Pebble Creek Nursing Center

Inspectors wroteBased on interview and record review the facility failed to ensure that it employed a qualified social worker on a full-time basis for one of one social worker positions reviewed for social services, in that: The facility, which was licensed for 120 beds, failed to employ a qualified social worker on a full-time basis since 05/20/2026. This failure put facility residents at risk of not having their psychosocial or discharge planning needs met.

Inspectors wroteBased on interview and record review, the facility failed to have a designated Infection Preventionist who had completed specialized training in infection prevention and control for 2 of 2 nurses reviewed as designated Infection Preventionists. The facility failed to ensure DON and ADON LVN K, designated Infection Preventionists, completed the required specialized training in infection prevention and control. This failure could affect the facility's ability to appropriately recognize and respond to communicable diseases and infections including COVID-19.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the resident had a right to be treated with respect and dignity including the right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms for 1 of 5 residents (Resident #3) reviewed for restraints. The facility failed to ensure Resident #3 was free from any physical restraint when a pillow was observed tucked under the bedsheet in a manner that restricted movement to Resident #3. This failure could place residents at risk for restricted movement, feeling of entrapment, decreased mobility, and possible injury. Record review of Resident #3's face sheet, dated 04/22/2026, reflected an [AGE] year-old female who was admitted to the facility on [DATE] and then readmitted on [DATE]. [...]

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. - The facility's kitchen staff failed to ensure a zip top bag that contained meat slices was sealed in the walk-in refrigerator on 03/28/2026.- The facility's kitchen staff failed to maintain safe consumable produce as evidence by overripened whole bananas with black peels in a container in the walk-in refrigerator. [...]

Inspectors wroteBased on observations, interview and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for one of eight residents (Resident#1) reviewed for ADL care. -The facility failed to ensure Resident #1's face was clean and free of facial hair on 03/30/26. This failure could place residents who required assistance with ADL's at risk for unmet care needs.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the resident had the right to and the facility must make prompt efforts to resolve grievances the resident may have and identify a Grievance Official who was responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusion, leading any necessary investigations by the facility, maintaining the confidentiality of all information associated with grievances, issuing written grievances decisions to the resident, and coordinating with state and federal agencies as necessary in light of specific allegations for 1 of 1 grievance binders reviewed. The facility failed to ensure they were adhering to the facility grievance policy to receive and track grievances that were filed orally by residents prior to 3/13/2026. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that the residents had the right to a dignified existence for 2 (Resident #5 & Resident #6) of 4 residents reviewed for resident rights. The facility failed to ensure the urinary collection bags for Resident #5 and Resident #6's catheters were covered with a privacy bag. This failure could place residents at risk for a loss of dignity, decreased self-worth and decreased self-esteem. Resident #5: Record review of Resident #5's face sheet dated 01/22/2026, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview, 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 disease and infection for 3 of 4 residents (Resident #5, Resident #7, Resident #8) reviewed for infection control. The facility failed to ensure the urinary catheter bag for Resident #5, Resident #7, and Resident #8 were anchored and secured to prevent infection. This failure could place residents at risk of infection due to improper care practices. Resident #5: Record review of Resident #5's face sheet dated 01/22/2026, revealed an [AGE] year-old female who was admitted to the facility on [DATE]. [...]

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 4 (Resident #1, Resident #8, Resident #9, Resident #15) of 6 residents reviewed for dignity with meal assistance. The facility failed to ensure that Residents #1 was assisted with eating while staff were seated at eye level. The facility failed to ensure that Residents #8 was assisted with eating while staff were seated at eye level. The facility failed to ensure that Residents #15 was assisted with eating while staff were seated at eye level. The facility failed to ensure staff asked Resident #9 if the resident wanted to wear a clothing protector. [...]

Inspectors wroteBased on observation, interview 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 disease and infection for 1 of 2 residents (Resident #12) reviewed for infection control in that: The facility failed to ensure staff followed infection control practices during wound care when Wound Care Nurse did not change gloves between contaminated and clean tasks for Resident #12. This facility failure could place residents at risk for worsening pressure injuries, pain, and a decline in health.

Inspectors wroteBased on 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 11 residents (Residents #16) reviewed for Neglect. The facility failed to immediately implement protective measures on 03/03/25 when the charge nurse reported to the DON concerns related to Resident #6 not receiving anticonvulsant medication according to the physician's order. The facility proceeded to allow the doses to be missed during the weekend of 3/08/25-03/09/25 without interventions/protections during that time. An Immediate Jeopardy (IJ) situation was identified on 05/18/25. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident's drug regimen was free of significant medication errors for 1 (Resident # 16) of 6 residents reviewed for pharmacy services. The facility failed to administer Resident #16's Levetiracetam 100 mg/ml 7.5 ml by mouth two times on 03/08/25 at 8:00 a.m. and 8:00 p.m. and two times on 03/09/25 at 8:00 a.m. and at 8:00 p.m. according to physician orders. An Immediate Jeopardy (IJ) was identified on 05/18/25. While the IJ was removed on 5/20/25, the facility remained out of compliance at a severity level of actual harm not IJ with a scope of pattern because the facility had not had time to monitor their plan of removal for effectiveness. This failure placed residents on anticonvulsant medications at risk for harm, or neglect.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure in response to allegations of abuse, neglect, exploitation, or mistreatment the facility had evidence that all alleged violations were thoroughly investigated and prevent further abuse, neglect, exploitation, or mistreatment while the investigation was in progress for 1 of 11 residents (Residents #16) reviewed for abuse/neglect. - The facility failed to investigate, prevent, correct, and report alleged violations of neglect for Resident #16 when reported by LVN C on 03/03/25. An Immediate Jeopardy (IJ) was identified on 05/18/25. While the IJ was removed on 5/20/25, the facility remained out of compliance at a severity level of actual harm not IJ with a scope of pattern because the facility had not had time to monitor their plan of removal for effectiveness. [...]

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 6 of 15 residents reviewed (Resident #25, Resident #37, Resident #40, Resident #58, Resident #67, and Resident #76) for residents' rights, in that: The facility staff failed to knock before entering the room of Resident #25, Resident #37, Resident #40, Resident #58, Resident #67, and Resident #76. This failure could affect residents' self-esteem and dignity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents receive services in the facility with reasonable accommodation of resident needs and preferences for 2 of 11 residents (Resident #22 and #88) reviewed for call light placement. The facility failed to ensure call lights were within reach for Residents #22 and #88. This failure could affect residents by not having access to call for assistance resulting in needs not being met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident's environment was as free of accident hazards as possible for 3 of 30 residents (#18, #48, and #75) reviewed for accidents. -The facility failed to properly dispose of a retractable lancet device (small, pen like tool that holds a lancet (a small needle) used to prick the skin for blood sampling) in sharps container in one room (resident# 75). -The facility failed to properly dispose of a razor in one room (rResidents #18 and #48's room) This deficient practice could place residents at risk of harm or injury and contribute to avoidable accidents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature, for one test tray reviewed and for 3 residents (Resident #6, Resident #40 and Resident #41) of 18 residents interviewed in hallways 100 and 500. The facility failed to maintain food hot on regular diet, puree diet, renal diet, test trays and served cold meals to Resident #6, Resident #40 and Resident #41. This failure could place residents who ate in their rooms at risk of poor intake and/or foodborne illness.

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 out of 1 kitchen . The facility failed to cover and seal the meal carts containing the residents' meal trays while transporting them through four out of four hallways in the facility. The facility failed to ensure staff wore hairnets in the kitchen. The facility failed to maintain 1 ranch dressing container and 1 mayonnaise container free from drippings during the initial kitchen tour The facility failed to thaw ground meat under running cold water per policy during initial kitchen tour. The facility failed to maintain clean grease filters over the stovetop during the initial kitchen tour. The facility failed to maintain 2 of the 3 compartments' sinks within the appropriate temperature. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 4 residents (Resident #16) reviewed for clinical records, in that: The facility failed to ensure that LVN C documented completely and accurately in the resident's clinical record when Resident #16 had a seizure on 03/10/25. This deficient practice could affect residents that had history of seizures and at place them at risk of having incomplete and inaccurate medical records .

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice for 1 (Resident #44) of 12 residents observed for oxygen management. -Resident #44 utilized oxygen in his room and did not have an oxygen sign posted outside of the room. This failure could place residents on oxygen therapy at risk of receiving incorrect or inadequate oxygen support and decline in health and at risk of fire hazards by not posting oxygen signs outside the residents' rooms.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 (Residents #75) of 31 residents reviewed for infection control. The facility failed to keep rResident #75's bed sheet clean and free of blood stains. These deficient practices could place residents at risk for infection due to improper care practices.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents had the right to have reasonable access to the use of a telephone and a place in the facility where calls can be made without being overheard for 1 of 4 (Resident #1) residents reviewed for telephone use. The facility failed to provide a place for Resident #1 to make telephone calls without being overhead. This failure could place residents at risk of conversations being overheard and privacy rights not being respected.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan that included measurable objectives and time frames to meet a resident's medical and nursing needs and described the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 (Resident #1 and Resident #8) of 9 residents reviewed for care plans. -The facility failed to follow the comprehensive person-centered care plan for Resident #1's and #8's fall risk, by failing to have fall mats in place next to bed while residents were lying down in bed. This deficient practice could place residents in the facility at risk of not receiving the necessary care or services as indicated in their comprehensive person-centered plans developed to address their needs.

Inspectors wroteBased on interviews, and record reviews, the facility failed to ensure all residents were free from abuse for 1 (Resident #2) of 5 residents reviewed for abuse. On 08/01/24, CNA A was providing Perineal Care (cleaning the private areas of residents) to Resident #2. During the peri-care CNA A was observed being verbally and physically abusive, grunting, rough, and aggressive while turning Resident #2. CNA A was observed aggressively positioning Resident #2's legs and arms and aggressively putting on the brief, and Resident #2's bottoms. The following day 08/02/24 Resident #2 was assessed by the nursing staff revealing a 4 cm (a metric unit for the measurement of length of objects and small distances) by 3 cm left lower leg bruise, 7 cm by 4 cm left leg bruise, and 5 cm by 2 cm inguinal (relating to or situated in the region of the groin) area left side bruise. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good grooming and personal and oral hygiene for 2 of 5 (Resident #2, Resident #7) residents reviewed for assistance with peri-care. CNA A failed to provide perineal care with professional standards to ensure Resident #2 was clean, free of contamination. CNA K failed to provide perineal care with professional standards for Resident #7 to ensure they were clean, free of contamination. This failure could place residents who were dependent on staff for ADL care at risk for infections.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure nurse staffing data was posted and readily accessible to residents and visitors for two days (06/30/2024, and 07/01/2024) reviewed for nurse staffing information. The facility failed to post and maintain the required nursing staffing information to include facility name, current date, current resident census, and total number and actual hours worked by licensed and unlicensed nursing staff for dates of June 29th and July 1st, 2024. These failures could place residents, their families, and facility visitors at risk of not having access to information regarding facility regarding staffing schedule and facility census.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure that the residents environment remains as free of accidents hazards as is possible and each resident receives adequate supervision to prevent accidents for 1 (Resident #2) of 6 residents, and one (room [ROOM NUMBER]) of 5 rooms observed. During observations conducted on 05/14/24 at 9:08 am, the sharps container located in room [ROOM NUMBER] occupied by Resident #2, had two disposable razors exposed and reachable on top of the box. During observations conducted on 05/14/24 at 10:24 am, the sharps container located in room [ROOM NUMBER] had one syringe exposed and reachable on the top of the box. This failure could place residents at risk of accidents, and potential harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 2 of 6 residents reviewed for infection control. LVN E failed to use gown prior to providing care for Resident #46 who is on enhanced barrier precautions. RN F failed to use gown prior to providing care for Resident #74 who is on enhanced barrier precautions. This failure could place residents at risk for cross contamination and the spread of infection. Findings Included: [...]

Inspectors wroteBased on interviews and record reviews the facility failed to ensure the resident's had the right to be informed of the risks, and participate in, his or her treatment which included the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she preferred, for 3 of 20 residents (Resident#29, Resident #46, Resident # 90) reviewed for resident rights. The facility failed to obtain informed consent based on information of the benefits, risks, and options available from Resident #29 prior to administering Lorazepam, an antianxiety medication used to treat anxiety. [...]

Inspectors wroteBased on observation, interviews and record review the facility failed to ensure residents the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 (Residents #1) of 6 residents reviewed for accommodation of needs: Resident #1's call light was not left within his reach or within sight. This failure could place residents at risk of not having their needs met and a decline in their quality of care and life.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide necessary services to maintain good grooming and hygiene for a resident who was unable to carry out activities of daily living for 2 residents out of 3 (Resident #45, Resident #40). The facility failed to provide personal hygiene for Resident #45 and facial hair care for Resident #40. This deficient practice placed residents at risk of poor hygiene and decline in residents' self-esteem.

Inspectors wroteDuring observation, interview, and record review the facility failed to ensure residents with urinary incontinence received appropriate treatment and services to prevent urinary tract infections for 1 resident 1 (Resident #39). Resident #39's indwelling catheter tubing was laying on the floor. The facility failed to ensure Resident #39's subpubic catheter was properly secured . This failure placed resident at an increased risk of a Urinary Tract infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments and described in the plan of care for 1 of 3 (Resident #14) residents reviewed for care, in that: CNA A changed Resident #14's colostomy bag and wafer without being trained on how to perform the procedure. (A colostomy wafer is a plastic ring that adheres to the skin around the stoma which is an opening in the stomach and connects to an ostomy bag. The wafer, also known as a flange, baseplate, or skin barrier, is designed to protect the skin from the stool that passes through the stoma. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to medications in medication cart 1 of 4 reviewed for label and storage of drugs and biologicals. The facility failed to ensure medication cart #1 was locked when unattended. The facility failed to ensure discontinued medication was locked in medication rooms. This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm or drug diversions.

Inspectors wroteBased on observation, interviews, 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 reviewed for Food safety. The facility failed to close and seal food and seasonings, dispose of expired foods, and maintain a vent free of dust build up. This failure could affect residents by placing them at risk of food borne illness.

Inspectors wroteBased on interviews, and record reviews, the facility failed to ensure the MDS assessment accurately reflected the resident's status for 1 (Resident #82) of 6 residents reviewed for accuracy of MDS assessments. - The facility failed to ensure that Resident #82's MDS accurately reflected resident's behaviors related to physical behaviors directed toward others. This deficient practice could affect residents who receive MDS assessments and could cause residents not to receive correct care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide reasonable accommodation of needs for 2 (Residents #3 and #5) of 16 residents reviewed for call light button placement. -The facility failed to ensure that Residents #3's and #5's call lights were within their reach. This failure could place residents at risk of not being able to have their needs met.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident's medical and nursing needs, and services to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being for 1 of 5 (Resident #2) residents reviewed for care plans. -The facility failed to implement a comprehensive person-centered care plan for Resident #2 to include head of bed to be elevated 30 degrees due to continuous enteral feeding (nutrition delivered using the gut). This deficient practice could place residents in the facility at risk of not receiving the necessary care or services and not having personalized plans developed to address their needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident who is fed by enteral means receives the appropriate treatment and services for 2 of 5 (Resident #2 and Resident #15) reviewed for enteral feeding. -The facility failed to ensure that Resident #2 and Resident #15's head of bed was maintained at 30 degrees elevated according to physicians' orders. The failure could place residents receiving enteral feedings at risk of aspiration (when food or liquid goes into the lungs or airway).

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure residents the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 3 (Resident #1, Resident #2, and Resident #4) of 7 residents reviewed for call light response time. The facility failed to respond in a timely manner to Resident #1, 2, and 4's call lights. Staff failed to respond to Residents #2's call light notification for 47 minutes. This failure puts residents at risk of not being able to get assistance when using the call light system whatever needs or incidents occur.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident medical and nursing needs to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being for 1 of 7 residents (Resident #7) reviewed for care plans in that: The facility failed to implement a comprehensive person-centered care plan for Resident #7's oxygen therapy. This deficient practice could place residents in the facility at risk of not receiving the necessary care or services and having personalized plans developed to address their needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice for 2 (Resident #6 and Resident #7) of 10 residents observed for oxygen management. The facility failed to ensure Resident #6 and Resident #7 had an oxygen sign posted outside their bedrooms. This failure could place residents at risk of being exposed to combustion or flammability.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide care that in accordance with professional statndards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 of 9 (Resident #8) residents reviewed for medication administration. The facility failed to administer diarrhea medication (Imodium) as prescribed for Resident #8 who had history of loose stools on: 09/21/23 at 1:59 pm and 9:39 pm, 09/22/23 at 12:23 am, 12:04 pm, 9:48 pm, 09/23/23 at 12:04 pm and 9:48 pm, 09/25/23 at 9:59 pm, 09/26/23 at 12:59 pm. This failure could place residents at risk for not receiving their medications, not receiving the intended therapeutic effects of their medication and could contribute to possible adverse reactions.

Inspectors wroteBased on interview and record review the facility failed to provide written notice, including the reason for the change, before the resident's room or roommate in the facility is changed for 1 of 9 (Resident #9) residents reviewed for room changes. The facility failed to notify Resident #9's RP of room changes on 06/24/2023. This failure could place residents at risk for decrease quality of life being in a new environment.

Inspectors wroteBased on observation, interview, and record review the facility failed to consult with the resident's physician when there is a need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment) for 1 of 9 (Resident #8) residents reviewed for notification to NP/MD. The facility failed to notify NP/MD of Resident #8's unresolved loose stools. This failure could affect residents by placing them at risk of delay in medical treatment, hospitalization, and decline in condition.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 9 (Resident #8) residents reviewed for care plans. The facility failed to develop a care plan addressing Resident #8's history of loose stools. This failure could place residents at risk of not having their individual care needs met, which could cause a decline in physical health, psychosocial health, and quality of care.

Inspectors wroteBased observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals, and preferences for 1 of 9 (Resident #8) residents reviewed for oxygen therapy. The facility failed to ensure Resident #8's oxygen tank was full while receiving oxygen therapy. This failure could affect residents receiving oxygen therapy at risk for respiratory distress.

Inspectors wroteBased on observation, interview, and record review the facility failed maintain an effective pest control program so that the facility is free of pests and rodents for residents for 1 of 9 (Resident #9) residents reviewed for environment. The facility failed to keep Resident #9's room clean to avoid ants in room. This was determined to be past non-compliance at potential for more than minimal harm due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the inspection.

Inspectors wroteBased on observation and interview the facility failed to post notice of the availability of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction reports in areas of the facility that were prominent and accessible to the public. 1. The facility failed to verbally inform residents or by posting a sign letting the residents know the location of the most recent survey results. This failure could place residents at risk of not being able to fully exercise their rights to be informed of the facility's survey citation history.

Inspectors wroteBased on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the residents' rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 2 of 10 (Residents #3 and #26) residents reviewed for comprehensive care plans. 1. The facility failed to ensure Resident #3 comprehensive care plan addressed Resident #3's oxygen. 2. The facility failed to ensure Resident #26 pommel cushion in was included on her care plan. These deficient practices could place residents at risk of not receiving care and services to meet their needs.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident who was fed by enteral means received the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding which included but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers for 2 of 10 residents (Resident # 193 and Resident #87) reviewed for enteral feeding. 1. The facility failed to ensure Resident #193 enteral feeding was changed within 48-hour period. 2. The facility failed to ensure Resident #87's enteral feeding bag label had the time the administration of the feeding was begun and did not have the rate of administration. The feeding pump did not correctly reflect the amount of formula that had been delivered to the resident. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents received parenteral fluids must be administered consistent with professional standards of practice and in accordance with physician orders for 2 of 10 residents (Resident #197 and Resident #14) reviewed for midline/picc care. 1. Resident #197's midline (intravenous catheter) was dated 3/8/23, edges of dressing were loosened and dry blood around insertion site. 2. Resident #14 picc line dressing was not dated These failures placed residents at risk of developing an infection.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 2 of 10 residents (Residents #3 and Resident #86) reviewed for respiratory care. 1. The facility failed to ensure Resident #3 received oxygen according to physician orders. 2. The facility failed to ensure Resident #86 received oxygen according to physician orders. 3. The facility failed to ensure the residents on oxygen in 4 of 10 rooms (403, 404, 405, 414) had oxygen signs posted outside their bedrooms as there were no signs posted outside of their bedroom for oxygen use. This failure could place residents at risk of receiving incorrect or inadequate oxygen support and decline in health.

Inspectors wroteBased on the 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) kitchen reviewed for food and nutrition services 1. The facility failed to ensure food products in the dry storage, freezer, and in the refrigerator were correctly labeled, wrapped, and were not expired. 2. The facility failed to ensure 2 of 6 kitchen staff effectively wore hairnets exposing their hair. These failures could place residents at risk of food borne illness.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents had the right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience and not required to treat the residents medical symptoms for one of 10 residents (Resident #26) reviewed for restraints The facility failed to assess and document Resident #26's need for a pommel cushion in her wheelchair. This failure could place residents at risk of having items that restrict their movement without the items having been evaluated for their necessity to treat medical symptoms or conditions.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure assessments accurately reflected the resident's status for 2 of 10 residents (Residents #3 and Residents #26) reviewed for accuracy of assessments . 1. The facility failed to accurately reflect Resident #3's oxygen therapy on the Quarterly MDS assessment. 2. The facility failed to accurately reflect Resident #26 use of a pommel cushion in her wheelchair on her Annual MDS assessment. These failures could place residents at risk for inaccurate and incomplete MDS assessment which could cause residents not to receive correct care and services.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care and the facility failed to ensure the baseline care plan was developed within 48 hours of a resident's admission for 1 of 6 residents (Resident #197) reviewed for baseline care plan. The facility failed to ensure Resident #197 had a baseline care plan that addressed her midline IV catheter. This failure could place residents at risk of not receiving the care and services and continuity of care.

Inspectors wroteBased on observation, interview and record review the facility failed to provide treatment and services to prevent urinary tract infections for 1 of 12 residents (Resident # 57) reviewed for infection control. 1. The facility failed to ensure Resident #57's catheter bag was not on the floor. This failure place residents at increased risk for urinary tract infections. Record review of Resident #57's face sheet, dated 04/05/2023, documented a [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #57's admission History and Physical, dated 05/06/2022, documented she had a Foley (urinary) catheter in place. Her diagnoses included unspecified dementia (memory loss affecting daily activities) and that she had urinary incontinence (involuntary loss of urine from the bladder) . [...]

Inspectors wroteBased on observation , interview and record review the facility failed to provide pharmaceutical services, which included procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 1 resident of 7 residents (Residents #69) reviewed for pharmacy services. 1. The facility failed to ensure LVN D did not administer expired insulin to Resident#69. 2. The facility failed to ensure LVN D administered insulin to Resident #69 according to Manufacturer's Specifications. 3. The facility failed to maintain an accurate record of controlled drug destruction. These deficient practices could result in a decline in health due to incorrect monitoring of medication after administration and an accurate record of controlled drug destruction could result in drug diversion.

Inspectors wroteBased on interview and record review the facility failed to ensure the pharmacist reported any irregularities to the attending physician and the facility's medical director and director of nursing, and failed to ensure these irregularities were acted upon for one resident of five residents (Resident #51) reviewed for Drug Regimen Review. The facility failed to ensure the physician gave a reason for not accepting the pharmacy consultant recommendation in January 2023 that Resident #51 received gradual dose reduction for Risperdal (an antipsychotic). This deficient practice could place residents at risk of receiving unnecessary medications and dosages.

Inspectors wroteBased on interview and record review the facility failed to ensure residents who used psychotropic drugs received gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs for one resident of five residents (Resident #51) reviewed for unnecessary medications. The facility failed to ensure Resident #51 received a gradual dose reduction for Risperdal (an antipsychotic). This deficient practice could place residents at risk of receiving unnecessary medications and dosages.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure medication error rates were not 5 percent or greater. There were 2 errors out of 27 opportunities which resulted in a 7.41 percent error rate which involved 1 of 7 residents (Residents #69) reviewed for medications. 1. The facility failed to ensure LVN D did not administer expired insulin to Resident#69. 2. LVN D failed to ensure Resident #69 received a nutritional snack/meal within 15 minutes according to manufacturer's specifications . These failures could place residents at risk of not receiving medications according to physician orders.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents were free of significant medication errors for 1 of 7 residents (Resident #69) reviewed for significant medication errors. LVN D failed to administer insulin to Resident #69 according to Manufacturer's Specifications. This deficient practice could place residents' at risk of hypoglycemia .

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure medical records , in accordance with accepted professional standards and practices, were maintained on each resident that were accurately documented for 1 of 6 residents (Resident #197) reviewed for medical records. The facility failed to ensure Resident #197's treatment administration record accurately documented treatment for the residents midline dressing. This failure could place residents at risk of infection by not receiving treatment as ordered by physician.