Port Washington Post Acute

Inspectors wroteBased on interview and record review, the facility failed to ensure medication was available and provided for 1 of 3 residents (Resident 1) reviewed for significant medication errors. This failure placed residents at risk for inaccurate lab values, rehospitalization, and a diminished quality of life.

Inspectors wroteBased on observation and interview, the facility failed to provide a safe, functional, and sanitary environment and equipment in Storage room [ROOM NUMBER] located diagonally across from the nurses' station. This failure placed residents and staff at risk for cross contamination, substandard infection control, injury, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record reviews, the facility failed to identify, and to provide for needs and services in a timely manner for 2 of 3 residents (Resident 1 and Resident 2) reviewed for quality of care. This failure placed residents at risk for unmet needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure staff were adequately trained on newly implemented wander guard/elopement alarm system resulting in staff failing to recognize and respond timely to resident elopement alarms for resident assessed as at risk for wandering/elopement for 1 of 3 residents (Resident 1) reviewed for elopement. Resident 1 experienced harm when the resident exited the facility unsupervised in their wheelchair and then rolled down a hill, fell, and required emergency transport to the hospital where they were diagnosed with multiple facial fractures. This failure placed residents at risk of elopement, injury and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to prevent an altercation between 2 out of 3 residents (Resident 2 and Resident 3) reviewed for freedom from abuse. This failure placed residents at risk for injury, psychosocial harm, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to have sufficient staff to provide and supervise care for their residents as evidenced by information from 3 resident interviews (Resident 1, Resident 2, and Resident 3) and 3 staff interviews. The facility had insufficient staff to ensure residents received adequate assistance for their Activities of Daily Living (ADLs). This failure placed residents at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure discharge planning included involvement of community agencies and medication management for 2 of 3 Residents reviewed for discharge planning. This failure placed residents at risk for unmet care needs, psychological distress, re-hospitalization, and a decreased quality of life.

Inspectors wroteBased on observation and interview, the facility failed to provide attractive, palatable, and flavorful food for 3 of 3 residents (Resident 1, Resident 2, and Resident 3) reviewed for food quality. This failure placed residents at risk for health complications related to weight loss, less than adequate nutritional intake, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure altered consistency liquids were provided and consistent with resident's orders for 2 of 3 residents (Resident 2 and Resident 4) reviewed for hydration. This failure placed residents as risk for dehydration, aspiration (inhalation of foods or liquids into the airways), and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility administered Seroquel, an antipsychotic medication, without proper assessment, diagnosis, or interventions needed for this drug regimen for 1 of 3 residents (Resident 1) reviewed for unnecessary medications. Failure to complete a thorough evaluation before starting the medication as well as failure to provide necessary monitoring during the therapy placed residents at risk for sedation, a decreased quality of life, and death.

Inspectors wroteBased on observation, interview and record review, the facility failed to identify, address, and adjust care needs for 5 of 5 residents (Resident's 1, 2, 3, 4 and 5) who experienced dementia-related behaviors, and/or the negative impacts of those behaviors. This failure placed residents at risk of not achieving or maintaining their highest practicable level of mental and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure scheduled care and services for 2 of 3 residents (Resident 1 and Resident 2) reviewed for quality of care. This failure placed the residents at risk for decline in hygiene, unidentified weight changes, and diminished feelings of well-being.

Inspectors wroteBased on interview and record review, the facility failed to provide consistent specialized services for 1 of 3 residents (Resident 1) reviewed for rehabilitation therapies. This failure placed residents at risk for delayed maximum function and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to assess and monitor identified wound(s), perform ordered treatment(s), identify risk factors for skin breakdown, develop and implement interventions, and ensure routine skin check were conducted for 1 of 2 residents (Resident 8) reviewed for non-pressure skin conditions. Resident 8 experienced harm when their abdominal wound increased in size/worsened. These failures placed other residents that required would care at risk for altered wound healing, avoidable wound decline, delayed identification and treatment of newly developed wounds, pain, infection and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement pharmacy procedures that ensured medications were timely and accurately received, dispensed and administered to meet the needs of 7 of 7 residents (Residents 1, 2, 3, 4, 5, 6 & 7) reviewed for admission medication reconciliation. These failures placed residents at risk for ineffective or subtherapeutic treatment of underlying medical conditions due to omissions of time-sensitive and high-risk medications.

Inspectors wroteBased on interview and record review, the facility failed to protect resident's property from loss or theft for 1 of 3 residents (Resident 1) reviewed for abuse, neglect, and/or exploitation. This failure placed residents at risk for financial loss and diminished sense of security within the facility.

Inspectors wroteBased on interview and record review, the facility failed to log and investigate grievances for 1 of 1 resident (Resident 22) reviewed for grievances and for 3 of 8 Resident Council monthly meeting minutes (Months: March 2025, May 2025, & June 2025) reviewed for grievances. This failure placed residents at risk of abuse and neglect, grievances to not be responded to timely or at all, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure psychotropic medications (any drug affecting mental processes, emotions, and behavior) were adequately monitored, documented non-pharmacological interventions (NPIs, non-medication interventions to decrease behavior episodes), and/or had consent obtained for 5 of 7 residents (Residents 61, 22, 1, 2 & 3) reviewed for unnecessary medication or behaviors. This failure placed residents at risk of unnecessary medications, medication complications, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to report allegations of abuse, neglect, misappropriation (taking money or assets) and accidents to the State Agency within 24 hours, to log the allegation and/or accident in the facility's reporting log as required for 6 of 8 residents (Residents 61, 33, 58, 60, 20 and 63) when reviewed for abuse/neglect. This failure placed residents at risk for unaddressed abuse, neglect, misappropriation, psychosocial harm, decreased quality of life and other negative outcomes. Review of the facility's policy titled, “Abuse, Neglect, Exploitation and Misappropriation Prevention Program“, revised September 2024, showed the facility was to identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. [...]

Inspectors wroteBased on interview and record review the facility failed to conduct a thorough investigation for 6 of 7 sampled residents (Resident 45, 2, 58, 60, 61 & 63) reviewed for incident investigations. Failure to conduct a thorough investigation, to identify the root cause(s) and all contributing factors related to incidents and investigations placed residents at risk for unidentified abuse or neglect, risk for injury, unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide written notice of transfer at the time of transfer to the hospital for 3 of 3 sampled residents (Residents 10, 63 and 68) reviewed for hospitalization. This failure placed the residents at risk for lack of knowledge related to discharge and transfer status.

Inspectors wroteBased on record review and interview, the facility failed to provide a written bed hold notice, at the time of transfer to the hospital, for 3 of 3 sampled residents (Residents 10, 63 and 68) reviewed for hospitalization. This failure placed the residents at risk for not knowing their right to hold their bed while in the hospital and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to accurately assess 4 of 18 residents (Residents 47, 3, 31, & 28) whose Minimum Data Sets (MDS, an assessment tool) were reviewed. Failure to ensure accurate assessments regarding active diagnoses (Residents 3 and 31), restorative services (Resident 47), and mobility status (Resident 28), and placed residents at risk for unidentified and/or unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure Level 1 Pre-admission Screening and Resident Review (PASRR, document that screens resident for needing further mental health evaluations) were accurate and complete for 4 of 7 residents (Residents 3, 22, 53 & 61) reviewed for PASRR. This failure placed residents at risk of unidentified and unmet care needs related to mental health, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident care plans (CPs) were reviewed, revised, and accurately reflected residents' care needs for 7 of 18 sample residents (Residents 3, 63, 61, 31, 1, 42 & 47) whose care plans were reviewed. These failures placed residents at risk for unmet care needs and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure services provided met professional standards of practice for 7 of 18 sampled residents (Residents 45, 41, 3, 31, 63, 47 & 22) reviewed. The failure to obtain vital signs when required, follow medication hold parameters, notify providers when medications were held, administer oxygen at the ordered rate, clarify incomplete or conflicting orders, and only sign for tasks that were completed, placed residents at risk for medication errors and associated complications, unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents received the care they were assessed to require regarding cognitive services, laboratory testing, bowel management, podiatry services, dialysis services, and peripherally inserted central catheter (PICC) management for 8 of 18 sample residents (Resident 61, 22, 63, 3, 31, 4, 44 & 42) reviewed. These failures placed residents at risk for unidentified and unmet care needs, and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure services were provided to increase range of motion (ROM) and/or to prevent further decrease in range of motion for 4 of 4 sampled residents (Resident 61, 47, 2 & 53) reviewed for limited range of motion. These failures placed residents at risk for a decline in functional abilities, discomfort and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were assessed and potential accident hazards/falls were thoroughly investigated for 3 of 3 residents (Resident 61, 58 & 20) reviewed for fall investigations. This failure placed residents at risk of falls, injury, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure sufficient qualified nursing staff were available to provide care and services as evidenced by information provided in Resident/Surveyor interviews for 10 sampled residents (Resident 45, 22, 47, 63, 4, 53, 31, 41, 66 & 58) interviewed, and 8 staff (Staff MM, NN, LL, GG, X, S, L & T) interviewed. The facility had insufficient staff to ensure residents received assistance with activities of daily living, restorative services and staff documentation. These failures placed residents at risk for unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to complete annual performance evaluation reviews for 3 of 3 sampled certified nursing assistants (CNAs) (Staff W, HH & JJ) reviewed for nurse aide performance reviews. This failure placed residents at risk for receiving care from unskilled staff and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure monthly pharmacists recommendations for medication gradual dose reductions (GDRs) were responded to with accurate resident information and/or with completed resident-specific rationales for 3 of 4 (Residents 22, 61, & 41) reviewed for GDRs. This failure placed residents at risk of unnecessary medications and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications were dated when opened when required, and expired medications were discarded in accordance with professional standards of practice for 1 of 1 medication room, and 1 of 2 medication carts (B Hall Cart) reviewed. Additionally, facility staff failed to ensure treatment carts were closed and locked when left unattended and unsecure medications were not left at bedside. These failures resulted in residents having unsupervised access to medications and biologicals not intended for their use, and for receiving expired/outdated medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare and serve palatable food under sanitary conditions when reviewed for kitchen. These failures placed residents at risk of foodborne illness, meal displeasure and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure their antibiotic stewardship program tracked and monitored infections by completing monthly antibiotic line lists (a system to track all the infectious organisms in the building, to make sure they met criteria for antibiotic usage) with complete lists of symptoms, reevaluating residents for continued antibiotic use, and/or ensuring antibiotic stewardship by following up with staff with education regarding proper containers for urine cultures for 3 of 3 months (Months: April 2025, May 2025, and June 2025) reviewed. This failure placed residents at risk of unnecessary medication, the development of multidrug resistant organisms (MDROs), and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure they had a designated infection preventionist (IP) for the facility, to ensure the program monitored, tracked, and trended antibiotics and infections throughout the entire facility for 2 of 3 months reviewed (May 2025 and June 2025). This failure placed residents at risk of infection, unidentified care needs, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents received COVID-19 vaccinations for 3 of 6 residents (Residents 4, 22, & 39) reviewed for vaccinations. This failure placed residents at increased risk of complications from contracting COVID-19 and diminished quality of life.

Inspectors wroteBased on observation and interview, the facility failed to ensure kitchen equipment was maintained in a safe, functional, and working condition for 1 of 1 sampled freezer when reviewed for kitchen. This failure placed residents at risk of inadequate meal quality and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure they informed and provided written information to residents on their right to formulate an advance directive (AD, written instruction for the provision of health care when the individual is incapacitated, such as a living will or durable power of attorney (POA) for health care) for 2 of 4 residents (Resident 4 & 1) reviewed for advance directives. This failure placed residents at risk for not having their choice of who to care for them when incapacitated, not having their health care wishes honored, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide personal privacy during personal care for 1 of 1 sampled resident (Resident 45) reviewed for privacy. This failure placed residents at risk of loss of privacy during personal care, embarrassment and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure pressure injuries (PIs) were consistently assessed, and ordered pressure redistribution measures and equipment were in place and functional for 1 of 2 residents (Resident 3) reviewed for PIs. The failure to ensure an ordered low air loss mattress was in place and functional and to routinely assess identified PIs, detracted from the ability to determine if current treatments and interventions were effective and appropriate. This failure placed residents at risk for prolonged wound healing, unidentified decline, development of avoidable PIs, pain and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 1 of 1 residents (Resident 31) reviewed for indwelling urinary catheters (a flexible tube used to empty the bladder and collect urine in a drainage bag) had a valid medical justification for urinary catheterization, was assessed for removal of the catheter timely, and received catheter care in accordance with professional standards of practice. These failures placed residents at risk for loss of bladder tone and normal bladder function, urethral trauma and tearing and other negative health outcomes.

Inspectors wroteBased on interview and record review, the facility failed to ensure pain was appropriately addressed, monitored, and recorded, or to ensure side effect monitors were in place and non-pharmacological interventions (NPI's, non-medication interventions for pain) were documented for pain medications for 2 of 6 residents (Residents 47 & 2) reviewed for unnecessary medications or pain management. This failure placed residents at risk for an increase in pain, inability to perform therapy services, medication complications, and a diminished quality of life.

Inspectors wroteBased on observation and interview, the facility failed to provide food in accordance with preferences for 1 of 11 sampled residents (Resident 20) reviewed for dining. This failure placed residents at risk for potential dissatisfaction with meals and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received therapeutic diets as ordered by the physician for 2 of 10 residents (Residents 1 and 47) reviewed for dining. This failure placed the residents at risk for medical complication or nutritional deficits.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure comprehensive skin assessments were completed for 3 of 3 residents (Resident 1, Resident 2, and Resident 3) sampled for services meeting professional standards. This failure placed the residents at risk for unidentified skin impairments, worsening skin impairments, and rehospitalization.

Inspectors wroteBased on interview and record review, the facility failed to ensure 1 of 3 residents (Resident 4) were free of significant medication errors. This failure placed residents at risk for receiving medications not ordered by a provider, overdosing, and possible medical complications. Resident 4 was admitted to the facility on [DATE] with diagnoses to include an old myocardial infarction (heart attack) and heart disease. An assessment by social services on 07/04/2025 showed Resident 4 was mildly cognitively impaired. Resident 4 was sent to the emergency department at 12:30AM on 07/05/2025 for angina (chest pain). Review of the nursing progress note, dated 07/04/2025, showed Resident 4 began complaining of angina and 911 was called at 11:40PM. Staff G, Agency Licensed Practical Nurse (LPN), administered 81mg of chewable aspirin every five minutes for a total of 324mg. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide the equipment needed by 1 of 3 residents (Resident 1) to maintain or improve mobility. This failure placed residents at risk for decline in functional ability, frustration, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 2 of 9 residents who smoked (Resident 2 and Resident 3) were assessed and subsequent safety interventions were followed. The facility failed to ensure residents who smoked smoked in the designated smoking area and that smoke was not drifting through open windows. These failures put residents at risk for burns, fires, second hand smoke inhalation and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to store medications appropriately for 1 of 3 residents (Resident 1) reviewed for safe delivery of medications. This failure placed residents at risk for negative therapeutic outcomes and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain equipment in a fully functional manner for 4 of 4 mechanical beds (room [ROOM NUMBER] bed 1, room [ROOM NUMBER] bed 2, room [ROOM NUMBER] bed 1, & room [ROOM NUMBER] bed 1) reviewed for safe operating condition. This failure placed residents at risk for injury and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to implement proper procedures for a medical device for 1 of 1 residents (Resident 1) reviewed for services provided met professional standards. This failure placed the resident at risk for discomfort, infection, and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 3 of 7 staff members (Staff A, B and C) used personal protective equipment (PPE) in accordance with the Centers for Disease Control (CDC) guidelines when caring for residents with known COVID 19 (an infectious virus causing respiratory illness that may cause difficulty breathing and could lead to severe impairment or death) infections. This failure placed residents and staff at risk for contracting and spreading COVID 19.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide assistance with Activities of Daily Living (ADL) related to incontinent care, cleanliness and positioning in bed for 2 of 3 residents (Resident 1 and 2) reviewed for ADLs. This failure placed residents at risk for poor hygiene, impaired skin integrity, discomfort and loss of dignity.

Inspectors wroteBased on interview and record review, the facility failed to follow physician orders and monitor clinical conditions for 2 of 4 residents (Resident 3 and 4) reviewed for quality of care. This failure placed residents at risk of medical complications, infection, pain and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement interventions to prevent pressure ulcers (injury to skin and underlying tissue resulting from prolonged pressure) from developing for 1 of 3 residents (Resident 1) reviewed for wounds. This failure placed the residents at risk of clinical complications, pain and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure infection control standards were followed related to use of required personal protective equipment (PPE) with residents on transmission-based precautions (TBP) for 2 of 3 residents (Resident 1 and 2), reviewed for infection control. This failure placed residents, staff and visitors at risk for contracting and spreading infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a call light (device to request help as needed) within reach and failed to provide a bed extender for 1 of 5 residents (Resident 3) reviewed for environment. This failure placed the resident at risk for unmet care needs, pain and pressure injury, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to develop a personalized discharge plan based on each resident's identified needs, goals and preferences and implement it timely for 2 of 3 residents (Resident 1 and 2) reviewed for discharge planning. This failure placed residents at risk for delayed discharge, unmet care needs after discharge and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure menus were followed and modified diet textures were prepared in accordance with established guidelines and physicians' orders for 2 of 2 residents (Residents 35 & 125) reviewed for diet textures who were at serious risk for aspiration (inhalation of foods/fluids into the lungs), pneumonia, and choking. The facility's lack of an effective system to ensure residents at risk received the correct food texture represented a potential serious outcome including death and constituted an Immediate Jeopardy (IJ). Additionally, the facility failed to make a reasonable effort to honor food preferences for 1 of 7 residents (Resident 61) reviewed for food quality, placing the residents at risk for decreased intake, weight loss and a diminished quality of life. [...]

Inspectors wroteBased on observation and interviews, the facility failed to ensure dining services were provided in a respectful and dignified manner for 5 of 14 residents (Residents 54, 33, 15, 60, and 22) eating in the dining room. This failure placed residents at risk for feelings of dehumanization and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure quarterly personal fund statements were provided to residents with personal fund accounts for 4 of 4 sampled residents (Residents 11, 37, 43 and 46) reviewed for personal funds. This failure placed residents at risk of not having an accurate accounting of their personal funds held in a trust account by the facility.

Inspectors wroteBased on interview and record review, the facility failed to provide residents/resident representatives a written notice detailing the reasons for discharge/transfer and/or to provide a copy of the notice to the state Ombudsman office as required, for 6 of 8 residents (Residents 18, 19, 73, 16, 67 and 30) reviewed for hospitalizations. This failure placed residents at risk for inappropriate transfers and a lack of information regarding their rights and options related to bed-holds.

Inspectors wroteBased on interview and record review, the facility failed to provide the resident and/or resident representative, a written notice of the facility's bed-hold policy at the time of transfer for 4 of 8 residents (Residents 18, 19, 30, and 73) reviewed for hospitalizations. This failure placed residents at risk for emotional distress and a diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to implement a system in place that ensured periodic reconciliation and accounting for all controlled medications, for 2 of 2 medication carts (C cart & A cart) reviewed. Facility nurses' failure to consistently reconcile controlled medications at shift change and to co-sign the ledger to show both nurses validated the accuracy of the controlled medication count, placed residents at risk for misappropriation of their medication and detracted from the facility's ability to promptly identify potential diversion.

Inspectors wrote<Resident 62> Resident 62 was admitted to the facility on [DATE]. The Quarterly MDS, dated [DATE], documented the resident was cognitively intact. Resident 62 was prescribed mirtazapine for depression (a constant feeling of sadness or loss if interest) and to increase their appetite. Resident 62's EHR showed no orders for monitoring of target behaviors or side effects for the antipsychotic medication. On 06/17/2024 at 11:44 AM, Staff B, DNS, said she did not see orders for behavior or side effect monitoring for Resident 62 and her expectations is for there to be monitoring orders in the EHR. <Resident 68> Resident 68 was admitted to the facility on [DATE]. The admission MDS, an assessment tool, dated 05/21/2024, documented Resident 68 was moderately cognitively impaired. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure drugs and biologicals were labeled and dated in accordance with accepted professional standards of practice, and expired medications were discarded for 1 of 1 medication room and 2 of 3 medication carts (C1 & C2) that were observed. These failures placed residents at risk to receive expired medications and negative health outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain effective infection prevention and control practices to prevent the spread of infections and communicable diseases. Facility staff failed to follow accepted infection control practices during the provision of wound care for 3 of 3 residents (Residents 62, 40 & 69) reviewed for wound care, failed to perform hand hygiene after contact with residents and/or their environmental surfaces (Staff AA), and failed to wear required personal protective equipment (PPE) when providing care to residents on transmission based precautions for 3 of 3 residents (Residents 324, 53 & 10) reviewed for transmission based precautions. These failures placed residents at risk for facility acquired or healthcare-associated infections and related complications.

Inspectors wroteBased on interview and record review the facility failed to ensure mail was delivered unopened for 4 of 7 residents (Residents 25, 30, 43 and 46) reviewed for resident rights. This failure placed the residents at risk for lack of privacy and a diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to provide an Advanced Directive (AD, a written instruction of health care directions) for 2 of 9 residents (Residents 59 and 62) reviewed for ADs. This failure placed residents at risk for losing their right to have their healthcare preferences and/or decisions honored.

Inspectors wroteBased on interview and record review, the facility failed to file a grievance and to make a prompt effort to resolve the resident's grievance for 1 of 3 sampled residents (Resident 18) reviewed for personal property. This failure placed residents at risk for a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to complete a Significant Change Minimum Data Set (MDS), an assessment tool, for 1 of 2 residents (Resident 10) reviewed for hospice and end of life. This failure placed residents at risk for unidentified and unmet care needs and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure Minimum Data Sets (MDS), an assessment tool, accurately reflected residents' health status and/or care needs for 2 of 28 sampled residents (Residents 73 and 18) reviewed for MDS accuracy. The failure to accurately assess if residents had a terminal diagnosis or fall with major injury, placed residents at risk for unidentified and/or unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Pre-admission Screening and Resident Review (PASRR) assessment accurately reflected the resident's mental health diagnoses for 1 of 7 residents (Resident 73) reviewed for PASRR. This failure placed residents at risk for inappropriate placement and/or not receiving timely and necessary mental health services to meet their individualized mental health needs.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a care plan that was comprehensive and individualized, with measurable objectives, interventions and timeframes for how staff would meet the residents' needs related to opioids, for 1 of 4 sampled residents (Resident 18) reviewed for pain. This failure placed residents at risk for possible side effects of opioids, lack of follow up interventions related to opioids, for no reevaluation of care area, or of unidentified and unmet care needs and of a diminished quality of life.

Inspectors wroteBased on record review and interview, the facility failed to provide a Care Conference (a conference where staff and residents/families talk about life in the facility, review the progress of each patient and make adjustments, as needed, to the care plan), for 2 of 2 sampled residents (Resident 10 and 38) reviewed for care plan timing and revision. This failure placed residents at risk for unmet needs, diminished quality of care and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pressure ulcer treatment and services in accordance with professional standards for 2 of 7 sampled residents (Residents 10 and 40) reviewed for pressure ulcers. This failure placed residents at risk for untreated pressure ulcers, pain, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to timely identify, assess, and address the nutrition of residents with significant and/or trendable weight loss for 2 of 6 residents (Residents 69 and 61) reviewed for nutrition. The facility failed to ensure resident weights were consistently and accurately obtained, to honor residents' diet preferences, and to implement nutritional intervention recommended by the Registered Dietician (RD). These failures placed residents at risk for continued and/or unidentified weight loss, delayed nutritional intervention, and unmet nutritional needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pain management that met professional standards including the failure to monitor or reassess effectiveness of pain medication, to use non-pharmacological interventions when indicated, and to work with the practitioner to taper analgesics (pain relieving medications) when medically indicated, for 1 of 4 sampled residents (Resident 18) reviewed for pain. This failure placed residents at risk for side effects of medications for pain, unidentified and unmet care needs, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a medication error rate of less than five percent when 1 of 2 nurses (Staff P) incorrectly administered 3 of 25 medications in accordance with physician orders and/or manufacturer's guidelines for 1 of 3 residents (Resident 39) observed during medication pass. This resulted in a medication error rate of 8 percent. These failures placed residents at risk for ineffective treatment of underlying medical conditions and/or adverse side effects.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the quality and timeliness of laboratory services for 1 of 8 sampled residents (Resident 19) reviewed for urinary catheter or Urinary Tract Infection (UTI). This failure placed residents at risk for delay in diagnosis of infection, of sepsis, of potential complications, of increased length of stay, and of a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to promptly notify the provider of laboratory results that fell outside of normal ranges for 1 of 8 sampled residents (Resident 19) reviewed for urinary catheter or Urinary Tract Infection (UTI). This failure placed residents at risk for potential complications, of increased length of stay, and of a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure sufficient dietary staff were trained and competent in the preparation and provision of puree (food made to consistency of pudding) diets for 2 of 2 residents (Residents 35 & 125) reviewed for pureed diets. The failure to have sufficient staff available to ensure dietary staff were supervised until they were trained and competent in their duties, resulted in residents being provided the incorrect diet texture, and placed residents at risk for aspiration, choking risk and for food borne illness.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that 1 of 3 sampled residents (Resident 67) received foods that accommodated the residents' preferences and allergies. This failure placed residents at risk for meal dissatisfaction, allergic reaction, and a diminished quality of life.

Inspectors wroteBased on observations and interviews, the facility failed to ensure rooms were clean and linens changed timely for 4 of 9 residents (Residents 5, 6, 2, and 1) reviewed for physical environment. This failure placed residents at risk for dissatisfaction with their living environment, compromised dignity and a diminished quality of life.

Inspectors wroteBased on interviews and record reviews, the facility failed to provide bathing assistance for 3 of 8 residents (Resident 1, 2 and 3) reviewed for bathing. This failure placed residents at risk for poor hygiene, skin conditions and a diminished quality of life.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to provide wound care per physician orders for 2 of 2 residents (Resident 2 and 4) reviewed for wound care. This failure placed the residents at risk for medical complications and infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure services provided met professional standards of practice for 1 of 5 sampled residents (Resident 2) reviewed for care and services. The failure to follow physician's orders placed residents at risk for clinical complications, medication errors and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide adequate supervision and assistance at a community appointment for 1 of 3 resident (Resident 1) reviewed for supervision. This failure placed residents at risk for avoidable accidents, injury, pain, and emotional distress.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary care and services to treat and prevent worsening or development of a pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure) for 4 of 6 sampled residents (Resident 1, 2, 3 and 4), reviewed for pressure ulcers. Resident 1 experienced harm when they had deterioration of a pressure ulcer to the right buttock that required surgical treatment and the development of three additional pressure ulcers. These failures placed residents at risk for pressure ulcer development, deterioration of existing pressure ulcers, pain, and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure hand hygiene was performed during medication administration for 2 of 3 sampled residents (Resident 5 and 6) reviewed for infection control. This failure placed the residents at risk for exposure to communicable diseases.

Inspectors wroteBased on interview, observation and record review, the facility failed to consistently provide palatable food for 5 out of 7 residents (Resident 1, 2, 3, 4 and 5) reviewed for food. This failure placed residents at risk for weight loss, inadequate nutrition and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to inform the resident's representative of treatment decisions and discharge for 1 of 3 residents (Resident 6) reviewed for resident rights. This failure placed all residents and or their representatives at risk for not being included in their health care decisions and discharge planning.

Inspectors wroteBased on interview and record review, the facility failed to ensure sufficient staff were available to provide necessary care and services for 5 of 9 sampled residents (Residents 1, 3, 4, 5 and 6) reviewed for nursing services related to sufficient staffing. This failure placed residents at risk for unmet care needs, discomfort, and a diminished quality of life.

Inspectors wroteBased on interview, observation and record review, the facility failed to assess and monitor non-pressure wounds for 3 of 3 residents (Resident 1, 2 and 3) reviewed for wound care. This failure placed residents at risk for worsening skin conditions, medical complications, and unnecessary pain.

Inspectors wroteBased on observation and interview, the facility failed to ensure resident rooms were repaired and maintained for 3 out of 3 halls (Halls A, B and C) reviewed for homelike environment. This failure placed the resident at risk for compromised dignity and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to initiate, log, and timely resolve grievances voiced by residents during resident council. These failures left residents at risk for unresolved grievances, unmet needs, and frustration.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that the environment was free from accident hazards for 3 of 5 residents (Resident 2, 22, & 28) reviewed for accident hazards. This failure placed the residents at risk for an unsafe environment and diminish quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure oxygen therapy was provided in accordance with Physician's orders and accepted professional standards of practice for 2 of 2 residents (Residents 31 & 3) reviewed for respiratory care. Facility staff failed to administer oxygen at the ordered rate, to accurately record the flow rate of oxygen administered, to ensure oxygen concentrators had functional air filters, and to change oxygen tubing at the ordered frequency. These failures resulted in residents not receiving the ordered amount of oxygen and placed them at risk for adverse side effects related to oxygen therapy and unmet respiratory needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure there was a Registered Nurse (RN) working a minimum of eight hours each day for nine of 30 days reviewed for staffing. This failure placed residents at risk for delayed assessments/treatments and a diminished quality of care.

Inspectors wroteBased on observation, interview, and record review the facility failed to serve foods that were palatable, and at the proper temperature. Observation of meal preparation and interviews with 5 residents (Residents 12, 53, 28, 7 & 71) revealed concerns about the temperature and palatability of food served by the facility. These failures placed residents at risk for weight loss, decreased meal satisfaction and for diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents received foods in the appropriate form and/or nutritive content as prescribed by a physician, and/or assessed by the interdisciplinary team to support the resident's nutritional needs. Failure to ensure residents' received physician ordered therapeutic diets or portion sizes placed residents at risk for medical complications or nutritional deficits.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide grooming/personal hygiene needs and respectful resident care in a manner that promoted the resident's dignity for 2 of 2 residents (Residents 3 & 26) reviewed for dignity. This failure placed the residents at risk for embarrassment, diminished self-esteem, and a decrease in quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to inform a resident in advance of the risks and benefits associated with proposed psychotropic medication therapy (medications capable of affecting the mind, emotions, and behavior), wander guard placement (a device designed to help protect memory care residents against elopement) and obtain resident consent prior to implementing the proposed treatments/therapies for 1 of 5 Residents (Resident 18) reviewed for unnecessary medications. [...]

Inspectors wroteBased on interview and record review, the facility failed to honor bathing preferences for 2 of 2 residents (Residents 31 & 18) reviewed for choices. The failure to promote and facilitate resident self-determination, by honoring residents' choices related to bathing frequency, placed residents at risk for poor hygiene, feelings of powerlessness, and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure conveyance (the act of legally transferring property from one entity to another) of a resident's trust funds, including a final accounting of those funds within 30 days of discharge for 1 of 1 discharged resident (Resident 75) reviewed for trust accounts. This failure prevented the resident from having access to their funds for an extended period of time.

Inspectors wroteBased on interview and record review, the facility failed to accurately assess 3 of 25 sampled residents (Residents 12, 32 & 65) whose Minimum Data Sets (MDS, an assessment tool) were reviewed. Failure to ensure residents' cognitive patterns, mood, preferences, and medication use were assessed and/or accurately assessed, placed residents at risk for unidentified and/or unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to develop a baseline care plan within 48 hours of admission for one of 25 residents (Resident 62) reviewed for new admissions. Failure to ensure an initial care plan addressed wound care to the residents left knee wound site placed the resident at risk for unmet needs and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident care plans (CPs) were reviewed, revised, and accurately reflected resident care needs for 5 of 25 sampled residents (Residents 18, 31, 3, 28 & 22) whose CPs were reviewed. These failures placed residents at risk for unidentified/ unmet care needs and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure services provided met professional standards of practice for 4 of 21 sample residents (Residents 61, 31, 32, & 54) reviewed. The failure to obtain, follow, and clarify Physician's orders when indicated, only sign for those tasks that were completed, and failure to notify the physician when residents' medications were held, placed residents at risk for medication errors, delayed treatment, and adverse outcomes.

Inspectors wroteBased on interview and record review, the facility failed to ensure 1 of 5 residents (Residents 18) reviewed for unnecessary medications, were free from unnecessary psychotropic drugs. Facility staffs' failure to identify and monitor the target behaviors that the medication was intended to treat detracted from staffs' ability to monitor the effectiveness of the medication and the need for continued use. This failure placed the resident at risk to receive unnecessary medications and/or experience adverse side effects.

Inspectors wroteBased on observation and interview, the facility failed to ensure drugs and biologicals were labeled in accordance with accepted professional standards of practice and that expired medications were discarded for 2 of 2 medication carts and 1 of 1 medication room observed. These failures placed residents at risk to receive expired medications and to experience adverse side effects and other potential negative health outcomes.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure dental services were provided for 1 of 2 Medicaid residents (Residents 31) reviewed for dental services. Facility staffs' failure to follow up on dental referrals and to timely schedule an appointment with a denturist, placed the resident at risk for difficulty chewing, oral pain, decreased self-image and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to honor resident food preferences for 2 of 7 residents (Resident 6 & 18) reviewed for food. This failure placed the residents at risk of not having preferred foods, lack of dietary intake and a diminished quality of life.

Inspectors wroteBased on observation and interview the facility failed to prepare and serve food under sanitary conditions. Additionally, the facility failed to ensure the use of hair net during meal preparation in the kitchen. These failures placed residents at risk for cross-contamination and foodborne illnesses.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure standard infection control practices were followed related to: screening of staff /visitors upon entering the facility; performance of hand hygiene for 1 of 1 resident (Resident 62) observed during wound care and 1 of 3 residents (Resident 54) observed during medication pass; and sanitization of shared resident equipment after use, for 1 of 3 residents (Resident 54) observed during medication pass. These failures placed the residents, staff members and visitors at potential risk for acquiring and spreading bacteria and infectious diseases.

Inspectors wroteBased on observation and interview the facility failed to provide a safe environment for residents and visitors on 1 of 3 Wings (C-Wing) reviewed for environment. This failure placed residents and visitors at risk for accidents, injury, and diminished quality of life.