Professional Post Acute Center

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident safety for two of three residents sampled for falls (Resident 75 and Resident 66) when: 1. Resident 75 was receiving incontinent care (toileting; changing a soiled adult brief) by one Certified Nursing Assistant (CNA J) when she required two caregivers to assist, and subsequently fell out of her elevated bed (a mattress raised to the caregivers preference to provide care comfortably) when she was turned on her side; and, 2. Resident 66 fell after she was left unattended at her bedside while sitting in a shower chair (a specialized, waterproof chair used for bathing residents). These failures: 1. [...]

Inspectors wroteBased on observation, interview and record review, the Restorative Nursing Assistants (RNA) failed to carry out an ordered treatment to maintain or improve mobility and prevent decline in range of motion (ROM) for one resident (Resident 23) of two sampled residents when Resident 23's left-hand wrist brace was not applied on a daily basis. This failure had the potential for Resident 23's left hand paralysis to become contracted (a permanent or severe tightening of muscles, tendons, skin, and other soft tissues that leads to joint stiffness and limits normal movement).

Inspectors wroteBased on observations, interviews, and record review, the dietary staff failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for a census of 82 residents when a plastic scoop was left in the powdered sugar bin. This failure had the potential to contribute to the spread of foodborne illnesses for a vulnerable population.

Inspectors wroteBased on interview and record review, the facility nurses failed to ensure one resident (Resident 75) of twenty-two sampled residents was provided her orthopedic devices (leg splint and leg cast; braces) used to immobilize her recently fractured (broken bone) leg bones, when staff discarded them. This failure prevented Resident 75's fractured legs from being immobilized and stabilized, per physician orders, for over eight hours, placing her at risk of fracture displacement (broken ends of the bone are separated and no longer aligned, often requiring medical intervention for proper healing) and nerve damage, and caused her to experience pain, and feel fatigued and distressed.

Inspectors wroteBased on observations, interviews, and record review, the Certified Nursing Assistants (CNAs) failed to ensure infection prevention measures were implemented for one resident (Resident 8) of three sampled residents, when an unlabeled, uncovered, used urinal (a portable plastic bottle with a handle and a special opening used to collect urine) was found at Resident 8's bedside table next to a water pitcher and a nebulizer mask (a plastic cup that fits over your nose and mouth which connects to a machine that turns liquid medicine into a cool, breathable mist). This failure increased the risk of cross contamination and potential transmission of infectious diseases.

Inspectors wroteBased on interview and record review, the facility nurses failed to notify the physician when one resident (Resident 1), out of five sampled residents, did not consume the minimum amounts of fluid and nutrition the Registered Dietitian's (RD) calculated for Resident 1 in April 2026. This failure contributed to Resident 1's hospitalization with a diagnosis of hypovolemia (a critical condition in which there is a low volume of fluid in the body, often caused by dehydration) on 4/30/26.

Inspectors wroteBased on interview and record review, the facility failed to notify a resident representative of a decline in condition for one of three sampled residents, Resident 1, when Resident 1 was transferred to the hospital and Resident 1's family member (FM) was not informed. This failure caused FM to feel angry and confused when she learned Resident 1 was hospitalized from hospital staff who had called from the intensive care unit (ICU) to inform her Resident 1 was in critical condition and being intubated (a procedure where a breathing tube is inserted into the airway to bring oxygen to the lungs). During a phone interview on 5/4/26 at 8:58 a.m., FM stated she was the primary contact for the facility staff to call whenever there was a change in Resident 1's condition. FM stated on the night of 4/30/26, around 9 p.m. she received a phone call from staff at the local acute care hospital. [...]

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure professional standards of quality were delivered for one out of four sampled residents (Resident 1) when Resident 1 was left to self-administer his medications despite not having a medication self-administration assessment completed. This failure creates risks of medication errors such as overdose or missed doses, adverse drug interactions, and potential resident injury.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure medications were in locked compartments and only accessible for authorized persons for one out of three sampled residents (Resident 1) when medications were left on Resident 1's bedside table. This failure put the residents at high risks for unauthorized access to the medications, ingestion by the wrong resident with possible adverse reactions.

Inspectors wroteBased on interview and record review, the facility failed to ensure an environment free of falls for one resident (Resident 1) of three sampled residents when the facility:1. Did not initiate a person-centered care plan for Resident 1's fall risk prior to [DATE]; and,2. Did not analyze Resident 1's risk for a fall after worsening edema (swelling from an accumulation of fluid in the body's tissues) and possible deep vein thrombosis (DVT, a blood clot in a deep vein which can cause pain and swelling) in her lower legs. These failures contributed to Resident 1 sustaining a left fibula (one of the two bones in the calf) [NAME] fracture (a break of the upper fibula usually caused by twisting or forceful rotation of the ankle) from a fall. Cross reference F557.

Inspectors wroteBased on interview and record review, the facility failed to allow one resident (Resident 1) to retain her personal recliner chair which assisted in supporting Resident 1's lower back and venous insufficiency (a condition where the veins in the legs have difficulty in returning blood to the heart, often causing swelling and pain). This failure resulted in Resident 1 enduring back and leg pain. Cross reference F689.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a safe and sanitary environment for one out of four sampled residents (Resident 3) when Resident 3's commode (a portable toilet, often resembling a chair, designed for individuals with mobility limitations who may have difficulty accessing a traditional toilet) bucket (removable container of the commode that collects wastes) was covered with a blanket. This failure has the potential to spread germs and cause infections.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1) received care consistent with nursing professional standards of quality and the resident's individualized nursing care plan (document that contains essential information about a patient's condition, diagnosis, goals, interventions, and outcomes) when Resident 1 had symptoms consistent with a urinary tract infection (UTI- infection in any part of the urinary system, including the bladder and kidneys)over the period of approximately one month (approximately 3/5/2025 to 4/7/2025), including bladder pain and blood in her urine (hematuria), but nursing staff did not ensure her provider (physician or nurse practitioner) was notified, a urinalysis (test of urine; used to detect infection) was obtained, and the hematuria was monitored. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident (Resident 1) of four sampled residents was free from physical abuse when Resident 2 squeezed Resident 1 ' s left arm causing bruising and pain to Resident 1. This failure resulted in a physical injury and emotional distress to Resident 1.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to act upon pharmacy recommendation for 1 (Resident #73) of 6 sampled residents reviewed for unnecessary medications, psychotropic medication, and medication regimen review.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to maintain a medication error rate of 5% or less. There were two medication errors out of 27 opportunities, which yielded a medication error rate of 7.41% for 1 resident (Resident #10) of 4 residents observed for medication administration.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure the right one of seven sampled residents, Resident 1, to be free from physical abuse when, Resident 1, who had a history of yelling and screaming due to hallucinations, was slapped on the left side of her face by another resident, Resident 2, who had a care planned intervention to modify her environment by reducing the noise level due to a potential to demonstrate aggressive behavior. Resident 1 and Resident 2 were in rooms close to each other. This failure had the potential to result in physical injuries to Resident 1.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that an alleged violation of physical abuse to one of seven sample residents, Resident 1, was reported to the State Survey Agency immediately, but not later than 2 hours after the allegation of physical abuse was made, when Certified Nursing Assistant C witnessed Resident 2 slapped Resident 1 on the left side of her face on 8/25/24, at 3:30 p.m., and Licensed Nurse A reported the incident to the State Survey Agency via voicemail on 8/25/24, at 9:02 p.m., followed by a fax transmitted to the State Survey Agency on 8/25/24, at 9:13 p.m. The physical abuse allegation was reported by Licensed Nurse A to the State Survey Agency more than 5 hours after Certified Nursing Assistant C's allegation was made. [...]

Inspectors wroteBased on observations and interviews, the facility failed to ensure a safe and functional environment to three of seven sampled residents (Resident 3, 4, and 5) in room [ROOM NUMBER], when the sliding door and screen door locking mechanisms were broken. This failure had the potential to result in harm to these residents in case of a violent break-in situation or when accidentally left open during extreme weather patterns, jeopardizing their health and safety.

Inspectors wroteBased on observation, interviews and record review, the facility did not ensure the safety of 1 out of 5 sampled residents (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5), when Resident 4 eloped from the facility and was found .4 miles away by the Police Department. This failure had the potential for all residents at risk of elopement, to be at risk of falls, injury and possible death.

Inspectors wroteBased on interview and record review, the facility failed to ensure 1 resident (Resident 1) in a census of 86 residents received adequate pain management consistent with nursing standards of practice, the resident's individualized care plan, the resident's preferences, and facility policy. Resident 1 described his pain as severe and stated it was #5-9 (moderate to severe) on the pain scale (Pain Scale: a tool health care professionals utilize to help assess a person's pain; the pain scale is from 0 to 10, where 0 is no pain, and 10 is the worst pain imaginable) and his physician ordered him to receive Hydromorphone (also know as Dilaudid; a narcotic pain medication) 4 mg (milligrams) every 4 hours on a scheduled basis. Licensed nurses did not administer Hydromorphone as ordered by the physician because the facility ran out of the medication; [...]

Inspectors wroteBased on interview and record review, the facility's pharmacy failed to provide 1 resident (Resident 1) in a census of 86 residents with his routine pain medication (Hydromorphone, also known as Dilaudid) timely and failed to ensure nursing staff had access to the Hydromorphone located in the facility's e-kit (container with emergency medication storage). These failures contributed to Resident 1 to missing his Hydromorphone doses for approximately 24 hours on 10/28/2023 and missing his pain medication again multiple times from 12/11/23 through 12/14/23 which in turn: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to protect one of three sampled residents (Resident 1) from possible abuse and self-injurious behavior, when: 1. Two injuries of unknown origin, discovered on 1/01/24, were not investigated by the facility, and; 2. Resident 1, who had a history of skin lesions (A region in an organ or tissue which has suffered damage through injury or disease), was not protected from self-injurious behavior, nor were several new skin lesions documented, care planned or receiving any type of treatment at the time of discovery by the DEPARTMENT Surveyor. These findings had the potential to result in abuse and harm, including death from serious skin infections to Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure professional standards of practice were implemented for one of three sampled residents (Resident 1) when Administrator B (Facility ' s previous Administrator) failed to follow-up on an antipsychotic (A medication that affects brain activity associated with mental processes and behavior and treats symptoms of mental illness) consent form that was needed for Resident 1 to resume his preadmission antipsychotic therapy. This finding had the potential to result in harm, neglect, and inability for Resident 1 to reach his maximum health care potential.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the daily nursing staffing information was posted in a conspicuous place during a time of the day when visitors were allowed to enter the facility, during one of three visits by the Surveyor (On 12/14/24). This finding had the potential to result in inability for residents, visitors, and staff to review the staffing information, advocate for the residents ' care, and identify issues with staffing numbers, which could have contributed to decreased quality of care.

Inspectors wroteBased on interviews and records review, the facility failed to assess and provide necessary services to prevent the worsening of facility-acquired pressure ulcer (injuries to skin and underlying tissue resulting from prolonged pressure on the skin) for one of two sampled residents (Resident 1) when Resident 1 was found to have an open wound on her sacrum (the triangular bone just below the backbone) and coccyx (the tailbone) and the facility failed to: 1. Obtain a doctor ' s order for a routine wound treatment when a sacral wound was identified; 2. Assess and document the status of wound perimeter (refers to the surrounding area of the wound edge), wound bed (the base or open area of a wound) and healing progress as part of the pressure ulcer care plan; and 3. [...]

Inspectors wroteBased on observation, interviews, and records review, the facility failed to provide staff supervision for transfer and ambulation to one of two sampled residents (Resident 1) when Resident 1 required extensive (resident involved in activity; staff provide weightbearing support [staff supports some of the weight of the resident]) one-person physical assist with transfers and ambulation and was found lying at the hallway. This failure resulted in Resident 1 sustaining a right femoral fracture (a break in the thigh bone) and subsequently had a significant physical functional (the ability to perform basic and instrumental activities of daily living) decline.

Inspectors wroteBased on interviews and records review, the facility failed to ensure care plan conferences were conducted for two or two sampled residents (Residents 1 and 2). This failure resulted to Resident 1 ' s Representative and Resident 2 not being able to exercise their right to participate with care planning on continuing or changes in care, treatment, and healthcare goals that could affect Resident 1 and Resident 2 ' s quality of care and quality of life.

Inspectors wroteBased on interviews and records review, the facility failed to implement timely revision of ADL (Activities of Daily Living) Self Care Performance Deficit Care Plan for one of two residents (Resident 1) when the facility did not update the Care Plan for Resident 1 reflecting the decline in Resident 1 ' s functional status. These failure had the potential for facility staff to provide inadequate care and supervision to ensure Resident 1 ' s health and safety needs. (Reference F689, F686)

Inspectors wroteBased on observations, interviews and records review, the facility failed to meet nursing professional standards for one of two sampled residents (Resident 1) when a facility licensed staff provided wound treatment to Resident 1 without a physician ' s order. This failure had a potential risk for Resident 1 of adverse drug reaction. (Reference F686)

Inspectors wroteBased on interviews and records review, the facility failed to provide necessary services for one of two sampled residents (Resident 1) when: 1. The facility did not perform a rehabilitation screening for Resident 1 after the fall to evaluate any adverse effects from the fall and the potential need for rehabilitation services. 2. The facility waited for eight (8) days to perform a right hip X-ray (a type of medical imaging that creates pictures of the bones and soft tissues) after Resident 1 had complained of right hip pain and waited for another 8 days to obtain an order for weight bearing precaution after Resident 1 was found with right femoral fracture (a break in the thigh bone). [...]

Inspectors wroteBased on interview and record review, the facility failed to implement a Plan of Correction (POC-a document submitted by licensed health care facilities to respond to deficiencies identified in a survey of the facility conducted by state field staff) after they were cited on 4/20/23 for not having replaced or reimbursed several missing items for one of three residents (Resident 4). In this POC, which was approved by the DEPARTMENT 7/20/23, the facility agreed to reimburse Resident 4 for a list of missing items provided by Resident 1 ' s resident representative (Witness AA) but did not do it. This finding resulted in frustration, resentment, and anger to Resident 4 ' s family, which added to the grief of her loss in August of 2023.

Inspectors wroteBased on interview and record review the facility failed to adequately manage one of one resident's (Resident 5) pain control. This failure resulted in Resident 5 suffering unnecessary pain for eight days until the diagnosis of a fracture had been confirmed.

Inspectors wroteBased on interview and record review, the facility failed to ensure radiological services were provided in a timely manner for one of one resident (Resident 5) when a STAT (immediately) x-ray (a form of electromagnetic radiation, which is used to generate images of tissues and structures inside of the body) of the left knee was not completed for eight days. This failure resulted in a delayed diagnosis and treatment causing pain and suffering.

Inspectors wroteBased on observation, interview and record review the facility failed to treat four of ten sampled residents (Resident 1, Resident 2, Resident 6, and Resident 8) with respect and dignity when Resident 1 was not ensured access to a call light, assistance with answering phone calls from family, and had to call out/yell and wait for assistance, Resident 2 was left sitting or lying in his urine or feces for prolonged period of time, Resident 6 was left waiting a long time to get cleaned up, and Resident 8 feeling staff in the graveyard shift avoid cleaning him and left him lying in his feces and waiting for the morning to clean him up. These failures caused Resident 1 to feel frustrated, Resident 2 to feel staff did not care, Resident 6 to cry stating she felt like she was in a concentration camp, and Resident 8 stating he felt staff were doing it on purpose, and he felt bad and hurt.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a safe and homelike environment when one of nine air conditioning (AC) units of the facility was not replaced or repaired, and the emergency exit door by Nursing Station 2 and 3 was not repaired for an undisclosed long period of time, and the iron gate at the top of the stairs leading from the emergency exit door was not secured and left accessible to anyone from the driveway in front of the building. These failures exposed residents in at least 6 of 38 rooms (approximately 16 of 82 residents) and staff in the facility to uncomfortably hot environment in the summer and potentially extreme cold conditions this winter that could worsen the frail health conditions of the residents, cause an accident from the door falling or a break-in and harm to residents and staff from intruders through the open gate.

Inspectors wroteBased on interview and record review, the facility failed to establish a system for disposition of controlled substances in sufficient detail when two Licensed Nurses (Licensed Nurse G and Licensed Nurse H) did not know how to properly dispose of unused or wasted narcotic medication. This failure increased the risk for potential misuse and abuse of narcotic medication or could result in water pollution and unintentionally expose of the public to chemical from the medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to practice proper hand hygiene when four of seven Certified Nursing Assistants (CNAs) (CNA A, CNA B, CNA E, and CNA F) did not offer, encourage, clean or wash residents' hands prior to serving meal trays or before letting residents eat. The failure increased the potential to spread communicable diseases or infection among residents and staff in the facility and further compromise the already frail condition of the residents.

Inspectors wroteBased on interview and record review, the facility failed to report within 2 hours a suspected abuse incident between two residents (Resident 7 and Resident 11). This failure had the potential of placing residents at risk for further abuse, delay the assessment, and evaluation of the involved residents and management of psychosocial or physical injury, delay the investigation to determine the cause and extent of the conflict, or rule out abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure eight residents (Residents 2, 23, 54, 56, 62, 67, 72, 235) were free from verbal abuse and neglect by staff, including Staff I (Licensed Nurse), when: 1) Staff I communicated with residents in ways that caused discomfort to both residents and staff. 2) Staff I intimidated Resident 235 and Resident 54. 3) Resident 2 was afraid to ask Staff I for his as-needed pain medication to manage moderate or severe pain. 4) Six Residents in Resident Council vocalized fear of retaliation from Staff I. 5) Resident 23, Resident 2, Resident 62, Resident 67, and Resident 72 observed nursing staff sleeping during regular work hours at night. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement its abuse policy and procedure for one resident (Resident 56), when Resident 56 complained to Staff C (Social Worker) of potential abuse by Staff I (Licensed Nurse) with did not utilitze this knowledge and implement the facility's abuse policies. This failure resulted in Resident 56 not being free from abuse and being subjected to verbal abuse by staff and neglect that lead to anger, humiliation, and physical pain.

Inspectors wroteBased on interview and record review, the facility failed to report to State Agency an allegation of verbal abuse to the appropriate agencies for one resident (Resident 56), when Resident 56 complained about repeated, offensive communication from a licensed nurse and facility staff did not escalate the concern to the facility administrator or investigate the complaint. This failure resulted in delay of a State Survey Agency and facility investigation into verbal abuse affecting Resident 56, did not ensure Resident 56's safety, and caused feelings of anger, humiliation and racially profiling.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nursing staff demonstrated competency in clinical care and services, when the facility did verify ongoing competency of: 1) Licensed nurse ability to perform accurate blood sugar monitoring; 2) Licensed nurse skill at administering medication to residents; 3) Licensed nurse ability to ensure controlled wasting of narcotic medication; These failures had the potential to cause inappropriate monitoring of blood sugar, medication errors during administration, and not meeting residents' safety and infection control needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staffing requirements where met, when: 1. The facility did not have a designated Registered Nurse covering for the DON for several days, while the DON was out on medical leave. 2. The facility did not use the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week, These findings resulted in missed doses of IV (Intravenous) Antibiotic medication for Resident 137 on 5/6/21 and 5/7/21 due to not having a Registered Nurse employed on those dates, and had the potential to result in the inability to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of reach resident.

Inspectors wroteBased on observation, interview and record review, the facility failed to promote residents' respect and dignity to residents when: 1) Resident 141 did not get his meal tray at the same time as everyone else in the dining room. 2) Resident 25 watched other residents eat while he could not eat by mouth. 3) Resident 58 listened to Speech therapist conducted work in the day room. 4) Residents voiced grievance but did not get response from the facility. 5) Residents 2 and 62 had photographs taken while they were sleeping without their awareness or approval. These failures resulted in residents feeling angry, neglected, and disrespected.

Inspectors wroteBased on observation, interview and record review, the facility failed to keep residents informed of their rights and responsibilities when admission Agreements (A legal contract that states the rights of the residents and responsibilities of both the facility and the residents) were not provided to several residents upon admission to the facility and consents to treatment were not signed. This failure had the potential to result in violation of residents' rights.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a safe, clean, comfortable and homelike environment to all residents in the facility when: 1) Flying pests were observed in the dining room, conference room, and one resident room 2) Residents were exposed to rodents inside the facility 3) Staff stored cooked meat stored cooked meat for a pet's meal in a drawer inside one resident room. These failures had the potential to result in a decline of residents' psychosocial functioning and resident discomfort.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement care plans for activities for two of six residents (Resident 78 and Resident 72). This failure had the potential to result in deterioration of the residents' mental and physical health, and decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure care plans were revised and updated for two of six residents (Resident 23 and Resident 41) after suffering falls at the facility. As a result, the residents continued to suffer falls, which could have resulted in serious injuries and harm.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure professional standards of practice were implemented when: 1. A Licensed Nurse (STAFF I) did not inform other Licensed Staff on the floor that she was taking her lunch so they could cover for her during her leave. This failure had the potential to result in inability for other nurses to respond to medical emergencies and needs of the residents in STAFF I's assigned section. 2. Facility staff, including department heads, were observed using their cell phones for personal business during work hours. 3. Facility staff did not sign the MAR to indicate administration of opioid medication for Resident 56 after removing the medication from a pill pack. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe and accident free facility when: 1. The facility stored two unsecured oxygen tanks inside one of 19 resident's (Resident 58) room; 2. Two of six residents (Resident 23 and Resident 41) were not provided adequate care and supervision to prevent them from suffering multiple falls; 3. The facility did not perform a smoking assessment for one of six residents (Resident 5), and allowed Resident 5 to keep his own smoking supplies in his room; 4. Trained, licensed nursing staff did not observe residents who were eating during mealtime. 5. Flammable liquid was not stored in accordance with facility policy. These failures had the potential to cause resident resident harm, and did not ensure a safe environment for delivering care and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure sufficent staff available during the night shift to respond to residents' calls for assistance in a timely manner. This failure had the potential to result in poor quality of care and accidents to the residents requiring assistance in the middle of the night.

Inspectors wroteBased on observation, interview and record review, the facility failed to post the daily nursing staffing schedule daily. This failure could have resulted in unavailability of staffing information to residents and visitors for review.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one kitchen staff (STAFF Y) performed adequate hand hygiene during meal preparation. This failure had the potential to result in food-borne illness to the residents of the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure clinical documentation was complete and accurate when supplemental oxygen administration was not documented for one resident (Resident 183), and neurological checks (Evaluation of a patient's nervous system) indicated for one resident (Resident 41) where not completed. This failure had the potential to result in inability for staff to respond to the status and needs of the residents, and lack of availability of information to facilitate communication among the interdisciplinary team.

Inspectors wroteBased on interview and record review, the facility failed to ensure their Quality Assessment and Performance Improvement (QAPI) effectively identified and resolved concerns related to: 1. Allegations of abuse and neglect against staff, and; 2. Staff sleeping on duty. These failure had the potential to affect every resident's ability to maintain the highest level of well-being, and had the potential to expose residents to continued physician and/or psychosocial harm if concerns remained unresolved.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement infection prevention and control practices, when: 1. Staff did not practice hand hygiene during mealtime and did not offer residents hand hygiene during mealtime. 2. A Licensed Nurse did not wear a face mask properly, placing the residents at risk for the spread of infections. These failures have the potential for the transmission of infections or causing food borne diseases.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an effective pest control program, when it did not follow policy or take measures recommended by the pest control company to minimize pests. This failure enabled known pest problems to continue and had the potential to expose resident to diseases transmitted by rodents, flies and other insects, leading to unnecessary illness or death.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of six residents (Resident 51) received his scheduled showers twice per week. This failure had the potential to result in discomfort, skin infections and feelings of frustration and helplessness to Resident 51.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide an on-going activities program for two of six residents (Resident 78 and Resident 72) designed to meet the residents' interests. This failure had the potential to result in deterioration of the residents' mental and physical health, and decreased quality of life.

Inspectors wroteBased on observation, interview and record review the Facility did not determine the indication for one of five residents (Resident 140) to continue using a urinary catheter (a tube to drain the urine from one's bladder.) This failure resulted in Resident 140 missing a follow up Medical appointment. In addition, there is potential for the resident to develop a urinary tract infection from the external tube.

Inspectors wroteBased on observation, interview and record review, the failed to store and label medication appropriately, when the facility: 1) Did not use the appropriate temperature controls when storing medication. 2) Stored expired medication with medication intended for resident use 3) Stored medication in containers with an inappropriate labels These failures had the potential to result in administration of contaminated or unstable medication as well as use of medication beyond the medication's date of expiration, which could cause resident harm.