Pelican Ridge Post Acute

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the infection control practices were followed for one of 10 sampled residents (Resident 3). * The facility failed to ensure the staff wore proper PPE when providing treatment to Resident 3 who was on contact isolation for C. diff. This failure put the resident at risk for increased risk of infection and transmissions of diseases.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the pharmaceutical services to meet the resident's needs for one of 20 sampled residents (Resident 13). * The facility failed to follow the physician's order for the administration parameters set for the carvedilol (a medication to treat high blood pressure) and midodrine (a medication to treat low blood pressure) medications. This failure had the potential for negative outcomes for the resident.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure one of 12 sampled residents (Resident 2) was informed of the risks and benefits of proposed care, treatment, and treatment alternatives or options, and the choice to choose an alternative option in advance. * The facility failed to ensure Resident 2 and Family Member 1 were informed of the risks and benefits of using the IV fluid therapy, as well as providing alternative options for treatment. This failure had the potential for Resident 2 and Family Member 1 to not to be informed of the IV fluid solution and its potential effects, and prevent the resident from participating in choosing her treatment decisions.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of 12 sampled residents (Resident 9) was free from physical abuse . * Resident 9 was in the activities room when Resident 10 hit Resident 9's right hand. As a result, Resident 9 sustained redness to the right hand. This failure had the potential to negatively impact Resident 9's well-being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable well-being for one of 12 sampled residents (Resident 2). * The facility failed to weigh Resident 2 daily as ordered by the physician. * The facility failed to monitor Resident 2's condition after the resident sustained a bump on the head. These failures had the potential to negatively impact the resident's well-being.

Inspectors wroteBased on interview and medical record review, the facility failed to develop and implement a comprehensive person-centered care plan to reflect the individual care needs for one of 12 sampled residents (Resident 2). * The facility failed to ensure a care plan was developed to address Resident 2's use of IV fluids. This failure posed the risk of not providing appropriate, consistent, and individualized care to the resident.

Inspectors wroteBased on interview, medical record review, and facility document review, the facility failed to ensure care was coordinated with the hospice provider for one of 12 sampled residents (Resident 8) reviewed for hospice. * The resident's hospice binder was not completed to show when the hospice provider visited Resident 8. This failure had the potential for the resident not receive the ordered hospice care services.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the baseline care plan was developed to reflect the specific care needs for one of 18 sampled residents (Resident 10). * The facility failed to ensure a baseline care plan problem was developed to address Resident 10's surgical incision care upon admission to the facility. Resident 10 was admitted to the facility on [DATE], however, the facility had not assess, monitor and/or provide wound care to Resident 10's surgical incision until 9/2/25. This failure resulted in the resident's care needs not being met and had the potential to affect the resident's well-being.

Inspectors wroteBased on observation, interview, and the facility P&P review, the facility failed to provide services to attain or maintain the highest practicable well-being for one of 18 sampled residents (Resident 10). * Resident 10 was admitted to the facility from the acute care hospital on 4/17/25, with a surgical incision with three stitches on his left lateral thoracic region. The facility failed to assess and monitor the surgical wound, note the presence of the stitches and provide wound care since the resident's admission to the facility until the wound was brought to the facility's attention on 9/2/25, by the resident's outpatient dialysis clinic. This failure resulted in a delay in identifying the resident's surgical incision and providing the care required, which had the potential to place the resident at harm for impaired healing and increased risk for infection.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary care and services to one of three sampled residents (Resident 8) reviewed for fall. * The facility failed to provide the necessary care and services for Resident 8 who had a fall on 9/14 and 9/16/25, including the assessment of the resident's change in condition, neurological assessments and post fall assessments after the falls. In addition, the facility failed to notify the physician and the resident's representative of the fall incidents. This failure had the potential to delay the identification and treatment of a possible fall-related injury and posed the risk of additional falls and injury to the resident.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary respiratory care and services for two of 17 sampled residents (Residents 4 and 5). * The facility failed to ensure Resident 4's CPAP (Continuous Positive Airway Pressure. It is a treatment that uses a machine to deliver mild air pressure through a mask, which prevents the upper airway from collapsing during sleep. This is the most common treatment for a condition called obstructive sleep apnea) mask was stored in a sanitary manner. * The facility failed to provide a CPAP machine to Resident 5. These failures had the potential to affect the respiratory health and well-being of the residents in the facility.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed ensure the dialysis care was provided for two of four sampled residents (Residents 10 and18) reviewed for dialysis. * The facility failed to ensure Resident 10's dialysis access was assessed accurately as ordered by the physician. * The facility failed to ensure Resident 18 received the dialysis treatment in an outpatient dialysis center as ordered by the physician. These failures had the potential for the residents not being provided with the appropriate care and treatment, and the possibility of medical complications related to dialysis.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure the licensed nurses and certified nursing assistants (CNA) had specific competencies and standard of practice skill sets needed to provide the safe and efficient nursing care to the residents as evidenced by: * Resident 10 was admitted on [DATE], with a surgical incision with three sutures that was not assessed, monitored or had care provided from the date of admission until 9/2/25, when the wound was brought to the attention of the facility by the resident's outpatient dialysis clinic. This failure had the potential to put the Resident 10 at risk for care not provided in a safe and competent manner.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to follow the physician's order for one of 18 sampled residents (Resident 11). * The facility failed to administer lidocaine patches to Resident 11 per the physician's order. This failure had the potential to negatively impact the resident's well-being.

Inspectors wroteBased on interview and medical record review, the facility failed to develop and implement a comprehensive person-center care plan for to reflect the individual care needs for one of 18 sampled residents (Resident 10). * The facility failed to ensure a care plan was developed to address Resident 10's refusal of multiple aspects of his plan of care. This failure had the potential to cause inappropriate and inadequate plans of care for the resident.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to revise the resident centered care plan for one of three sampled residents (Resident 8) reviewed for fall. * The facility failed to revise Resident 8's care plan and reassess the effectiveness of the interventions of Resident 8's care plan when Resident 8 fell on 9/14 and 9/16/25. This failure placed the residents at risk of not being provided appropriate, consistent, and individualized care.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medical records were complete and accurate for two of 18 sampled residents (Residents 8 and 11). * The facility failed to ensure Resident 8's Monitor Record was accurate and complete. *The facility failed to ensure Resident 11's MAR was accurate. These failures had the potential for Resident 8 and 11's care needs not being met as the medical records were inaccurate. Findings 1. Review of the facility's P&P titled General Documentation Guidelines dated 10/2024 showed it is the policy of this facility to document relevant findings in the clinical record specific to each individual resident's needs and condition. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to obtain a complete and accurate informed consent (process in which a health care provider educates a patient about the risks, benefits, and alternatives of a given procedure or intervention to obtain agreement or permission for care, treatment, or services) for the psychotropic medications for three of 28 sampled residents (Residents 8, 86, and 154). * Resident 8's Informed Consent dated 8/17/25, for duloxetine 40 mg po QD (once a day) for depression had no date next to the physician's signature. * Resident 86's Informed Consent dated 7/25/25, for quetiapine 100 mg one tablet by mouth three times a day for psychosis and trazodone (antidepression medication) 100 mg one tablet by mouth every bedtime for inability to sleep had no resident signature on the informed consent. [...]

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide reasonable accommodations to meet the needs for three of 140 residents (Residents 1, 2, and 8). * The facility failed to ensure Resident 1, 2, and 8's call light was within the residents' reach. This failure posed a risk in a delay in providing care to the residents and the potential to negatively impact on the residents' well-being.

Inspectors wroteBased on interview, medical record review, and facility document review, the facility failed to provide the written Notice of Medicare Non-coverage (NOMNC) form CMS-10123 and the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) form CMS-10055 for one of three residents reviewed for beneficiary notification (Resident 7). The NOMNC and SNFABN forms are used to inform the residents of their potential financial liability, appeal rights, and protection should they wish to receive care and services that may not be covered by Medicare. This failure had the potential of not allowing Resident 7 and/or their representative to make an informed decision regarding their Medicare services.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure four of six sampled residents (Residents 3, 8, 86, and 154) reviewed for unnecessary medications were free from unnecessary medications. * The facility failed to ensure Resident 3 was monitored for an adverse events such as orthostatic hypotension, and failed to show documented evidence an AIMS assessment was conducted for the use of the Risperdal (antipsychotic medication). * The facility failed to ensure Resident 8's order for lorazepam (antianxiety medication) PRN had a duration for use, failed to show documentation for non-pharmacological interventions for the use of duloxetine (antidepressant medication), and failed to show documentation of the behavior monitoring for the depression. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to develop and implement a comprehensive person-centered care plan to reflect the individual care needs for one of 28 final sampled residents (Residents 138). * The facility failed to develop a care plan problem when Resident 138 developed a DTI (Deep Tissue Injury) in the right heel. This failure posed the risk of not providing appropriate, consistent, and individualized care to Resident 138.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to provide the necessary care and services for one of one final sampled resident reviewed for ADL care (Resident 102). * The facility failed to ensure Resident 102's long fingernails were trimmed. This failure had the potential for Resident 102 to experience physical discomfort and skin breakdown due to scratching with long fingernails.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure three of six final sampled residents (Residents 2, 96, and 138) and one nonsampled resident (Resident 71) reviewed for pressure injury were provided with the necessary care and services. * The facility failed to provide LAL mattress to Resident 138 per the resident's plan of care for wound management and skin maintenance. In addition, the facility failed to ensure Resident 138's LAL mattress setting was accurate to the resident's weight and was not in static mode while the resident was in bed when the LAL mattress was provided. [...]

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to provide the appropriate care and services for the use of the GT for three of seven final sampled residents (Residents 41, 94, and138) reviewed for the GT feeding. * The facility failed to ensure the physician's order was followed for Resident 41's enteral feeding. * The facility failed to ensure the HOB (head of the bed) was elevated at a minimum 30-degree angle when the enteral feeding was infusing via GT to reduce the risk of aspiration (entry of food, liquid or foreign material into the airway) for Residents 94 and 138. These failures posed the risk of complications related to the use of GT.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary respiratory care services for five of five final sampled (Resident 1, 19, 86, 124, and 135) and two non-sampled residents (Resident 40 and 60) reviewed for respiratory care. * The facility failed to ensure the administration of oxygen to Resident 1 was documented. * The facility failed to ensure Resident 19's nasal cannula tubing was labeled and dated. * The facility failed to ensure Resident 40 was administered oxygen per the physician's order. In addition, the facility failed to ensure the humidifier bottle was changed and not left empty for Resident 40. * The facility failed to ensure the nasal cannulas for Resident 60 were stored properly when not in use. * The facility failed to ensure Resident 86's nebulizer storage bag was changed weekly. [...]

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary dialysis care for four of five final sampled residents (Residents 1, 9, 41, and 116) reviewed for dialysis. * The facility failed to monitor Resident 1's fluid intake and specify the fluid restriction per the physician's order. In addition, the facility failed to ensure Resident 1's dialysis access assessments pre- and post-dialysis were accurate and complete, and Resident 1's BP (blood pressure) was not taken on the right upper extremity. Furthermore, the facility failed to ensure the medications scheduled to be administered to Resident 1 on the days the resident had dialysis treatments had a physician's order to be held or were rescheduled. [...]

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure three of 28 final sampled residents (Resident 2, 5, and 138) were free from the unnecessary drugs. * Resident 2 was administered metoprolol (medication to treat high blood pressure) on numerous occasions when Resident 2's BP (blood pressure) was below the parameter prescribed by the physician. In addition, Resident 2 was administered midodrine (medication to treat low blood pressure) on numerous occasions when Resident 2's BP was above the parameter prescribed by the physician. Furthermore, the facility failed to ensure Resident 2's antibiotic was held when an adverse side effects were documented. * The facility failed to ensure Resident 5's anticoagulant was held when an adverse side effects were documented. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medication error rate was below 5% during medication pass observation. The facility's medication error rate was 6.9%. One of four licensed nurses (LVN 7) was found to have made errors during the medication administration. * Resident 138 had a physician's order for Nystatin Suspension (antifungal medication) 100000 unit/ml give 5 ml by mouth four times a day for oral thrush, swish and swallow. LVN 7 instructed Resident 138 to swish and spit, rather than swish and swallow, and did not follow the bold writing instructions on the label on the medication bottle to shake the Nystatin Suspension prior to the administration of the medication. [...]

Inspectors wroteBased on interview and medical record review, the facility failed to ensure Resident 1 was free from significant medication errors for one of 28 final sampled residents (Resident 1). * The facility failed to ensure the vancomycin (antibiotic medication), apixaban (anticoagulant medication), and metoprolol (antihypertensive medication) medications scheduled to be administered to Resident 1 on the days the resident had dialysis treatments had a physician's order to be held or were rescheduled. In addition, the facility failed to notify the physician when these medications were not administered to Resident 1. This failure placed Resident 1 at risk for significant side effects and medical complications.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure medications were stored as per the facility's P&P and outdated medications and medical supplies were not available for residents' use. * The facility failed to ensure orally administered medications were kept separate from externally used medications in Medication Rooms A and B, and Medication Cart A. * The facility failed to ensure the expired medications and medical supplies were not available for resident use in Medication Carts B and C. * The facility failed to ensure for safe storage of the medications observed at the bedside for Residents 2, 23, 25, 97, and 138. These failures had the potential to result in unsafe medication administration and negatively impact the residents' well-being.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen. * The facility failed to ensure the sanitary condition of the hood over the stove was maintained. * The facility failed to ensure the kitchen utensils had a smooth cleanable surface and in good condition. * The facility failed to ensure the kitchenware and kitchen utensils were clean and free of food particles or residue. * The facility failed to ensure the cutting boards were kept in a sanitary condition and with cleanable surface. * The facility failed to ensure the clear plastic trays were air dried prior to storing and stacking. These failures had the potential for cross contamination and foodborne illnesses to the residents consuming the food prepared in the facility's kitchen.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to maintain proper infection control practices. * The facility failed to accurately identify HAI in the monthly surveillance report. * The facility failed to ensure the residents' clothing and blankets from the laundry were handled in a sanitary manner. The spring lift inside a blue basket truck was observed with ripped edges, and when lifted, the bottom of the basket was pieces of paper, dryer sheets, towel and a sock. In addition, the AC filters of the AC in the clean area, and the AC near the folding area were observed dusty * The facility failed to ensure CNA 7 did not use the same pair of gloves and gown when providing care to Resident 1 on EBP (Enhanced Barrier Precaution) and then to Resident 159 who was not on EBP. [...]

Inspectors wroteBased on interview, medical record review, facility document review and facility P&P review, the facility failed to implement their P&P related to the pharmaceutical procedures. * The facility failed to ensure the morphine (a controlled medication which has potential for abuse or dependence and under strict government control) medication was documented as administered to the resident when it was signed out on the Controlled Drug Record (CDR) for one nonsampled resident (Resident 15). This failure had the potential for Resident 15 to be exposed to the medication errors and diversion of the controlled medications. * The facility failed to ensure there were two nurse signatures on the Medication Disposition Record Log of the non-controlled drugs for multiple medications. This failure had the potential for diversion of the non-controlled medications.

Inspectors wroteBased on interview and facility document review, the facility failed to ensure the Facility Assessment addressed or included the following: 1. Active involvement of required individuals in developing the Facility Assessment;2. A plan to maximize recruitment and retention of direct care staff; and3. A contingency plan for staffing needs. These failures had the potential not to meet the residents' care needs if the assessed population's needs and resources were not comprehensively identified and addressed.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the medical record was complete for one of 28 final sampled residents (Resident 8). *The facility failed to ensure Resident 8's information on the POLST (Physician Orders for Life-Sustaining Treatment) was filled out. This failure had the potential for the resident's care needs to not be met as their medical information was inaccurate.

Inspectors wroteBased on observation, interview, facility document review, and medical record review, the facility failed to ensure one of eight sampled residents (Resident 1) was treated with dignity and respect when the facility failed to send some of Resident 1's belongings upon discharge from the facility. This failure had the potential to negatively affect Resident 1's well-being.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the discharge instructions were documented for one of two sampled residents (Resident 1) reviewed for discharge. This failure had the potential for Resident 1 to have an inappropriate discharge.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to protect the resident's rights to be free from the physical abuse when Resident 2 pushed a table hitting Resident 1 in the head resulting in a small movable mass with minimal redness and flaky skin located on the top right side of Resident 1's head. * The facility failed to ensure the concern was addressed when Resident 2 verbalized he was unhappy with his roommate on 3/19/25. Additionally, the facility failed to ensure Residents 1 and 2 were separated when the nurse noticed both residents were using verbal aggression towards each other and Resident 2 stated I will hurt you on 3/23/25. This failure had the potential to negatively impact the residents' well-being.

Inspectors wroteBased on interview, facility document review, and facility P&P review, the facility failed to thoroughly investigate the allegation of abuse for Residents1 and 2. * The facility failed to interview Residents 1 and 2's roommate after Residents 1 and 2 had had the verbal and physical altercation in their room. This failure had the potential for the abuse allegation to not be thoroughly investigated.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to implement the systematic approach to ensure the effective monitoring of the acceptable parameters of nutrition status for two sampled residents (Residents3 and 4). * The facility failed to ensure Resident 3 was assessed and monitored by the IDT when Resident 3 had a severe weight loss of 51 lbs. (-23.29%) in the last six months, 14 lbs. (6.39%) in one month from 9/12 - 10/16/24, and 30 lbs. (14%) from 1/3 - 2/16/25. In addition, the facility failed to initiate a COC for Resident 3 when there was a severe weight loss, including notifying the physician, and legal representative. * The facility failed to ensure Resident 4 was assessed and monitored by the IDT when Resident 4 had a severe weight loss of 17 lbs. (12.14%) in one month. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the medical record was accurate for one of three sampled residents (Resident 2). This failure had the potential for the resident's care needs not being met as the medical information was inaccurate.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the appropriate care and services to prevent the UTI for two of three sampled residents (Residents1 and 2) reviewed for the use of the indwelling urinary catheters. * The facility failed to ensure Resident 1's indwelling urinary catheter drainage bag was not laying on the floor. * The facility failed to ensure the physician was notified when Resident 2 had a change in condition due to frequent leakage of the indwelling urinary catheter and clarify the size of the indwelling urinary catheter prior to be inserted. These failures had the potential for not providing the necessary care and services and posed a risk for adverse complications related to the indwelling urinary catheter use.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the POLST was followed for one of four sampled residents (Resident 1). This failure resulted in Resident 1 receiving CPR when found unresponsive despite the resident's request for resuscitative measures to not be followed as indicated in Resident 1's signed POLST.

Inspectors wroteBased on observation, interview, facility P&P, and facility document review, the facility failed to ensure the nutritive content of the pureed food for the American menu was preserved and the food served was palatable as evidenced by: * The pureed vegetables were cooked and held in a hot oven more than one hour prior to the meal service. * The bread was hard and crusty in texture. These failures had the potential to not meet the nutritional needs for the residents consuming food prepared in the kitchen.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the food safety and sanitary requirements were met in the kitchen as evidenced by: * The facility failed to ensure proper labeling and dating of the opened food in the freezer. * The facility failed to ensure the food preparation equipment were properly air dried prior to storage. * The facility failed to ensure the food preparation equipment were in good condition. These failures had the potential to cause foodborne illnesses in a medically vulnerable resident population who consumed food prepared from the kitchen.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to conduct the regular inspection of the residents' beds and assess for areas of risk for entrapment for four sampled residents (Residents 16, 32, 34, and 95) and four nonsampled (Residents 18, 49, 77, and 96) reviewed for the use of siderails. * The facility failed to conduct a routine bed inspection for all the facility beds. In Addition, the facility failed to ensure the entrapment assessments were properly conducted to identify areas of possible entrapment with the use of side rails and the facility failed to conduct the routine bed inspection for Residents 16, 18, 32, 34, 49, 77, 95, and 96. These failures had the potential for entrapments for these residents using the side rails.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the audible sound and visual light could be heard and seen from the call light panel at the nurse's stations for 16 of 63 rooms. * Room N's restroom call light did not light at the door and did not sound at the Nursing Station B's call panel. * Room O's restroom call light did not light at the door and did not light and sound at the Nursing Station B's call panel. * Resident 16's call light had a dim light above the door and was not audible. * The facility failed to ensure the call light system for Rooms A to M had an audible sound in the call light panel at the Nursing Station A. These failures had the potential for the staff not to hear and see the call light resulting in delayed provision of assistance to the residents.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to properly obtain the informed consents (permission granted in the knowledge of the possible consequences) for the use of psychotropic medications (medications affecting brain activity) and treatments from the responsible party (person designated to make decisions on behalf of the residents) for one of five final sampled residents (Residents 64) reviewed for unnecessary medications. This failure posed the risk for Residents 64 and his responsible party to not be informed of Resident 64's medications and the potential side effects.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to provide the reasonable accommodations to meet the needs two nonsampled residents (Residents 38 and 124) observed during the initial tour. * The facility failed to ensure Residents 38 and 124's call lights were within the residents' reach. This failure had the potential to negatively impact the residents' psychosocial well-being or result in a delay to receive care.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to clearly identify the current code status to obtain a copy of an advance directive and provide the written information regarding the rights to formulate the advance directives for three of 26 final sampled residents (Residents 24, 48, and 99) reviewed for advance directives. * The facility failed to clarify and honor Resident 99's desire not to prolong life in case of incapacity. Resident 99's advance directive showed the resident did not wish to prolong life in case of incapacity, while Resident 99's POLST showed to attempt CPR. * The facility failed to ensure the copy of Resident 48's advance directive for healthcare was obtained and maintained in the resident's medical record. * The facility failed to ensure Resident 24 was offered information on how to formulate an advanced directive. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to develop the comprehensive care plans to reflect the individual care needs for four of 26 final sampled residents (Residents 46, 116, 120, and 374). * The facility failed to develop a care plan problem to address Resident 116's left heel pressure injury. * The facility failed to develop a care plan to address Resident 120's need for fluid restriction and the use of ertapenem sodium injection solution (an antibiotic used to treat infections caused by bacteria) intravenously (into or by means of a vein or veins) for treatment of empyema of pleura (an infection that spreads directly from the lung that leads to a buildup of pus in the pleural space (thin space inside the chest wall). * The facility failed to develop a care plan problem to address Resident 46's left air pain and ear treatments. [...]

Inspectors wroteBased on interview, medical record review, and facility document review, the facility failed to provide the necessary ADL care and services for two of two residents (Residents 48 and 374) investigated for ADL care. * Resident 48 was provided with only two showers on 7/15 and 7/18/24, instead of twice a week since his admission on [DATE]. * Resident 374 was provided with only one shower on 7/14/24, instead of twice a week since her admission on [DATE]. These failures posed the risk of the residents not being provided with the appropriate care which could negatively impact their psychosocial well-being.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent the development of new pressure injury (areas of damaged skin caused by staying in one position for a long time which reduces blood flow to the area and causes the skin to die and develop a sore) and promote healing of existing pressure ulcer for two of three sampled residents (Residents 103 and 116) reviewed for pressure injury. * The facility failed to ensure Resident 103's wound care was provided in a manner to decrease infection and cross contamination as per the facility's P&P. * The facility failed to ensure Resident 116's bilateral lower extremities were offloaded as per the physician's order. These failures had the potential for deterioration of wound and delay of wound healing for these residents.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure two of five residents (Residents 48 and 120) reviewed for nutrition and hydration status maintained their acceptable nutritional and hydration status. * The facility failed to follow the RD's recommendations to provide two Boost VHC (a very high calorie complete nutritional drink which provides 530 calories per eight fluid ounce serving, with 22 grams of protein and 26 vitamins and minerals) every meals and to discontinue health shakes. In addition, the facility to clarify the physician's order whether to provide Boost VHC TID (three times a day) or with meals. * The facility failed to monitor Resident 120's fluid intake while on fluid restriction to assess and maintain proper hydration. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility's P&P review, the facility failed to provide the necessary care and services to maintain the intravenous accesses for one nonsampled residents (Resident 97). In addition, the facility failed to ensure the PICC line external catheter and arm circumference measurements were performed and documented in the medical record. These failures had the potential to delay the identification of catheter related complications for the residents.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to provide the necessary respiratory care for three of three sampled residents (Residents 54, 95, and 374) investigated for respiratory care. * The facility failed to ensure Resident 374's Yankauer suction (an oral suctioning tool used in medical procedures) was stored in a set-up bag when not in use. In addition, the facility failed to ensure Resident 374's oxygen saturation levels and administration of oxygen were documented in the MAR. * The facility failed to ensure Resident 95's oxygen saturation levels and administration of oxygen were documented in the MAR. * The facility failed to ensure Resident 54's nasal cannula tubing was stored in a set up bag when not in use and the nasal canula was observed on the floor and Resident 54's bed. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P, the facility failed to ensure the accurate documentation of two controlled medications on the Controlled Drug Record for one nonsampled resident (Resident 724). This failure had the potential for medication diversion (illegal distribution or abuse of prescription drugs or their use for unintended purposes) of controlled medications.

Inspectors wroteBased on interview, medical record review, facility P&P review, and facility document review, the facility failed to ensure one of five sampled residents (Residents 64) reviewed for unnecessary medications was free from the unnecessary psychotropic medications (any medication which may affect brain activity associated with mental processes and behavior). * The facility failed to ensure Resident 64's monthly behavior summary was completed for the use of Seroquel (a medication used to treat schizophrenia), and sertraline (a medication used to treat depression). In addition, the facility failed to ensure the behavior manifestation and side effects for the use of antipsychotic medications were monitored. These failures had the potential to place the residents at risk for receiving unnecessary medications and increased risk of serious adverse reactions from the medications.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 16%. One of four licensed nurses observed (LVN 6), was found to have made errors during the medication administration observation. * LVN 6 failed to ensure Resident 10's HR was taken prior to administering the metoprolol (blood pressure medication) and failed to administer the medications as per the physician's order. These failures had the potential to negatively affect Resident 10's health.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one nonsampled resident (Resident 10) was free from a significant medication error. *The facility failed to ensure Resident 10's HR was taken prior to administering the metoprolol (blood pressure medication). This failure had the potential to cause Resident 10 to have abnormally slow heart rate and negatively affect the resident's health.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the residents' medications were stored and labeled properly when: * The facility failed to ensure a multi-dose vial for one nonsampled resident (Resident 39) was labeled with the opened date in Medication Room B. This failure posed the potential risk of residents receiving expired medication. * The facility failed to ensure the medications for the discharged residents (Residents 115, 726, and 727) were placed in the designated location for medication destruction in Medication Room A. This failure have the potential for medications to be accidentally administered to residents. * The facility failed to ensure the discontinued medication for one nonsampled resident (Resident 45) was removed from the medication cart; [...]

Inspectors wroteBased on interview and facility P&P review, the facility failed to implement their P&P on foods bought to the facility by the residents' family members or visitors to ensure the safe food handling practices were followed for one of 26 final sampled residents (Resident 95). * The facility failed to ensure opened food items at Resident 95's bedside were refrigerated when needed to be refrigerated. This failure had the potential for unsafe food handling which could lead to food borne illness.

Inspectors wroteBased on observation, interview, medical record review, facility P&P review, and facility document review, the facility failed to ensure the proper infection prevention practices for the facility's Water Management Program in the laundry room and for two of four residents reviewed for antibiotic use (Residents 116 and 120). * The facility did not have documentation to show they followed their Water Management Program. * The facility failed to maintain the clean enviroment in the clean linen area in the laundry room * The facility failed to ensure a physician's order was obtained for Resident 116 for contact isolation precaution related to ESBL in urine. In addition, the facility failed to ensure the CNA observed contact isolation precaution practices while providing care for Resident 116. [...]

Inspectors wroteBased on observation, interview, facility document review, the facility failed to ensure the facility equipment were maintained in a safe operating condition when: * The facility failed to ensure corrective actions were taken when the quality control results for the glucometers (a device that measures the amount of sugar in the blood) were out of range for Medication Carts A and B. This failure had the potential risk of inaccuracy for the blood glucose test results. * The facility failed to ensure there was no ice buildup and brownish stain in the freezer of the medication refrigerator in Medication Room A. This failure had the potential for the equipment to not function in the way it was intended.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the comprehensive plan of care was revised to reflect the resident's care needs for one of 26 final sampled residents (Resident 116). * The facility failed to ensure Resident 116 comprehensive care plan was revised to show the resident's current antibiotic medication and contact isolation precaution. This failure had the potential for not providing necessary care and services to meet the resident's needs.

Inspectors wroteBased on observation and interview, the facility failed to store trash in a sanitary manner as evidenced by: * The facility failed to ensure three of fours dumpsters were properly covered. This failure had the potential to harbor pests.

Inspectors wroteBased on interview and facility documentation review, the facility failed to submit a complete and accurate direct care staffing information to CMS. This failure posed the risk of inaccurate auditable data reporting.

Inspectors wroteBased on interview and medical record review, the facility failed to provide the necessary care and services to ensure one of 26 final sampled residents (Resident 48) attained and maintained his highest practicable well-being. * The facility failed to coordinate and follow up for Resident 48's needed medical appointments per the transfer orders from the acute care hospital. Resident 48's scheduled medical appointment to the infectious disease clinic was marked as completed; however, there was no documentation Resident 48 went to the infectious disease clinic. In addition, Resident 48 was supposed to be scheduled for a medical appointment with the oncology clinic, but it was discontinued, and no documentation it was scheduled nor followed up. This failure had the potential for Resident 48 to not receive appropriate medical care and treatments.

Inspectors wroteBased on interview and medical record review, the facility failed to provide the necessary care and services to ensure one of three sampled residents (Resident 1) attained and maintained her highest practicable physical well-being. * The facility failed to administer Resident 1's medications as ordered by the physician. This failure had the potential for Resident 1to not receive the appropriate care and services to treat her medical conditions.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of two sampled residents (Resident 1) received the medications as prescribed by the physician and failed to inform the physician of the missed medications. This failure created the risk of complications and ineffective therapeutic effects of the medication for Resident 1.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the pharmaceutical services to ensure accurate reconciliation and administration of medication for one of 13 sampled residents (Resident 11). * Resident 11's hydrocodone/acetaminophen (narcotic pain medication) tablets were removed and signed out from the controlled medication record; however, they were not documented as administered. This failure had the potential for medication administration errors, inaccurate reconciliation, and drug diversion.

Inspectors wroteBased on interview and medical record review, the facility failed to develop the comprehensive plan of care to reflect the individual care needs for one of 13 sampled residents (Resident 6). * The facility failed to develop a care plan problem to address Resident 6's pain. This failure posed the risk of not providing appropriate, consistent, and individualized care to Resident 6.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the treatment and care in accordance with the professional standards of practice for one of nine sampled residents (Resident 1). * The facility failed to provide Resident 1's wound treatment as ordered by the physician. * The facility failed to provide Resident 1's colostomy belt (use to secure ostomy appliances and provide support) as ordered by the physician. * The facility failed to ensure the weekly wound assessment was completed for Resident 1 as per the facility's P&P. These failures had the potential for Resident 1 not to receive appropriate care and treatment.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the baseline care plan was developed to reflect the specific care needs for one of two sampled residents (Resident 1). * The facility failed to ensure a baseline care plan problem was developed to address Resident 1's risk for falls. This had the potential for the resident's care needs not being met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the food safety and sanitation requirements were met in accordance with professional standards for food service as evidenced by: * The facility failed to ensure the kitchen equipment was clean and free of food particles. * The facility failed to ensure proper back-flow prevention by having air gaps for the drain pipes from the sink, ice machine, and dishwasher. * The facility failed to ensure the kitchen staff used facial hair covering properly. * The facility failed to ensure the temperature of the nourishment refrigerator used to store resident food was maintained at the acceptable range. * The facility failed to ensure the resident silverware was handled in a sanitary manner. * The facility failed to ensure the kitchen utensils were covered. [...]

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to provide the reasonable accommodation to meet the care needs for one of 21 final sampled residents (Resident 64). * The facility failed to ensure Resident 64's call light was within the resident's reach. This failure had the potential to negatively impact the resident's psychosocial well-being or result in delayed provision of care.

Inspectors wroteBased on interview and facility document review, the facility failed address the grievances presented by the residents during the resident council meetings (an organized group of residents meeting on a regular basis to discuss facility concerns and areas for improvement). This failure had the potential for a delay in provision of care of the residents.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to offer assistance to formulate an advance directive, and/or maintain a copy of the resident's advance directive in the medical records for seven of 21 final sampled residents (Residents 36, 59, 60, 64, 72, 85, and 95 ). This failure put the residents at risk of not having their wishes for treatment known and the potential for the residents' decisions regarding their healthcare and treatment options not being honored.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the RD's recommendation was implemented for one nonsampled resident (Resident 8). This failure had the potential to negatively impact the resident's well-being.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services related to a PICC for one of 21 final sampled residents (Resident 30). The facility failed to follow their P&P to obtain the measurement of the external length of the catheter upon admission and during dressing changes. This failure posed the risk for the resident to develop complications such as catheter migration and dislodgement.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to provide the necessary care and services to attain and maintain the highest practicable physical well-being for one of 21 final sampled residents (Resident 408). The facility failed to ensure Resident 408's dialysis access site was assessed accurately. This failure had the potential to not provide the appropriate care and treatment to the resident.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed ensure accurate reconciliation of the controlled medication for one nonsampled residents (Resident 8) and failed to implement the facility's P&P on disposed of the discontinued controlled medications. These failures had the potential for drug diversion.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure two of 21 final sampled residents (Residents 30 and 408) were free from unnecessary medications. * Resident 30 was administered stool softeners on multiple days even though the resident was documented as having loose stools. * Resident 408 was administered midodrine (blood pressure medication) when the resident's blood pressure was above the parameter prescribed by the physician. These failures posed the potential of complications related to unnecessary medications.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure one of 21 final sampled residents (Resident 60) was monitored for adverse effects of psychotropic medication. This failure had the potential for the resident to experience adverse effects of the psychotropic medication.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure the medications were properly stored. This failure posed the risk for administering the expired and/or discontinued medications.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to maintain accurate medical records for three of 21 final sampled residents (Residents 26, 87, and 408). This failure put the residents at risk for not receiving appropriate care due to inaccurate medical records.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to follow the infection control practices for one of 21 final sampled residents (Resident 30). * Resident 30's urinary catheter drainage bag was observed directly touching the floor. This failure placed the resident at risk for urinary tract infection.