Park View Nursing and Subacute

Inspectors wroteBased on interview and record review, the facility failed to notify the physician when a resident's blood sugar (BS) was elevated, in accordance with facility policy and the physician's order for one of five residents (Resident 48) reviewed under unnecessary medications. [...]

Inspectors wroteBased on interview and observations, the facility failed to maintain resident protected health information ([PHI] - any health information that can be used to identify a specific individual which must remain confidential to prevent harmful consequences) by not shredding or covering pharmacy medication labels (a label that includes the residents name, date of birth , name of pharmacy, name of medication, dose, its indication and instructions of use) containing resident medical information on medication bubble packs (medication packaging system that contains individual doses of medication per bubble) and medication manufacturer packages, prior to disposing in the waste container, affecting Resident 6, 48 and 73 in one (1) of two (2) inspected Medication Rooms (Medication Room Subacute.) As a result, the privacy and confidentiality of Resident 6, 48 and 73's medical records were [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure one (1) of five (5) sampled residents (Resident 75) was free from unnecessary (any medication in excessive dose, excessive duration, without adequate indication for its use and monitoring) use of psychotherapeutic drug (any medication capable of affecting the mind, emotions, and behavior) in accordance with facility policy and procedures by failing to monitor episodes of anxiety manifested by repetitive worrying about her health condition for buspirone (a psychotropic medication used for anxiety) every shift between 5/1/2026 and 6/3/2026. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for three (Resident 32, Resident 48, and Resident 75) of 19 sampled residents by failing to: 1. Ensure that Resident 32's Care Plan (a document outlining a detailed approach to care customized to an individual resident's need) included measurable goals and outcomes for cerebrovascular accidents ([CVA] - an interruption in the flow of blood to cells in the brain] caused by heart failure,) prophylaxis ([PPX] - action taken to prevent disease,) and use of enoxaparin (medication used to prevent CVA and Deep Vein thrombosis [DVT] - a condition when a blood clot forms in one or more of the deep veins in the body). As a result, Residents 32 did not have an identified goal to monitor the effectiveness of Resident 32's enoxaparin use related to CVA PPX. 2. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents who were incontinent (lacks voluntary control over urination) of bladder (organ in the pelvis that stores urine) received appropriate treatment and services to prevent urinary tract infections (UTI, common infections that happen when bacteria infect the urinary tract) for three of three sampled residents (Resident 25, Resident 10, and Resident 99) reviewed under urinary catheter care area by failing to: a. Ensure Resident 25's urinary catheter tubing (a tube that is inserted into the bladder, allowing urine to drain) was positioned without coils or loops to allow urine to flow freely into the urinary catheter bag (container that connects to a urinary catheter and collects urine). b. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide residents with necessary respiratory care and services that is in accordance with professional standards of practice to three of five sampled residents (Resident 7 Resident 48, and Resident 5) reviewed under the respiratory care area by failing to ensure the residents' oxygen tubing (a flexible, clear hose that delivers oxygen to a patient during oxygen therapy) was changed every seven days. These deficient practices had the potential to negatively affect the provision of care and services related to oxygen therapy and placed the residents at increased risk for respiratory distress and infection.

Inspectors wroteBased on interview and record review the facility failed to: 1. Have an available supply of bumetanide (a medication used for congestive heart failure [CHF] - condition where the heart does not pump blood efficiently to the rest of the body) in the facility affecting 1 (one) of five (5) observed residents (Resident 41) for medication administration. As a result, medication administration and availability of medications did not follow facility policy and procedures, resulting in Resident 41 not receiving bumetanide on 6/2/2026 for the 9 a.m. dose. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents who receive heparin (an anticoagulant [a blood thinner that treats and help prevents blood clots]) were monitored for potential side effects (unintended, undesirable effect of a medication or medical treatment) as indicated in the physician's orders for one of five residents (Resident 48) reviewed for unnecessary medications. This failure placed Resident 48 at risk for undetected side effects, potentially resulting in life-threatening complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five (5) percent (%). Two (2) medication errors out of 32 total opportunities contributed to an overall medication error rate of 6.25% affecting two (2) of five (5) residents observed for medication administration (Resident 41 and 74.) The medication errors were as follows: 1. Resident 41 did not receive bumetanide (a medication used for congestive heart failure [CHF] - condition where the heart doesn't pump blood efficiently to the rest of the body) as ordered by Resident 41's physician. 2. Resident 74 was to be administered crushed (a medication turned to soft powder) metoprolol succinate ER 24-hour (a slow-release medication used for high blood pressure throughout a 24-hour period) tablet. [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to secure the keys for one of three medication carts (Medication Cart 2), leaving the keys unattended and allowing unauthorized access to the cart and its contents, including but not limited to Controlled Medications ([CM] - medications which have a potential for abuse and may also lead to physical or psychological dependence, also known as Controlled Drugs). This deficient practice placed residents at risk for unauthorized access to medications, including controlled substances, which could result in medication diversion, misuse, overdose, theft, delayed administration of prescribed medications, and potential harm to residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure safe and sanitary food storage and distribution practices when:A case of thickened dairy drink was served beyond the printed best by date. A bag of dry pasta was stored without a seal or closure. A utensil scoop store inside container of white flour. These deficient practices had the potential to result in harmful bacterial growth that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or toxins) in 55 of 89 residents who received food from the facility kitchen. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care in a manner that maintained a resident`s dignity and respect by failing to ensure Certified Nursing Assistant 1 (CNA 1) knocked prior to entering a resident`s room for one of one resident (Resident 92) reviewed under the dignity care area. This deficient practice violated the resident's right to be treated with respect and dignity and had the potential to affect Resident 92`s sense of self-worth and self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide one of three sampled residents (Resident 32), a safe, clean, comfortable, and homelike environment when the facility failed to ensure Resident 32's living area was kept clean and clutter-free. This failure had the potential to make the resident feel uncomfortable and place the resident at increased risk for accidents and infections.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident or their representative participated in the Interdisciplinary Team (IDT- an interdisciplinary team is a group of health care professionals working collaboratively toward a common goal. This team includes professionals with different roles involved in treating a patient's condition or diagnosis) care planning process conducted on 11/9/2025 for one of 19 residents (Resident 92) reviewed under Care Planning. This deficient practice had the potential to result in Resident 92 not receiving person centered care (person-centered care allows patients to make informed decisions about their treatment and well-being) to meet the resident`s needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care in accordance with professional standards and facility policy and procedures (P&P) for one (1) of five (5) residents (Resident 74) observed for medication administration, by failing to not crush (pressing very hard so that the shape is destroyed and forms a soft powder) metoprolol succinate ER 24-hour (a slow-release medication used for high blood pressure throughout a 24-hour period) tablet. This deficient practice had the potential to result in Resident 74 to experience medication adverse effects (unwanted, uncomfortable, or dangerous effects that a medication may have,) and health complications such as stomach irritation, and ineffective blood pressure control resulting in Resident 74's health and well-being to be negatively impacted.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents received care consistent with professional standards of practice to prevent pressure injuries (PI/PU, injuries to the skin and underlying tissue resulting from prolonged pressure) for two of four residents (Resident 66 and 82) by failing to ensure: 1. Resident 66's both heels were floated (a technique of offloading [any method used to reduce or remove] that involves completely suspending or elevating a body part off a bed or support surface) on pillows. 2. Resident 82's low air loss mattress (LALM - designed to distribute a patient's body weight over a broad surface area and help prevent skin breakdown) was set to the resident's weight per physician`s order. These failures placed the residents at risk of discomfort, development of new pressure ulcers and delayed wound healing.

Inspectors wroteBased on observation interview and record review, the facility failed to ensure the environment was free from accidents and hazards by failing to ensure the floor mat did not have the over-bed table on top of the floor mat for one of four sampled residents (Resident 29) investigated under accidents care area. This failure placed Resident 29 at risk for injury should a fall occur.

Inspectors wroteBased on interview, and record review, the facility failed to ensure that a resident who was receiving dialysis (clinical purification of blood as a substitute for the normal function of the kidney) treatment received services consistent with professional standards of practice by failing to ensure the post dialysis assessment was completed for one of two sampled residents (Resident 29) investigated under the dialysis care area. This deficient practice placed the resident at risk for missed monitoring and delayed identification of complications associated with renal disease and dialysis, including hypertension, fluid overload, shortness of breath, and the potential need for hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to maintain complete and accurate clinical records for one of five sampled residents (Resident 48) reviewed for unnecessary medications by failing to document Resident 48's blood glucose (BG-the main sugar found in the bloodstream) levels and the insulin (medication that lowers the blood sugar) administered to Resident 48, in the Medication Administration Record (MAR) on 5/28/2026 and 5/30/2026. This failure placed the resident at risk for not receiving appropriate care and treatment due to incomplete information in the medical record.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Certified Nursing Assistant 3 (CNA 3) and the Physician Assistant (PA) wore appropriate personal protective equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) while performing high contact activities (tasks involving prolonged or close physical interaction) to one of three sampled residents (Resident 47) placed on enhanced barrier precautions (EBP- infection control interventions to prevent the spread disease). This failure had the potential to result in staff spreading multidrug-resistant organisms (MDRO - bacteria or germs that have developed resistance to multiple antibiotics, making infections hard to treat) to other residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of three sampled staff, (Certified Nursing Assistant [CNA] 3 and Licensed Vocational Nurse [LVN] 3), received enhanced barrier precautions (EBP - infection control interventions to prevent the spread disease) competency training. This failure had the potential to result in the spread of infectious organisms (germs that may cause disease or harm) to residents when staff are not trained, assessed, and monitored to ensure infection control and prevention standards of practice are followed.

Inspectors wroteBased on interview and record review, the facility failed to ensure Registered Nurse 1 (RN 1) documented on a resident's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications given to a resident) right after administering insulin (hormone that regulates the amount of glucose [sugar] in the blood) lispro (rapid-acting insulin) for one of two sampled residents (Resident 1). This deficient practice had the potential to result in medication errors and negatively affect the delivery of care and services to Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure a grievance submitted on behalf of a resident's family member was addressed and investigated per the facility's policy and procedure (P&P) for one of two sampled residents (Resident 1). This deficient practice violated the resident's right to have their grievance addressed and had the potential for further concerns to not be addressed.

Inspectors wroteBased on interview and record review, the facility failed to provide a summary of a resident's baseline care plan (a document that summarizes a resident's needs, goals, and care/treatment) to a resident and/or their representative for one of two sampled residents (Resident 1). This deficient practice had the potential to negatively affect the residents' care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper use of a low air loss mattress (LALM - a specialty bed that alternates pressure to help heal and prevent pressure ulcer/injuries [PU/PI- injuries that breakdown the skin and underlying tissue when an area of skin is placed under pressure]) by placing multiple layers of linens on top of the LALM for one of thirteen sampled residents (Resident 2). This deficient practice had the potential to increase the resident's risk of skin breakdown and/or delayed healing of existing PU/PI.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement policies and procedures (P&P) for the use of a low air loss mattress (LALM - a specialty bed that alternates pressure to help heal and prevent pressure ulcer/injuries [PU/PI - injuries that breakdown the skin and underlying tissue when an area of skin is placed under pressure]) for 12 of 12 sampled residents (Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8, Resident 9, Resident 10, Resident 11, Resident 12 and Resident 13) reviewed for PU/PI prevention. This deficient practice resulted in inconsistent use of the LALM and had the potential to compromise its effectiveness placing residents at risk for skin breakdown and/or delayed healing of PU/PI.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the call light (an alerting device for nurses to assist a patient when in need) was within a resident`s reach while in bed for one of three sampled residents (Resident 2). This deficient practice had the potential to result in a delay in meeting the residents' needs for assistance which could have left the resident feeling isolated, a sense of decreased self-worth, self-esteem and dignity along with an increased risk for falls or accidents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident's ankle foot orthosis (AFO-a medical device worn on the lower leg and foot to support, stabilized and improve function of the affected joint) was properly applied in accordance with the physician's order for one of three (Resident 1) sampled residents. This deficient practice had the potential to promote the development of further contractures (a condition of shortening and hardening of muscles, tensons or other tissue, often leading to deformity and rigidity of joints), decreased movement, strength and overall health status.

Inspectors wrote2. During a review of Resident 76's admission Record, the admission Record indicated the facility admitted Resident 76 on 5/1/2025 with diagnoses that included, but not limited acute and chronic respiratory failure with hypoxia (low levels of oxygen in your body tissues), malignant neoplasm (cancerous tumor) of the larynx (area of the throat known as the voice box), dysphagia (swallowing difficulties), and difficulty walking During a review of Resident 76's H&P, dated 4/8/2025, the H&P indicated Resident 76 did not have the capacity to understand and make decisions. During a review of Resident 76's MDS, dated [DATE], the MDS indicated Resident 76 had the capacity to make himself understood and to understand others. The MDS indicated Resident 76 needed moderate assistance with activities such as oral hygiene and dressing and movements such as rolling left to right and sit to stand. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a licensed nursing staff possessed the competency (a measurable pattern of knowledge, skills, abilities, behaviors that an individual needs to perform work roles successfully) necessary to follow a physician's order by failing to take a Resident 62's apical pulse (a pulse point on the chest that gives the most accurate reading of the heart rate taken with a stethoscope [a device to listen to the heartbeat]) before giving a heart medication for one (LVN 2) of four licensed nurses observed during the medication pass observation. This deficient practice had the potential to cause complications such as bradycardia (slow heart rate with less than 60 beats per minute [bpm.]) dizziness, and syncope (fainting).

Inspectors wroteBased on observation, interview, and record review, the facility failed to have the pharmacy exchange the emergency kit (e-Kit, a collection of medications that need to be given immediately such as pain or antibiotic medication) within 72 hours according to the facility's policy and procedure for two (Subacute Nursing Station, Skilled Nursing Facility Nursing Station) of two Medication Rooms. This had the potential for medications to not be available in emergency situations.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from any significant medication errors for one (Resident 62) of four residents observed during the medication pass observation. Licensed Vocational Nurse 2 (LVN 2) failed to check Resident 62's apical pulse (a pulse point on the chest that gives the most accurate reading of the heart rate taken with a stethoscope [a device to listen to the heartbeat]) before giving a heart medication. This deficient practice had the potential to cause complications such as bradycardia (slow heart rate with less than 60 beats per minute [bpm.]) dizziness, and syncope (fainting).

Inspectors wroteBased on observation, interview and record review, the facility failed to prepare foods in a form designed to meet individual needs when seven of eight residents on puree diet (food that is prepared in a way that is smooth with no lumps and has a texture like pudding) were served puree lemon crisp that was too thick. This deficient practice had the potential to result in a resident having difficulty swallowing and choking.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen by failing to: 1. Ensure peppers stored in refrigerator were labeled with a date when placed in the refrigerator. 2. Ensure the temperature of food items on the tray line (a system of food serving in which a tray is moved along an assembly line to ensure a resident gets their prescribed diet) were taken. 3. Ensure Dietary Aide1 (DA 1) did not touch his glasses with a gloved hand multiple times and did not wash hands or change gloves until asked by the Dietary Supervisor to do so. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Develop and implement a comprehensive person-centered care plan (CP, a plan for individual's specific health needs and desired health outcomes) with individualized oral care interventions for one of one sampled resident (Resident 67) with a tracheostomy (a surgical procedure to create an opening through the neck into the trachea [windpipe]) and dependent on ventilator (a medical device that helps a person breathe when they are unable to do so on their own) during a random observation. This deficient practice had the potential to cause health complications for Resident 67 due to inadequate oral hygiene. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper technique for administering medications through an enteral tube (a tube inserted into the gastrointestinal tract to deliver nutrition and medications) for one of two residents (Resident 74) observed during the medication administration task observation when: 1. Excess crushed tablets were left in the medication cup after the medication was administered. 2. The enteral tube was not flushed with the amount of water indicated in the physician's order between medications. These deficient practices had the potential to cause complications for Resident 74 including clogging the enteral tube and not receiving the full amount of medication as ordered.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary services to maintain oral hygiene for one of one sampled resident (Resident 67), who is unable to carry out activities of daily living, when Resident 67's lips were dry, cracked and had a thick layer of dried saliva and skin on them. This deficient practice resulted in Resident 67 having poor oral hygiene and had the potential to negatively affect the residents' psychosocial wellbeing.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who was incontinent (lacks voluntary control over urination) of bladder (organ in the pelvis that stores urine) received appropriate treatment and services to prevent urinary tract infections (UTIs, common infections that happen when bacteria infect the urinary tract) by failing to ensure the urinary catheter did not coil (unwanted twist or bend) or loop to one of one sampled residents (Resident 60) reviewed under the urinary catheter (a tube that is inserted into the bladder, allowing urine to drain) care area. This deficient practice had the increased potential for Resident 60 to obtain a UTI.

Inspectors wroteBased on interview and record review, the facility failed to ensure the hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) center completed a post-dialysis assessment (evaluation done after hemodialysis by the hemodialysis licensed nurses) by not ensuring the dialysis center recorded a resident's post dialysis weight (the weight after fluid is removed during the dialysis treatment) on 5/15/2025. This deficient practice had the potential for Resident 43 to have unidentified complications after dialysis treatment such as abnormal vital signs (pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medication was properly stored when one of three inspected medication carts (Subacute Medication Cart 2) had an unlabeled, unpackaged tablet in the bottom of a cart drawer. This deficient practice placed residents at risk of receiving an incorrect or expired medication.

Inspectors wroteBased on interview and record review, the facility failed to ensure the accuracy of a medical record when one of twelve residents investigated under the Advance Directive care area (Resident 34) had an Advance Directive Acknowledgement form that indicated the resident had an Advance Directive when he did not. This deficient practice resulted in inaccurate documentation of the existence of an Advance Directive in Resident 34's medical record.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive care plan (a document that summarizes a resident's needs, goals, and care/treatment) with resident-centered interventions to address a resident's preference of wanting keep food at the resident's bedside for one of three sampled residents (Resident 2). This deficient practice had the potential outcome to have a negative affect Resident 2's quality of life, as well as the quality of care and services received.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's discharge summary was completed for one of three sampled residents (Resident 3). This deficient practice had the potential for inconsistent care coordination due to incomplete records for Resident 3.

Inspectors wroteBased on interview and record review, the facility failed implement their hydration and prevention of dehydration policy by failing to ensure one of three sampled residents (Resident 1) intake (consumption) was documented in the resident's medical record. This deficient practice had the potential to place Resident 1 at risk for dehydration and placed Resident 1 at risk for medical complications related to inadequate hydration.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement their policy on preventing foodborne illness (refers to illness caused by the ingestion of contaminated food or beverages) for one of one sampled resident (Resident 2) by failing to ensure cooked eggs found on Resident 2's bedside table were discarded and not left on Resident 2's bedside table for over 24 hours. This deficient practice placed Resident 2 at risk for foodborne illnesses.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement its policy titled, Enhanced Barrier Precautions (EBP - an infection control method that uses targeted gown and gloves to reduce the spread of multidrug-resistant organisms [MDROs - microorganisms, mainly bacteria, that are resistant to one or more classes of antimicrobial [a substance that kills microorganisms such as bacteria or mold, or stops them from growing and causing disease agents]), and Hand washing/Hand hygiene (HH - cleaning hands by either washing with soap and water, or by using a hand sanitizing [removing germs] gel) by failing to ensure: 1. Certified Nurse Assistant 1 (CNA 1) donned (to put on) a gown while changing the bed linen for one of three sampled residents (Resident 1) on EBP. 2. CNA 1 perform HH after removing gloves for one of three sampled residents (Resident 1) on EBP. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain residents' room temperature level between 71-81 degrees Fahrenheit (F- unit of measure for temperature), as required by the federal regulation for one of three sampled residents (Resident 3) and two of seven rooms (Room A and Room B). This deficient practice resulted in the Resident 3's increased level of discomfort and had the potential to negatively impact the residents' quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy and procedure (P&P) titled, Physical Environment, Power Strip (a device that provides multiple electrical outlets connected to a single cable that plugs into an electrical outlet) Policy, by not placing power strips in a safe location while in use for two of three sampled residents (Resident 2 and Resident 4). This deficient practice had the potential for residents, visitors, and staff to have an increased risk of falls, trips, and occupational hazards (hazard experienced in the workplace) while in the facility.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy and procedure on Fall Management and Neurological (deals with problems affecting the nervous system [includes the brain, spinal cord, and a complex network of nerves]) Evaluation by failing to ensure a neurological assessment was completed after an unwitnessed fall on 8/17/2024 for one of three sampled residents (Resident 1). This deficient practice had the potential to result in a delay of care and placed the resident at risk of not receiving appropriate care due to incomplete resident medical care information that may lead to additional falls or complications.

Inspectors wroteBased on interview and record review, the facility to implement their facility's pain management policy by failing to ensure Licensed Vocational Nurse 1 (LVN 1) notified the physician timely to obtain orders to treat residents' pain of for one of three sampled residents (Resident 1). This deficient practice had the potential to result in Resident 1 to experience continued unrelieved pain on 8/18/2024 and not reach the highest possible level of comfort.

Inspectors wroteBased on observation, interview and record review, the facility failed to complete the food preference assessment within 48 hours as per facility policy and protocol for four of five sampled residents (Resident 1,2,3 and 4). This deficient practice had the potential to result in decreased meal intake which can then lead to weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light (a device used by a resident to signal his/her need for assistance from staff) was within reach for three of 24 sampled residents (Resident 2, 7, and 70). This deficient practice had the potential to cause a delay in resident care and for the residents' needs to remain unmet.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident's clinical records were updated with an advance directive (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to healthcare providers) for four of nine sampled residents (Resident 26, 58, 29 and 82) by failing to maintain current copies of the residents' advance directives in their medical records. This deficient practice had the potential to result in confusion in the care and services for Resident 26, 58, 29, and 82 and placed the residents at risk of receiving unwanted treatments and/or not receiving appropriate care based on their wishes.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a written document that summarizes a patient's needs, goals, and care/treatment) for three of 24 sampled residents (Residents 82, 30, 32) as evidenced by: 1. Resident 82 did not have a care plan in place for antibiotic-use that the resident was receiving for a urinary tract infection (UTI- an infection in any part of the urinary system). 2. Resident 30 did not have a care plan in place for Restorative Nursing Assistant (RNA, a program designed to ensure each resident maintains their physical and functional abilities) exercises that accurately reflected the physician's orders. 3. Resident 32 did not have a care plan in place for obstructive and reflux uropathy (a disorder of the urinary tract that occurs due to obstructed urinary flow). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the low air loss mattress (LAL - a specialty bed that alternates pressure to help heal and prevent pressure ulcers [an injury that breaks down the skin and underlying tissue when an area of skin is placed under pressure]) was set correctly for three of five sample residents (Resident 29, 48, and 62). This deficient practice had the potential to increase the resident's risk of skin breakdown.

Inspectors wroteBased on interview and record review, the facility failed to ensure licensed nurses attempted non-pharmacological interventions (any type of healthcare intervention which is not primarily based on medication) prior to administering as needed (prn) opioid pain medication (medication used to treat moderate to severe pain) on multiple dates for one of 24 sampled residents (Resident 30). This deficient practice had the potential to place the resident at increased risk of experiencing adverse side effects (undesired harmful effect resulting from a medication or other intervention) from opioid pain medication.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure there was documented evidence that multiple doses of Zosyn (an antibiotic [medicine that fights bacterial infections]) intravenous solution (IV- a medical technique that administers fluids, medications, and nutrients directly into a person's vein) were administered per physician's order for one of two sampled residents (Resident 2). This deficient practice had the potential for the resident to develop antibiotic-resistant bacteria (when bacteria change to resist antibiotics that used to effectively treat them) due to misuse which could lead to infections taking longer to heal. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure resident's insulin (a hormone that lowers the level of glucose [sugar] in the blood) was dated when opened for two of two sampled residents (Resident 12 and 387). 2. Ensure an eye drop medication was not used past the expiration date for one of one sampled resident (Resident 33). These deficient practices had the potential to diminish the effectiveness of the medications. 3. Ensure only authorized personnel had access to one of two medication rooms (Medication room [ROOM NUMBER]). This deficient practice resulted in unauthorized personnel having access to resident medications and had the potential for drug diversion (illegal distribution or abuse of prescription drug).

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection control practices for three of 24 sampled residents (Residents 337, 187, 188) by failing to: 1. Ensure a resident's nasal cannula (a medical device that provides supplemental oxygen or increased airflow to people who need respiratory help) was not touching the floor for Resident 187. 2. Ensure the urinals (a container used to collect urine) of Residents 187 and 188 were labeled with a resident identifier. These deficient practices had the potential to place the residents at increased risk of contracting an infection. 3. Label the intravenous (IV - into or by means of a vein or veins) administration set (medical device used to deliver IV fluids or medications) used to administer an antibiotic (medication that inhibits the growth of or destroys bacteria in the body) for Resident 337. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an indwelling urinary catheter (a flexible tube inserted into the bladder and left in place to continuously drain urine) collection bag (attached to the catheter tube for the purpose of collecting urine) was covered with a privacy bag (dignity bag- a bag that conceals urine in the collection bag) for one of two sampled residents (Resident 58). This deficient practice had the potential to affect the residents' sense of self-worth and self-esteem.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure a STAT (immediately) specimen for Fecal Occult Blood Test (a lab test used to check stool samples for hidden blood) was collected timely when one of one sampled resident (Resident 25) had a bowel movement. 2. Ensure the result of the FOBT was followed up with the laboratory and the result relayed to the provider promptly for one of one sampled resident (Resident 25). This deficient practice had the potential to delay the necessary intervention for a positive occult blood test which could lead to complications such as anemia (low levels of health red blood cells [delivers oxygen to tissues in your body]).

Inspectors wroteBased on interview and record review, the facility failed to promote and facilitate resident's self-determination through support of choice, by denying two out of two residents (Resident 44 and 57) their preferred meal at dinner time. This deficient practice violated the residents' rights in food preferences and had the potential to affect the residents' sense of self-worth and self-esteem.

Inspectors wroteBased on interview and record review, the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one of five sampled residents (Resident 82) by failing to ensure the Physician's Order for Life-Sustaining Treatment (POLST - a written medical order that helps give residents with serious illnesses more control over their own care by specifying the types of medical treatment they want to receive during serious illness) form was complete for Resident 82. This deficient practice had the potential to result in Resident 82 receiving treatments that were undesired during the event of a medical crisis in which Resident 82 could no longer communicate Resident 82's wishes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent the presence of insects and flies and seal off possible entryway for pests for one of one sampled resident (Resident 3). This deficient practice had the potential to cause an infection to 89 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to accommodate food preferences for milk and more fruits each meal for one of three sampled residents (Resident 1). This deficient practice had the potential to result in decreased meal intake and can lead to weight loss.

Inspectors wroteBased on interview and record review, the facility failed to ensure Nurse Practitioner 1 (NP 1) did not willfully falsify ( knowingly make a false entry into a resident ' s medical record) progress notes for one of three sampled residents (Resident 1) on 1/22/2023, 2/6/2023, and 2/21/2023. This willful material falsification (WMF - when a staff purposefully documents false information in a medical record) resulted in the clinical record of Resident 1 fraudulently reflecting the care provided.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive person-centered care plan (a plan for an individual's specific health needs and desired health outcomes) to address and accommodate the resident's food preferences for milk and more fruits each meal for one of three sampled residents (Resident 1). These deficient practices had the potential to result in a delay in or lack of delivery of care and services.

Inspectors wroteBased on interview and record review, the facility failed to provide a safe, and comfortable environment for residents, staff and the public when on 1/7/2023, a stranger was able to enter the facility and steal food from the employee breakroom. This deficient practice placed the residents, staff, and the public safety at risk from issues such as theft.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a skin assessment was accurately completed during a weekly summary assessment for one of three sampled residents (Resident 2). This deficient practice placed Resident 1 at risk for further skin break down due to not receiving care and treatment related to the newly identified skin redness and red bumps on Resident 2's back and left shoulder.

Inspectors wroteBased on interview and record review, the facility failed to implement its abuse prohibition policy by not conduct pre-employment screening prior to hiring Certified Nurse Assistant 1 (CNA 1) who was accused of rough handling for one of four sampled residents (Resident 1). CNA 1 was hired on 1/2/2024 but the pre-employment screening was done after three months of employment. This deficient practice had the potential to place the residents at risk for elder abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure Certified Nurse Assistant 1 (CNA 1) provided two-person physical assistance (help from two person) when using a mechanical lift (a device used to move those who are unable to stand on their own or whose weight makes it unsafe to move or lift them manually) machine to transfer the resident from the wheelchair to the bed for one of eight sampled residents (Resident 1). This deficient practice had a potential for resident to experience discomfort during transfer and may lead to accident such as fall, and injury.

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Ensure one tube of Diclofenac Sodium External Gel 3% (used externally [outside of body] to relieve pain from arthritis [painful inflammation and stiffness of the joints] in certain joints such as those of the knees, ankle, feet, elbows, wrists and hands) for Resident 2 was placed with a cap in a separate compartment (separate division or section) from oral medications in one of two inspected medication carts (Medication Cart 2 [MC 2]). 2. Ensure one box of Diclofenac Sodium External Gel 1% for Resident 3 was placed in a separate compartment from oral medications in one of two inspected medication carts (MC 2). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control practices by failing to ensure a used, unclean (with brown spots inside) bedside commode (a portable toilet) bucket was not left on top of the trash bin inside a resident's bathroom for one of eight sampled residents (Resident 1). This deficient practice had the potential to spread infection and cross contamination (the physical movement or transfer of harmful bacteria [germs] from one person, object, or place to another) among staff and other residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure that one of four sampled residents (Resident 3) had a physician's order to administer supplemental oxygen (O2 - a treatment that provides you with extra oxygen to breathe in) prior to providing the resident with supplemental O2. This deficient practice had the potential to result in complications from excess or lack of sufficient oxygen level in the body and may lead to a negative impact in the resident's overall health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program and prevent cross contamination (the transfer of bacteria or other microorganisms from one substance to another) for one of two sampled residents (Resident 1) by: 1. Not changing the nebulizer (a small machine that turns liquid medicine into a mist that can be easily inhaled) tubing and the mask weekly as ordered by the physician. 2. Not storing the nebulizer tubing and mask in a bag when not in use. These deficient practices placed residents at risk of respiratory infection.