Park View Care Center

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility for 1 (Residents #10) of 5 residents reviewed for call lights. The facility failed to ensure Residents #10's call lights were answered in a timely manner. This failure could place residents at risk for decreased quality of life, self-worth and dignity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible for 1 (#11) of 5 resident rooms (room [ROOM NUMBER]B) reviewed for accidents and hazards. The facility failed to ensure that a mechanical lift was locked when not in use in room [ROOM NUMBER]B. This failure could place residents, visitors and staff at risk of falls and/or injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for one (Resident #1) of seven residents reviewed for resident rights. 1. The facility failed to ensure Resident #1 was adequately dressed, on Tuesday 07/14/26 at 5:10 am. He was sitting behind the south nurses station counter, in a Geri chair, and only had on shorts and a white towel over his chest with no shirt on. 2. The facility failed to ensure Resident #1 was adequately dressed, on Tuesday 07/14/26 at 5:36 pm. He was sitting behind the nurses' station counter in a Geri chair, and was asleep with a blue hospital gown on. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that residents had the right to be free from abuse for 3 (Resident #1, Resident #2, Resident #3) of 7 residents and 3 staff members reviewed for abuse. The facility failed to ensure that Resident #1 was supervised while in the facility. The facility failed to keep staff and residents free from accidents and hazards due to Resident #1's physical and aggressive behaviors. Resident #1 was the aggressor in 5 altercations involving 2 (Resident #2 and Resident #3) residents. As a result Resident #2 preferred to stay in her room to avoid any confrontations with Resident #1. Resident #2 expressed that did not feel safe and started the transfer process to a different facility. This failure could place residents at risk for severe and long-lasting impact for physical, psychological and emotional wellbeing. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program to ensure the facility was free of pests and rodents for 2 of 3 nurses' station (North Station and Central Station) and 2 of 3 dining rooms (North Dining Room and Central Dining Room), for 2 of 8 residents (Resident #1 and Resident #4) reviewed for pest control. 1. The facility failed to ensure the North Station nurses' desk and North Dining Room were free from flies. 2. The facility failed to ensure the Central Station nurses' desk and Central Hall dining room were free from flies. This failure could place residents at risk for the potential spread of infection, cross-contamination, and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review , the facility failed to ensure residents had the right to a safe, clean, comfortable and homelike environment to include housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 2 of 8 residents (Resident #2 and Resident #3) reviewed for environmental conditions. The facility failed to ensure the privacy curtains for Resident #2 and Resident #3 were maintained in a clean and sanitary manner free of dried vomit. This failure could place residents at risk of living in an unsanitary, unsafe environment and a diminished quality of life.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 4 of 15 residents (Residents # 1,2,3, and 4) reviewed for infection control when CNAs A, B, C, and D were serving meals. During lunch meal delivery to Hall 100 CNAs A, B, C, and D delivered trays to Residents #1,2,3, and 4, without using hand sanitizer. This failure could place residents at risk of exposure and/or possible transmission of communicable diseases and infections.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure residents had the right to a safe, clean, comfortable and homelike environment to include housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 3 of 32 residents (Residents #95, #86 and #14) and 1 of 3 shower rooms (Shower room [ROOM NUMBER]) reviewed for environmental conditions.1. The facility failed to ensure the privacy curtains for Residents #95, #86 and #14 were maintained in a clean and sanitary manner free of dried brown substances.2. The facility failed to ensure the walls in Shower room [ROOM NUMBER] were properly maintained and free of cracked and missing tiles. These failures could place residents at risk of living in an unsanitary, unsafe environment and a diminished quality of life. 1. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure that a resident who was unable to carry out activities of daily living received the necessary services to maintain grooming and personal care for 4 of 32 residents (Residents #12, #27, #81, and #86) reviewed for ADL care. The facility failed to ensure nail care, to include trimming and cleaning, was provided to Residents #12, #27, #81, and #86. The failure placed the residents at risk of hygiene and safety risks such as nail tearing, injury, and functional difficulties.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents with limited range of motion received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion for 1 of 5 residents (Resident #86) reviewed for restorative care. The facility failed to obtain a physician order and care plan for the use of a splint for Resident #86's left hand contracture (a permanent tightening of the muscles). This failure could place residents at risk of increased contractures, not receiving care and services to maintain their highest level of well-being and decline.

Inspectors wroteBased on interview and record review the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 1 resident (Resident #72) reviewed for dialysis documentation. The facility failed to ensure nurses documented ongoing assessments of Resident #72's condition and monitoring complications before and after dialysis treatments. This deficient practice could place residents at risk of complications from dialysis due to the lack of documentation between the facility and dialysis center in the event of a medical event.

Inspectors wroteBased on interviews and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. The facility failed to ensure the dishwasher's chemical concentration and temperatures were logged. These failures could place residents at risk of foodborne illness.

Inspectors wroteBased on observation and interview, the facility failed to dispose of garbage and refuse properly for 3 of 3 dumpsters. (Dumpsters #1, #2, and #3)1. The facility failed to ensure the doors were completely shut on dumpster #1 2. The facility failed to ensure the lids were closed on dumpsters #1 and #3.3. The facility failed to ensure used incontinent briefs and other garbage were not on the ground surrounding the dumpsters. These failures could place residents at risk of an unsanitary environment and could attract pests, rodents and other animals.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain safe and functional essential kitchen equipment in the facility's only kitchenThe facility failed to ensure the seal on the walk-in freezer door was replaced properly. These failures could place residents at risk of not having essential equipment maintained and in working order.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that residents who received nutrition by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 1 of 11 residents (Resident #14) reviewed for enteral feeding. The facility failed to follow physician's orders of providing Resident #14 with her 16 hours of her enteral feeding intake from 02/10/26 to 02/11/26. This failure could place residents at risk for a decline in health or adverse effects due to inappropriate management of G-tube care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 1 of 2 medication rooms (North medication room) reviewed for pharmacy services. The facility failed to remove expired Bisacodyl suppositories, with an expiration date of 01/21/26 and Acetaminophen suppositories, with an expiration date of 01/09/26, from the North medication room refrigerator. This failure could place residents at risk of receiving medications that were ineffective.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program, including hand hygiene, designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 residents (Resident #45) reviewed for infection control practicesThe facility failed to ensure CNA C performed hand hygiene prior to and during incontinence care for Resident #45. These failures could place residents at risk of cross-contamination and infections.

Inspectors wroteBased on interviews and record reviews, the facility failed to establish policies regarding smoking, smoking areas, and smoking safety that also take into account nonsmoking residents for 2 of 2 residents (Residents #11 and #72) reviewed for smoking. The facility failed to ensure the quarterly smoking assessments were completed to determine Resident #11 and Resident #72 for capability and safety. This failure could place the residents at risk for unsafe smoking causing harm.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure full visual privacy for each resident in 6 rooms of 30 rooms (Rooms # 12, # 15, #23, # 71, #72 and #77) reviewed for privacy. The facility failed to maintain functional window blinds to provide privacy for the residents of Rooms #12, # 15, #23, # 71, #72 and #77. This failure could place residents at risk for exposure and decreased sense of dignity.

Inspectors wroteBased on interview and record review, the facility failed to permit a resident to return to the facility after being hospitalized or placed on therapeutic leave for 1 of 3 residents (Resident #1) reviewed for bed hold. The facility failed to re-admit Resident #1 after he was hospitalized for having shortness of breath. Emergency services attempted to return Resident #1 on 12/18/25 and again on 12/19/25, and the facility sent him back to the hospital. This failure could place residents at risk of not getting the care and services required.

Inspectors wroteBased on interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 resident of 8 residents (Resident #2) reviewed for care plans. The facility failed to address Resident #2's wound, and her non-compliance with care in her care plan. This failure could place residents at risk of not receiving the care they require.

Inspectors wroteBased on observations, interviews, and record reviews, the facility staff failed to ensure that clinical records on each resident, in accordance with accepted professional health information management standards and practices were accurately documented for 1 of 4 residents (Resident #1) reviewed for clinical records. The facility failed to code Resident #1's oxygen treatment on his MDS. This failure placed residents at risk of not receiving adequate care and treatment for oxygen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe, functional, sanitary, and comfortable environment for 1of 3 shower rooms (located on Central Station) reviewed for physical environment. The facility failed to ensure a shower room on the Central Station had two working shower curtains, a working shower head, and a clean toilet. The failure placed residents at risk for illness and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program to ensure the facility was free of pests for 3 of 3 hall locations (North Station, Central Station, South Station), nurse's stations, Central Station dining room and 1 of 1 biohazard closet reviewed for physical environment. The facility failed to ensure North Station, Central Station, South Station, and nurses' stations, Central Station dining room, and the biohazard closet were free from gnats. This failure could place residents at risk for the potential spread of infection, cross-contamination, and decreased quality of life.

Inspectors wroteBased on interview, observation, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident #1) of three residents reviewed for infection control. The facility failed to ensure Resident #1, who was on enhanced barrier precautions for ESBL, received tracheostomy care via sterile technique. This failure placed all residents at risk for the spread of infections and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for one of six residents (Resident #1) reviewed for abuse. The facility failed to ensure Resident #1 had the right to be free from abuse when Resident #2 physically assaulted him on 07/10/25. This failure could place residents at risk for abuse. Review of Resident #1's admission Record, dated 07/15/25, reflected he was a [AGE] year-old male who was originally admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident #1's Quarterly MDS Assessment, dated 06/04/25, reflected he had a BIMS score of 15 indicating no cognitive impairment. [...]

Inspectors wroteBased on interviews 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 of each resident for 1 of 3 residents (Resident #2) reviewed for medically related social services. The facility failed to ensure Resident #2's colonoscopy referral was followed-up on to ensure an appointment was scheduled for her to receive the procedure. This deficient practice could place residents at risk for their medical needs not being met and a decreased quality of life.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents (Resident #1) observed for infection control. The Wound Care Nurse failed to wear a gown while providing care for Resident #1, who was on enhanced barrier precautions. This failure could lead to the resident being exposed to infections from other residents.

Inspectors wroteBased on interviews and record reviews the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 4 residents (Resident #1) reviewed for abuse. The facility failed to ensure Resident #1 had the right to be free from abuse when Resident #2 struck him in the face on 02/18/25. This failure could place residents at risk of injury and anxiety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assist residents in obtaining routine and 24-hour emergency dental care for 1 of 5 residents (Resident #3) reviewed for dental care. The facility failed to assist Resident #3 obtain a follow-up appointment with the Dentist for a root canal by failing to ensure payment was made to the Dentist. This failure could cause the resident unnecessary dental pain.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were not given psychotropic medications unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for 1 of 6 residents (Resident #25) reviewed for psychotropic medications. The Psychiatric NP prescribed Resident #25's seroquel for a medical condition the resident did not have. This failure could place residents at risk of receiving psychotropic medications unnecessarily.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program to keep the facility free of roaches for 6 of 15 residents (Residents #56, #62, #99, #106, #114 and #121) reveiwed for pest control. The facility failed to ensure the facility was free of roaches. This failure could affect residents by placing them at risk for the potential spread of infection, cross-contamination, food-borne illness, and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat each resident with respect, dignity, and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for 2 of 2 residents (Residents #82 and #109) reviewed for feeding assistance. 1. CNA A failed to maintain Resident #82's dignity and respect by standing while feeding the resident her lunch meal on 12/03/24 at 12:39 PM. 2. LVN B failed to maintain Resident #109's dignity and respect by standing while feeding the resident her lunch meal on 12/03/24 at 1:00 PM. The failure could negatively affect the mental and psychological well-being of all residents who required the assistance of staff with eating.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 2 of 10 residents (Residents #26 and #34) reviewed for accommodation of needs. 1. The facility failed to ensure Resident #26's call light was placed within reach. 2. The facility failed to ensure Resident #34's call light was placed within reach. These failures could place residents at risk of injuries and unmet needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who needed respiratory care were provided such care, consistent with professional standards of practice for 1 of 1 resident (Resident #102) reviewed for oxygen orders. The facility failed to administer oxygen for Resident #102 as ordered by the physician. This failure could place residents at risk of receiving incorrect or inadequate oxygen support, resulting in a decline in health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures that assured the accurate dispensing and administering of all drugs and biologicals to meet the needs of each resident for 1 of 5 (Resident #26)residents reviewed for pharmaceutical services. LVN D failed to follow the facility policy for flushing Resident #26's gastrostomy tube with 5-10 mL (or prescribed amount) of water before, between, and after medications, when she administered Vitamin D 125 mcg, Magnesium Oxide - mg supplement, and Sodium Chloride table 1 gm to the resident. These failures could put residents who received medications via gastrostomy tube at risk for overload and aspiration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure it was free of a medication error rate of five percent (5%) or greater, 3 errors of 33 opportunities for errors leading to 6.06% medication error rates, for one of five staff (LVN D) observed for medication pass. The facility failed to ensure LVN D administered all the crushed medication in the medication cups without leaving residue for Resident #26 and failed to mix prior to administration. These failures resulted in a 6.06% medication error rate and could put residents at risk who received medications via g-tube for tube occlusion, not receiving the correct dose of medication, and those that took orally not getting intended therapy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 12 residents (Resident #124) reviewed for equipment safety. The facility failed to provide Resident #124 with a bed that had functional wheel locks. This failure could place residents at risk of falls due to unsafe equipment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from abuse for one of six residents (Resident #1) reviewed for abuse. The facility failed to ensure the Administrator did not verbally abuse Resident #1 when he cursed at him during a conversation. This failure could affect the residents at the facility and place them at risk for physical, verbal, and/or psychosocial harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from abuse for one of six residents (Resident #1) reviewed for abuse. The facility failed to ensure Resident #1 was free from abuse per the policy when the Administrator verbally abused Resident #1 when he cursed at him during a conversation. This failure could place residents at risk for physical harm, psychosocial harm, unsafe environment, and further abuse.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for 2 (the Main Dining Room and the North Station Dining Room) of 3 dining rooms reviewed for environment. The facility failed to ensure that chairs were in good condition and not in need of repair in the Main Dining Room and North Station Dining Room. This failure could affect residents and the staff by placing them at risk for diminished quality of life due to lack of a well-kept environment.

Inspectors wroteBased on observation and interview, the facility failed to provide a safe, clean, comfortable and homelike environment for daily living in 4 resident rooms (Rooms #40, #50, #51, and #76) of 10 resident rooms reviewed for environment. The facility failed to ensure resident rooms, Rooms #40, #50, #51, and #76, were maintained and in sanitary condition. This failure could place all residents at risk for a reduced quality of life and unsanitary and hazardous living conditions.

Inspectors wroteBased on observations, interviews, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public in 2 dining rooms (North and Central Dining Rooms) of 3 dining rooms reviewed for environment. The facility failed to ensure the North and Central Dining Rooms were maintained and in sanitary condition. This failure could place all residents at risk for a reduced quality of life and unsanitary and hazardous living conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 3 residents (Resident #2) reviewed for abuse. The facility failed to ensure Housekeeping Supervisor did not verbally abuse Resident #3 on 12/10/23. This failure could place residents at risk of abuse, humiliation, intimidation, fear, shame, agitation, and decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement their written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 2 of 5 residents (Residents #2 and #3) reviewed for abuse and neglect. 1. CNA F and Housekeeper G failed to immediately report an instance of abuse on 12/10/23 when the Housekeeping Supervisor verbally abused Resident #2. 2. Social Worker A failed to immediately report an allegation of misappropriation of property on 11/20/23 when Resident #3 alleged some of her money was missing from her bank card. These failures could place residents at risk of abuse, physical harm, mental anguish, and emotional distress.

Inspectors wroteBased on interview and record review, the facility failed to ensure all alleged violations involving abuse, neglect and exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but no later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury, to the administrator of the facility and to other officials, which included the State Survey Agency, in accordance with State law through established procedures for 2 of 5 residents (Residents #1 and #2) reviewed for abuse and neglect. 1. The facility did not report to the State Survey Agency when Resident #1 reported allegations of abuse with 2 hours. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a private meeting space for the residents' monthly council meetings for 7 of 7 confidential residents reviewed for resident council. The facility failed to provide a private space for resident council meetings. This failure could place residents, who attended resident council meetings, at risk of not being able to voice concerns due to a lack of privacy.

Inspectors wroteBased on observations, and interviews the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 3 of 6 residents (Residents #46, #109, and #132) reviewed for safe clean homelike environment. 1. The facility failed to ensure Residents #46, #109, and #132 had toilet paper to maintain hygiene. 2. The facility failed to ensure Resident #132's bathroom was cleaned daily. 3. The facility failed to ensure the floor of the COVID unit was cleaned daily. These failures could place residents at risk of infection and decreased sense of self-worth.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an ongoing program of activities designed to meet the interests and the physical, mental, and psychosocial well-being of 7 of 7 residents reviewed for activities. The facility failed to ensure there were organized activities provided to the residents during the COVID-19 outbreak according to 7 residents who attended the confidential group interview. The failure placed residents at risk for a diminished quality of life, isolation, lack of stimulation, and a decline in mental status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 3 of 4 residents (Resident #244, #132, and #136) reviewed for quality of care. 1. The facility failed to elevate Resident #244's bilateral (affecting both sides) lower extremities as ordered by the physician. 2. The facility failed to ensure Resident #132 received his medicated cream for his facial rash. 3. The facility failed to schedule a follow-up appointment with a Neurosurgeon for Resident #136 according to discharge orders by a physician at the local hospital after the resident was seen for generalized weakness due to a traumatic brain injury. This failure could place residents at risk of worsening of their conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents had a medication error less than 5 percent resulting in an error rate of 18.18% for four of eight residents (Residents #22, #48, # 93, and #132) reviewed for pharmacy services. The facility failed to ensuure LVN A and MA D administered medications appropriately for Residents #22, #48, # 93, and #132. This failure could place residents at risk of a worsening of their medical conditions by not receiving the therapeutic effects of medications prescribed for them.

Inspectors wroteBased on observation and interview, the facility failed to ensure medications were stored in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys. The facility failed to ensure all drugs and biologicals were stored securely for 1 of 18 residents (Resident #85) and 2 of 3 medication rooms observed for medication storage. 1. The facility failed to secure the locked medication rooms on Central and North Stations. 2. The facility failed to ensure Resident #30 did not have 1 bottle of nasal spray and two bottles of saline stored at the resident's bedside table not locked in a lock box, or secured in the medication cart or medication room. These failures could place residents at risk of accessing medications not prescribed for them.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen 1. The facility failed to ensure food stored in the freezer was properly labeled and dated. 2. The facility failed to ensure the dishwasher had an appropriate level of sanitizer. These failures could place residents at risk for food contamination and food borne illness.

Inspectors wroteBased on interviews, record reviews, and observations the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 6 (Residents #54, #64, #95, #137, #134, and #345) of 35 residents reviewed for infection control. 1. The facility failed to test and isolate Resident #137 when she was symptomatic for Covid. 2. The facility failed to clean and disinfect Resident #95's room after he tested positive for Covid placing his roommate at risk for Covid. 3. The facility staff failed to use proper personal protective equipment when entering a positive Covid room to provide lunch to Residents #54 and # 64 These failures could place residents at risk of exposure toCovid.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents for 7 (Rooms 22, 24, 25, 46, 50, 51, and 61) of 25 rooms reviewed for environment. The facility failed to maintain total visual privacy by allowing the window blinds for rooms 22, 24, 25, 46, 50, 51, and 61 to be missing several slats. This failure placed residents at risk of a lack of privacy, feeling insecure, or uncomfortable in their rooms.

Inspectors wroteBased on interview and record review, the facility failed to ensure each employee received instruction in HIV, falls, restraints, resident rights, dementia, and ANE (abuse, neglect, and exploitation) competency-based training as part of orientation and annually, for 5 of 12 staff (MA, CNA, RN, LVN, and Hospitality Aide) reviewed for training, in that: The facility failed to ensure Reference Checks and Trainings-Resident Rights, Dementia, HIV, Falls, Restraints, and ANE (Abuse, Neglect, and Exploitation) were completed during orientation and prior to start date. These failures could place residents at-risk for abuse and neglect due to lack of training.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents the right to personal privacy for 1 of 35 residents (Resident #26) reviewed for dignity. CNAs E and G failed to use the privacy curtain or close the door when Resident #26 was lying in bed with no clothes on from the waist down. This deficient practice could place residents at risk for psychosocial harm due to a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to follow up with the State mental health authority for 1 of 6 residents (Resident #137) reviewed for preadmission screening for individuals with a mental disorder and individuals with intellectual disability. The facility failed to follow up with the State mental health authority after Resident #137 was found to have a mental illness after admission to the facility. This failure could place residents at risk of not receiving specialized services deemed necessary by the State mental health authority.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who are fed by enteral means receive the appropriate treatment and services to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, and metabolic abnormalities in that they failed to ensure physician orders were followed for one resident of two residents (Resident #107) reviewed for enteral nutrition. 1. LVN S failed to check for tube placement and residual volume prior to the 9:00 AM bolus feeding as ordered by the physician. 2. LVN S failed to provide Resident #107 his 1:30 PM bolus feeding as ordered by the physician. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident who needs respiratory care was provided such care, consistent with professional standards of practice for one of three residents (Residents #69) reviewed for oxygen. 1. The facility failed to ensure Residents #69 orders for oxygen administration were being accurately provided. 2. The facility failed to ensure Resident #69 concentrator was with water. This failure placed residents who received oxygen therapy at risk for inadequate or inappropriate amounts of oxygen delivery and ineffective treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a centralized staff work area, for 2 of 144 residents (Resident #10 and #23) reviewed for call lights. The facility did not adequately equip Resident #10 and Resident #23 with a call light to allow residents to call for assistance. This failure could place residents who rely on the call light system to have a delayed response or no way contact staff to meet their needs.

Inspectors wroteBased on observation and interview, the facility failed to ensure that the daily nurse staffing was posted as required each day for four (10/24/23, 10/25/23, 10/26/23, and 10/27/23) of four days reviewed for nursing services and postings. The facility failed to update the daily staffing information posting on 10/24/23, 10/25/23, 10/26/23, and 10/27/23. This failure could affect residents, their families, and facility visitors by placing them at risk of not having access to information regarding staffing data and facility census.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes the measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 (Resident #1) of 7 residents reviewed for comprehensive care plans. The facility failed to implement in Resident #1's care plan about his complaints about not getting medications. The facility failed to develop interventions and goals for seizure and psychotropic medications for Resident #1. This failure could place residents at risk for decreased quality of life and not having their needs met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 3 residents reviewed for accidents. The facility failed to ensure the necessary level of assistance was provided to safely care for Resident #1 during incontinence care. CNA B provided incontinence care without assistance, resulting in Resident #1 falling out of bed and dislocating her finger. This failure could place residents at risk for serious injuries or harm, decline in health, and decreased quality of life.