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Inspectors wroteBased on interview and record review, the facility failed to ensure staff immediately reported allegations of verbal abuse after witnessing the alleged incident, resulting in a delayed investigation. This failure had the potential to affect all 119 residents residing in the facility by preventing the facility from promptly initiating its abuse investigation and implementing timely interventions to protect residents from potential ongoing abuse, compromising residents' right to a safe environment free from abuse.

Inspectors wroteBased on interview and record review, the facility failed to protect residents' right to remain free from employee verbal abuse for 4 (R1, R4, R5, and R6) of 4 residents reviewed for abuse in a total sample of 6 residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure signed consents for the use of psychotropic medications (a drug which affects behavior, mood, thoughts, or perception) were obtained from the resident's representative related to the risks and benefits of using psychotropic medications for one of one resident (R2) reviewed for psychotropic medication use.

Inspectors wroteBased on interview and record reviews, the facility failed to ensure medication were administered as ordered by a Physician for one of three residents (R1) reviewed for medication administration. Findings Include:On 4/7/2026 at 11:40am R1said that she does not receive her medication at 6am and that medication help to balance her thyroid. On 4/7/2026 at 2:00pm this writer reviewed R1 electronic medication administration record indicating that on 3/5/2026, 3/28/2026 and 4/3/2026 at 6am levothyroxine sodium 125mcg. did not have a signature. On 4/9/2026 at 1:00pm V9(Nurse) said I did not work on those days, I think I would have signed them out or maybe I forgot to sign them out. On 4/9/2026 at 1:45pm V2 (Director of Nursing-DON) said I expect the nurses to sign out all medications if it is not signed it was not given. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its smoke policy by allowing residents to smoke near the main entry door and not having metal containers with self-closing cover devices in smoking areas. This applies to all four smokers (R1, R2, R3, and R4) reviewed for safe smoking in a sample of 4.

Inspectors wroteBased on observation, interview, and record review the facility failed to revise and update the comprehensive care plan for one resident identified with injury of unknown origin. This deficiency has the potential to affect 1 of 3 residents (R1) reviewed for Injury of Unknown Origin in a sample of 3. Findings Include:R1 admitted to facility on 11/6/2018. Diagnosis information includes senile degeneration of brain, Alzheimer's disease, primary generalized osteoarthritis, vascular dementia. On 11/25/2025 at 10:43AM, R1 in the second-floor dining room, seated on the wheelchair with pillow on her back and no protective (geri) sleeves worn was observed. [...]

Inspectors wroteBased on interview and record review the facility failed to notify the local emergency room hospital of a resident's transfer for 1 of 1 resident (R1) reviewed for admission, transfer and discharge.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide adequate supervision for residents at high risk for falls and failed to implementing interventions for a resident with wandering behaviors. These failure applied to three of five residents (R52, R56, and R61) reviewed for falls and resulted in R52 sustaining a right hip fracture and a head injury requiring medical treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that staff provide shower and grooming for residents who are dependent on staff for Activities of Daily Living (ADL). This failure affected four (R16, R24, R28, and R86) of five residents reviewed for ADL care.

Inspectors wroteBased on interview and record review, the facility failed to provide residents with palatable and attractive food. This failure affected 13 of 13 residents (R20, R24, R28, R38, R32, R84, R70, R41, R117, R126, R69, R78, and R35) reviewed for dining.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that staff provide incontinence care in a timely manner for a resident assessed as dependent on staff for Activities of Daily Living (ADL). This failure affected one (R24) of one resident reviewed for incontinence care.

Inspectors wroteBased on observation, interview, and record review, facility staff failed to follow facility medication administration policy of ensuring that staff document the administer narcotic medications in the narcotic count sheet, and failed to ensure that the narcotic medications are properly reconciled by staff. These failures affected three (R39, R43 and R70) of five residents reviewed for psychotropic medications and have the potential to affect residents in the North wing, TCU, and memory care units of the facility.

Inspectors wroteBased on interview and record review the facility failed to provide Quality of Care/Treatment related to clinical management of Urinary Tract Infection (UTI) affecting 1 of 4 (R3) residents reviewed for Quality of Care/Treatment. Findings Include: On 3/11/2025 at 11:05 AM V3 (Assistant Director of Nursing/IP) stated on 1/13/2025, he received an order from V18 (Nurse Practitioner) to start R3 with antibiotic Bactrim twice a day for 3 days. V3 stated he entered the order into the electronic medication administration (EMAR) to reflect first dose in 1800 to be administered by nurse on duty. Bactrim antibiotic was ordered STAT from Pharmacy and delivered on 1/14/2025 at 12:31AM to facility. V3 stated first dose of antibiotic can be obtained in the facility convenience box (also known as pixes, capsca). [...]

Inspectors wroteBased on interview and record review the facility failed to ensure a resident was free from physical abuse to 1 of 9 resident (R4) reviewed for physical abuse in the sample of 9.

Inspectors wroteBased on interview and record review the facility failed to return a resident's personal belongings after discharge from the facility for 1 of 3 residents (R1) reviewed for misappropriation of property in the sample of 9 .

Inspectors wroteBased on interview, record review the facility failed to ensure the prescribed treatment was performed for a resident's surgical wound and failed to ensure medical information was sent with a resident's surgical follow up appointment. This applies to 1 of 3 residents (R2) reviewed for quality of care in the sample of 9.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were provided with enough bath towels. This failure affected two of two (R1, R2) residents reviewed for supplies.

Inspectors wroteBased on interview and record review, the facility failed to properly monitor/supervise a high fall risk resident and ensure safety during incontinence care. This affected one of three (R2) residents reviewed for safety during care. This failure resulted in R2 rolling out of bed suffering a laceration to the head which required six sutures at the hospital. Findings Include: R2 is a [AGE] year old with the following diagnosis: malignant neoplasm of the stomach, dementia, anxiety disorder, and repeated falls. An Incident note dated 6/5/24 documents the CNA (V10 - Former CNA) called the nurse's attention to R2's room. R2 was observed lying on R2's left side on the floor with a red substance noted on the floor. R2 stated that R2 rolled out of bed. Pressure was applied to the head by wrapping with gauze to stop the bleeding. 911 was called. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure call light cords were within reach for 4 residents (R6, R7, R8, and R9) out of 9 residents reviewed for call light accessibility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure facility kitchen staff are wearing hair restraints (e.g., hairnet, hat and/or beard restraint) while preparing food to prevent hair from contacting food. This deficiency has potential to affect 127 residents who consumes meal from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep the controlled substance medications in the refrigerator per pharmaceutical/manufacturer's recommendation. This deficiency affects four (R36, R41, R97 and R98) of four residents reviewed for Medication Storage.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident's environment is free from accident hazards and each resident receives adequate supervision to prevent accidents for 1 of 3 residents (R35) in a sample of 27 residents reviewed for medication safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to check for GT (gastrostomy tube) placement prior to administration of medication and enteral feeding. This deficiency affects one (R71) of one resident in the sample of 27 reviewed for tube feeding management.

Inspectors wroteBased on observation, interview, and record review, the facility failed to disinfect/sanitize medical equipment (digital blood pressure monitor and pulse oximeter) used after each resident during medication administration. This deficiency affects two (R86 and R112) of six residents in the sample of 27 reviewed for Infection control.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement and develop fall preventive interventions to residents who are at risk for falls. This deficiency affects all four (R1, R2, R3 and R4) residents reviewed for Fall Prevention Management.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow diet ordered by the physician. This deficiency affects one (R2) of three residents reviewed for Therapeutic diets prescribed by physician.

Inspectors wroteBased on observation, interview and, record review, facility to follow their policy to ensure all dry foods and frozen foods are labeled and dated, and failed to ensure all pots are washed, sanitized and air dried. These failures have the potential to affect 115 residents in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. label opened inhalers, multidose vials of Insulin and nasal sprays with open and discard dates used by residents and stored in 4 of 4 carts in a sample of 7 carts reviewed for medication storage; 2. ensure no food items are kept inside the medication refrigerator; 3. ensure narcotics are counted at the beginning and end of each shift; 3. discard medications of expired and discharged residents; and 3. ensure medication cart is secure. These failures affect 27 residents (R88, R11, R31, R46, R86, R38, R22, R78, R68, R83, R6, R75, R35, R9, R99, R371, R369, R370, R372, R2, R373, R97, R111, R55, R30, R91, and R16) and have the potential to affect all 89 residents who reside in the 1st and 2nd floor of the facility.

Inspectors wroteBased on interview, observation, and record review, the facility failed to follow recommended dietary interventions and physician order for one resident (R33) in a sample of 24 residents reviewed for nutrition.

Inspectors wroteBased on interview and record review, the facility failed to ensure the timely reordering of a routine medication, and failed to ensure the availability of routine medication to enable continuity of care for one (R97) resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication was administered as ordered by the residents physician for one (R97) resident out of sample of 24 residents reviewed. Findings Include: R97s' facesheet documents R97 has diagnoses not limited to: chronic kidney disease stage 3, benign prostatic hyperplasia (BPH), type 2 diabetes mellitus, GERD (Gastroesophageal Reflux Disease), Anemia, Essential hypertension, gout, and cerebral infarction. R97s' POS (Physician Order Sheet) documents the following order: start date- 11/03/2022 Tadalafil tablet 5mg- Give 5mg by mouth one time a day for BPH. R97s' medication administration record documents medication is scheduled at 9:00am daily. On 12/15/2022 at 11:07 AM, V25, Registered Nurse/RN stated, Yes, I am the nurse assigned to care for (R97) today. [...]