol (gastrointestinal agent) medication was administered to Resident 47 with food. These failures created the risk for the residents to have potential side effects or complications related to the medications.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one nonsampled resident (Resident 77) was free from significant medication error. * The facility failed to ensure the Macrobid (urinary antibiotic) medication was administered to Resident 77 with food and the medication was not crushed. This failure placed Resident 77 at risk for significant side effects and medical complications.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the staff implemented the proper storage, labeling, and disposal of medications in a safe manner. * The facility failed to dispose of the expired medications in Medication Room A. * The facility failed to dispose of the expired medications inside Treatment Cart A. * The facility failed to ensure Medication Cart B was not left unlocked and unattended. These failures had potential to result in unsafe medication administration, cross-contamination of the medications, and posed the risk for non-licensed staff to have access to the medications.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the personal food policy for one of 19 final sampled residents (Resident 76) was followed. * Resident 76 had a personal ice chest observed soiled and with food items inside. This failure posed the resident at risk of storing the food items which may cause food borne illnesses.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to conduct a regular bed inspection as part of a regular maintenance program to identify areas of possible entrapment for one of five residents (Resident 12) reviewed for side rails. * Resident 12's medical record failed to show documented evidence the entrapment assessment was conducted prior to the use of side rails. This failure had the potential to negatively impact the resident resulting in possible entrapment, serious injuries, and death.

Inspectors wroteBased on interview, medical record review, and facility document review, the facility failed to ensure the MDS assessment contained accurate resident information for one of 19 final sampled residents (Resident 59). * The facility failed to ensure the accurate height and weight measurements were documented on Resident 59's MDS assessment. This failure had the potential for resident not to have an individualized plan of care for the resident's needs.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to revise the comprehensive care plan for one of 19 final sampled residents (Resident 11). * The facility failed to revise the comprehensive care plan to reflect Resident 11's use of temazepam (used to help promote sleep) medication from PRN to routine administration. This failure posed the risk of Resident 11 not receiving the appropriate care and treatment.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the medical record for one of 19 final sampled residents (Resident 9) was accurate. * The facility failed to document Resident 9's weight accurately. This failure had the potential for the resident's care needs not being met as their medical information was inaccurate.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to develop a plan of care to reflect the individual care needs for two of three sampled residents (Residents 1 and 2). * The facility failed to develop a care plan to address Resident 1's wandering behavior by attempting to enter to other female rooms. * The facility failed to develop a care plan to address Resident 2's elopement risk. These failures posed the risk of the residents not receiving the appropriate treatment and services.

Inspectors wroteBased on interview, closed medical record review, and facility P&P review, the facility failed to provide the necessary care and services to prevent accident hazards for one of three sampled residents (Resident 1). * The facility failed to ensure Resident 1 did not eloped from the facility. This failure had the potential to place Resident 1 at risk of serious injury.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to promote the healing of a pressure injury for one of three sampled residents (Resident 3). * The facility failed to provide a LAL mattress for Resident 3 who had a Stage 3 pressure injury (characterized by full-thickness skin loss, where the damage extends into the subcutaneous tissue (fat). While adipose tissue (fat) is visible, bone, tendon, or muscle are not exposed. The wound may have a crater-like appearance, and slough (dead tissue) or eschar (a scab) may be present, but they do not obscure the depth of the wound. Undermining and tunneling (where the wound extends under the skin's surface) can also occur). This failure had the potential to cause and delay the healing of resident's pressure injury.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided for three of three sampled residents (Residents 1, 2, and 3). * Residents 1 and 2's care plan failed to properly address the use of floor mats for safety. * Residents 2 and 3's post fall neurological assessments were incomplete. These failures had the potential for adverse events related to falls to happen.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure two of three sampled residents (Residents 1 and 3) remained free from accident hazards. * The facility failed to assess Residents 1 and 3's ability to handle containers and consume the hot beverages as per the facility's P&P. In addition, Resident 1 spilled a cup of hot chocolate on her left shoulder extending down to the posterior back causing redness and blisters to Resident 1's left shoulder and left upper back. These failures posed the risk of injury to the other residents who were consuming hot liquids in the facility.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen as evidenced by: * The facility failed to ensure the kitchen utensils had a smooth cleanable surface and in good condition. * The facility failed to ensure the kitchen utensils were clean and free of food particle or residue. * The facility failed to ensure the heavy-duty blenders used for puree preparation were air dried prior to storing. * The facility failed to ensure the sanitary condition of the hood over the stove was maintained. These failures had the potential for cross contamination and foodborne illnesses to the residents consuming the foods prepared in the facility's kitchen.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the residents' entrapment assessments were accurate and complete for 15 of 15 residents (14 final sampled residents, Residents 12, 13, 23, 33, 44, 47, 49, 77, 80, 83, 85, 87, 540, and 541 and one nonsampled resident, Resident 24) reviewed for side rail use. This failure had the potential to negatively impact the residents resulting in possible entrapment, serious injury, and death.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the reasonable accommodations to meet the needs for one of 19 final sampled residents (Resident 540) and four nonsampled residents (Residents 9, 17, 81, and 740). * The facility failed to ensure the call lights were within reach and accessible for Residents 9, 17, and 740. * The facility failed to ensure the bed control was within reach and accessible for Resident 81. * Resident 540's call light button was observed not working. These failures had the potential to negatively impact the resident's psychosocial well-being or result in a delay to receive care.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the information on how to formulate an advance directive was provided to one of 19 final sampled residents (Resident 33). In addtion, the facility failed to ensure the POLST form was complete and copy of advance direction was obtained and maintained the medical record for two of 19 final sampled residents( Resident 23 and 87). These failures had the potential for the facility to provide treatment and services against the resident's wishes.

Inspectors wroteBased on observation and interview, the facility failed to maintain a clean and homelike environment for two of 19 final sampled residents (Residents 33 and 49) and two nonsampled residents (Residents 27 and 86). * Resident 86 was observed walking into resident Shower Room A to take a shower. Shower Room A was observed with a soiled towel on the bathroom floor and several unpackaged clean adult briefs lying on the floor and shower chair. * Resident 49 resided in Room C. Room C was observed with scratches and unpainted areas on the walls and bathroom door frame. The Room C curtains were observed with stains and discoloration. * Resident 27 resided in Room B. Room B was observed with scratches and unpainted areas on several areas of the walls. * Resident 33 resided in Room A. Room A was observed with scratches and chipped paint on several areas of the walls. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the Level 1 PASRR contained accurate information for two of 19 final sampled residents (Residents 53 and 77). * Resident 77 had a diagnosis of unspecified psychosis and major depressive disorder and was prescribed Seroquel (an antipsychotic); however the Level I PASRR showed Resident 77 had no diagnosed mental illness and was not prescribed psychotropic medications. * Resident 53 had a diagnosis of depressive disorder; however, the Level 1 PASRR screening showed Resident 53 had no diagnosed mental illness. These failures posed the risk for the residents' inappropriate placement in a long-term care nursing home when a PASRR Level II evaluation was not done.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 19 final sampled residents (Resident 62) was free from the accident hazards. * The facility failed to place the floor mattresses on both sides of Resdient 62's bed as ordered by the physician and resident's care plan for Resident 62. This failure had the potential for serious injury to the resident.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to maintain the IV accesses for two of two residents (one final sampled resident, Resident 77 and one nonsampled resident, Resident 63) reviewed for IV care. * The facility failed to ensure the PICC line external catheter and arm circumference measurements were completed and documented in the residents' medical records for Residents 63 and 77 upon admission to the facility. In addition, the facility failed to obtain a physician's order for the care and maintenance of the PICC line for Resident 77, failed to develop a plan of care for the use of PICC, and failed to ensure the PICC dressings were changed weekly as per the facility's P&P for Residents 63 and 77. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the appropriate pain management for one of one final sampled resident (Resident 87) reviewed for pain management. * The facility failed to administer pain medication according to the physician's order for Resident 87. This failure had the potential for ineffective pain management for Resident 87.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to attain and maintain the highest physical well-being for one of one final sampled resident (Resident 23) reviewed for dialysis. * The facility failed to ensure the intake and output for Resident 23 were monitored and documented as ordered. This failure had the potential for Resident 23 having an excess of fluids, which could affect other vital organs in the body due to the resident's impaired kidney function.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure four of 19 final sampled residents (Residents 53, 77, 80, and 83) and one nonsampled resident (Resident 24) remained free from the accident hazards due to the use of side rails. * The facility failed to ensure the Physician's Documentation of Informed Consent for Resident 83 was accurately completed, had missing physician's signature, and was undated. * The facility failed to ensure the physician's order was obtained and care plan was initiated for the use of side rails for Residents 77 and 80. * The facility failed to obtain the physician's order and initiate a care plan problem for the use of the bilateral half side rails for Residents 77 and 80. [...]

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the pharmaceutical services to ensure accurate reconciliation for the controlled medications for one of 19 final sampled residents (Resident 541) and three nonsampled residents (Residents 48, 741, and 742). * The facility failed to ensure the administration of the controlled medications for Residents 54, 741, and 742 were accurately reconciled and documented in the MAR. * The facility failed to ensure the administration of the controlled medication for Resident 48 was documented in the controlled drug record and MAR. * The facility failed to ensure the Controlled Substance Shift Count Log for Medication Cart C was completed every shift. These failures posed the risk for diversion of medications.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure five of five final sampled residents (Residents 13, 23, 77, 83, and 541) reviewed for unnecessary medications were free from the unnecessary psychotropic drugs. * The facility failed to ensure Resident 13's consent for Seroquel (antipsychotic medication) was signed and dated by the physician. * The facility failed to ensure Resident 83's consent for Risperdal (antipsychotic medication) was signed and dated by the physician. * The facility failed to ensure Resident 541 with prescribed Seroquel was monitored for orthostatic hypotension and number of behavior episodes; and provided non-pharmacological interventions. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one nonsampled resident (Resident 76) was free from the significant medication errors. * The facility failed to ensure Resident 76 received Keppra (anticonvulsant medication) and metformin (antidiabetic medication) due to leakage from medication cup. This failure had the potential to cause Resident 76 to have convulsion (a medical condition that causes the body to shake uncontrollably), high blood glucose and negatively affect the resident's health.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure proper storage, labeling, and disposal of medications. * The facility failed to ensure the expired medications for one nonsampled resident (Resident 740) in Medication Room A's refrigerator were discarded. * The facility failed to ensure the expired medications were removed from the current treatment supply in Treatment Cart A. * The facility failed to ensure the orally administered medications were stored separate from externally used medications and supplies in Medication Cart A. * The facility failed to ensure the medication bottles and medication tray were kept clean and free of sticky residue in Medication Cart A. [...]

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the use and storage of food brought to the facility by the family members or visitors. This failure had the potential to cause foodborne illnesses to the medically vulnerable resident population who consume food brought from outside sources.

Inspectors wrote2. Medical record review for Resident 291 was initiated on 10/7/24. Resident 291 was admitted to the facility on [DATE]. Review of Resident 291's Physician Orders for Life-Sustaining Treatment (POLST) dated 9/25/24, showed Resident 291's advance directive was not available. However, review of Resident 291's Advance Directive Acknowledgment form dated 9/29/24, showed Resident 291 had not executed an advance directive. On 10/8/24 at 1439 hours, an interview and concurrent medical record review was conducted with the SSD. The SSD verified the discrepancy specific to if Resident 291 had formulated an advance directive. The SSD stated the information documented on Resident 291's POLST dated 9/25/24, specific to whether Resident 291 had formulated an advance directive was inaccurate. 3. Medical record review for Resident 49 was initiated on 10/7/24. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure two of five final sampled residents (Residents 23 and 80) reviewed for vaccinations were assessed for the COVID-19 vaccination status or offered the COVID-19 vaccine. This failure put the residents at risk for increased risk of infection and transmission of COVID-19.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure the essential equipment was maintained in safe operating condition. * The facility failed to ensure the glucometer quality control test was done and the results were accurately documented for two of two glucometer devices reviewed. This failure had the potential for the residents requiring glucose checks to have inaccurate readings.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the privacy was provided during care for one of five sampled residents (Resident 3). * Privacy was not provided for Resident 3 during the ADL care. * Resident 3's medical information was left exposed twice on a computer monitor screen at the nurses' station. These failures had the potential to violate the resident's right to privacy.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure the environment was free of pests. * Cockroaches were found in the conference room. This failure had the potential for spread infections.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services for one of three sampled residents (Resident 2). * The facility failed to ensure the Bactroban (antibiotic ointment) ointment was applied during the wound care treatment as ordered by the physician for Resident 2. In addition, the facility failed to provide treatment in the sacrococyx (fusion between sacrum and coccyx) area as ordered by the physician for Resident 2. * The facility failed to ensure the Bactroban ointment was ordered and available for wound care as ordered for Resident 2. These failures had the potential for Resident 2 not to receive appropriate care and treatment.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the accuracy of the medical record for one of two sampled residents (Resident 1). This had the potential for the resident's care needs not being met as the clinical information was not accurate.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen. * The facility failed to implement their P&P to ensure proper storage of food items in the residents' refrigerator. The facility failed to ensure proper labeling and dating of food items in the refrigerator used for the residents' food brought in by the visitors. * The facility failed to ensure the kitchen equipment and utensils were clean. * The facility failed to air dry food storage containers used for food portioning. These failures had the potential to cause foodborne illnesses in a medically vulnerable resident population consuming food prepared in the kitchen.

Inspectors wroteBased on observation, interview, medical record review, and document review, the facility failed to accurately assess a deteriorating pressure ulcer for one of 19 sampled residents (Resident 75). * Resident 75's pressure ulcer was evaluated as a Stage 2 pressure ulcer when the wound had deteriorated to an unstageable pressure ulcer. This failure posed the risk for the resident to not receive the proper care and develop complications from a pressure ulcer.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary GT care and services for one of 19 final sampled residents (Resident 39) and one nonsampled resident (Resident 35). * The facility failed to ensure Resident 39 was administered the total amount of enteral feeding as ordered by the physician. Furthermore, the facility failed to notify Resident 39's primary physician of Resident 39's multiple refusals of GT feeding due to possible feeding intolerance. * The facility failed to ensure Resident 35 was positioned safely at 30-45 degrees during medication administration via GT. In addition, LVN 3 failed to perform hand hygiene before donning gloves and before administering the medications via GT. These failures posed the risk for developing complications related GT.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary respiratory care and services for three of 19 final sampled residents (Residents 9, 17, and 379). * The facility failed to ensure a physician's order for oxygen was obtained for Resident 379 prior to oxygen administration. This failure had the potential for Resident 379 receiving unnecessary oxygen. * Resident 17's physician's order for the oxygen therapy settings did not match the oxygen settings included in the care plan. This failure posed the risk for the resident to not receive the appropriate amount of oxygen which may result in negative physical outcome. * Resident 9's nebulizer was placed on top of the trash can. This failure posed the risk for contamination of oxygen equipment and increasing the residents' risk for acquiring infection.

Inspectors wroteBased on interview and medical record review, the facility failed to provide the necessary care and services to attain and maintain the highest practicable physical well-being for one of 19 final sampled residents (Resident 48). * The facility failed to consistently complete Resident 48's post dialysis (the clinical purification of blood as a substitute for the normal function of the kidney) assessments when the resident returned to the facility from dialysis center. This failure had the potential to compromise the facility's ability to identify and address potential complications after dialysis.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary pharmacy services and ensure accurate reconciliation of controlled medications for three of 19 final sampled residents (Residents 55, 69, and 75). * The facility failed to ensure administration of the controlled medications for Resident 55 was accurately documented to ensure accurate reconciliation and prevent the medication administration errors. In addition, several medications were not documented as administered to Resident 55 in the MAR on 1/28, 1/29, and 1/31/22. These failures created the risk for diversion of controlled medications and medication administration errors. [...]

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to provide adequate monitoring of medications for one of 19 final sampled residents (Resident 64). *Resident 64 was receiving apixaban (blood thinner) and was not monitored for the adverse effect of bleeding. This failure had the potential to negatively impact the resident's well-being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure two of five unnecessary medication sampled residents' (Residents 55 and 64) psychotropic medications were monitored for its use. * The facility failed to ensure informed consents were obtained for Resident 55's use of Ambien (medication used to treat sleep problem) and duloxetine (antidepressant medication) medications. In addition, the facility failed to ensure Resident 55's behavior for the use of duloxetine medication was monitored as per the physician's order. * The facility failed to ensure Resident 64's behavior for the use of Prozac (medication for depression) was accurately monitored. These failures had the potential to negatively impact the residents' well-being.

Inspectors wroteBased on observation and interview, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 18.52%. * LVN 3 failed to administer Resident 35's medications as ordered by the physician. Resident 35's eye drops was not administered as ordered because it was unavailable. Significant amounts of amlodipine (medication to control blood pressure, docusate sodium (stool softener), vitamin C (supplement and multivitamins with minerals (supplements) were left in the medication cups during medication administration via GT. In addition, LVN 3 failed to administer free water flushed in between the administration of four medications. These failures created the risk of complications and ineffective therapeutic effects of the medications.

Inspectors wroteBased on observation and interview, the facility failed to store the drugs and biologicals in a safe manner. * An expired bottle of povidone iodine (medication used for skin disinfection) was observed in Medication Cart 1. * Multiple expired Covid-19 Antigen tests (a test used to check for the presence of the Covid-19 virus ) were stored in Medication room [ROOM NUMBER]. These failures had the potential to result in unsafe administration of medications.

Inspectors wroteBased on observation and interview, the facility failed to ensure the garbage and refuse were properly stored in two of four dumpsters. The garbage dumpsters were overflowing with garbage, which prevented the lid from fully closing. This failure had the potential to attract pests/rodents that carried diseases.