Providence St. Elizabeth Care Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care in a manner that maintained or enhanced a resident's dignity and respect in full recognition of their individuality for one of three sampled residents (Resident 2) when on 4/1/2026 at 8:22 a.m., Resident 2 was observed in the facility's Rehab Room with a urinary catheter (also known as an indwelling catheter, a hollow tube inserted into the bladder to drain or collect urine) that was not covered with a dignity cover (a fabric, cloth, or vinyl sleeve designed to cover the external urine collection bag). This deficient practice had the potential to negatively affect the resident's psychosocial wellbeing (a person's overall mental and social health, combining how they feel inside [emotions] with how they relate to others and their environment) and loss of dignity.

Inspectors wroteBased on interview and record review, the facility failed to provide care in accordance with professional standards of care for one of three sampled residents (Resident 1) when the facility failed to:1. Implement the Registered Dietitian's (RD - a credentialed food and nutrition expert who uses evidence-based science to help people improve their health, manage diseases, and create personalized meal plans) recommendations and doctors' orders after Resident 1 was noted with a Change of Condition (COC), on 3/9/2026, of 4 pounds (lbs. - a unit of measurement) in one (1) month.2. Obtain weekly weights for Resident 1 after Resident 1 was noted with a COC, dated 3/9/2026, of a 4 lbs. weight loss in 1 month. These deficient practices had the potential for Resident 1 to experience weight variance (fluctuation).

Inspectors wroteBased on interview and record review, the facility failed to implement its policies and procedures related to discharge planning for one of four sampled residents (Resident 1). The facility received a Notice of Medicare Non-Coverage ([NOMNC] a form from the Centers of Medicare & Medicaid services that skilled nursing facilities must provide to residents informing them Medicare-covered services are ending, and the right to appeal or contest the decision). The facility failed:1. To provide the NOMNC notice to Resident 1 or responsible party, which included the process of how to file an appeal.2. To provide discharge instructions or teachings to Resident 1 or responsible party.3. To develop an individualized care plan specifically covering the needs of Resident 1 with the inclusion of responsible parties.4. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement its policies and procedures related to comprehensive care planning for one of four sampled residents (Resident 1) by: 1. Failing to provide an individualized care plan related to discharge which specifically covered the needs of Resident 1's care, with the inclusion of Resident 1's responsible party. 2. Failing to provide discharge instructions or teachings to Resident 1 or responsible party prior to discharge. 3. Failing to ensure Resident 1 was not discharged to home with an intravenous ([IV] an access point for administering medication directly into the bloodstream) still intact. Resident 1 was discharged to home on [DATE]. On 12/26/2026, the Assistant Director of Nursing (ADON) went to the home of Resident 1 to provide teaching and remove Resident 1's IV needle and dressing. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement its policies and procedures related to nursing staff competency for one of four sampled residents (Resident 1), by:1. Failing to provide an individualized care plan related to discharge which specifically covered the needs of Resident 1' care, with the inclusion of responsible party.2. Failing to provide discharge instructions and teachings to Resident 1 or responsible party prior to discharge.3. Failing to ensure Resident 1 was not discharged to home with an intravenous ([IV] an access point for administering medication directly into the bloodstream) still intact. Resident 1 was discharged home on [DATE]. On 12/26/2026, the Assistant Director of Nursing (ADON) went to Resident 1's home to provide teaching and remove Resident 1's IV needle. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement its policies and procedures related to residents and or responsible party notification rights for one of four sampled residents (Resident 1). The facility received a Notice of Medicare Non-Coverage ([NOMNC] a form from the Centers of Medicare & Medicaid services that skilled nursing facilities must provide to residents informing them Medicare-covered services are ending, and the right to appeal or contest the decision) notice for Resident 1, which included the process of how to file an appeal, but Resident 1 nor the responsible party(s) of Resident 1 were not provided the notice. This deficient practice denied Resident 1 and the responsible party the rights to make informed decisions related to Resident 1's care, the rights to stay in the facility, and discussion and implementation of safe discharge planning needs. [...]

Inspectors wroteBased on interview and record review, the facility failed to account for and update the personal belongings for one of four sampled residents (Resident 1). This deficient practice increased Resident 1's risk for loss of personal belongings while residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to implement its policies and procedures related to documentation for one of four sampled residents (Resident 1). Resident 1 was discharged home on [DATE]. On 1/6/2026, while onsite at the facility, the State Survey Agency (SSA) identified newly added documentation on Resident 1's files added on same date, 1/6/2026. This deficient practice resulted to inaccurate account of Resident's 1 records. Cross reference F726.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure its medication error rate was below five (5) percent (%) for two of five sampled residents (Residents 1 and 69) during the Medication Administration Facility Task conducted on 12/30/2025. The facility had seven (7) medication errors out of 29 observed opportunities on 12/30/2025 during the 9 a.m. routine medication pass (a structured process of administering medications to ensure residents receive medications safely, accurately, and timely), resulting in an overall medication error rate of 24.14%. The facility failed to:1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure one of five sampled residents (Resident 1) was free of any significant medication errors (the observed or identified preparation or administration of medications which are not in accordance with the prescriber's order, manufacturer's specifications, and accepted professional standards) when the facility failed to:A. Obtain a physician's order to crush Resident 1's medications for administration via gastrostomy tube (g-tube, also known as an enteral tube - a soft tube inserted through the abdominal wall directly into the stomach, providing a way to deliver nutrition, fluids and medicine for individuals with swallowing difficulties). B. [...]

Inspectors wroteBased on interview and record review, the facility's licensed nursing staff failed to provide care in accordance with professional standards for two of two sampled residents (Residents 1 and 33) reviewed for subcutaneous (sq - under the skin) anticoagulant (medicine that slows down the blood's clotting process, preventing dangerous clots from forming in the heart or blood vessels) use and for one of one sampled resident (Resident 12) reviewed for insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) use by failing to rotate (a method to ensure repeated injections are not administered in the same area) sq heparin (a type of anticoagulant), enoxaparin (a type pf anticoagulant), and insulin. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pain management consistent with professional standards of practice and the residents' goals and preferences for two of two sampled residents (Resident 44 and 21) reviewed under the Pain Management care area by failing to: 1. Ensure the Licensed Nurse (LN) administered as needed (PRN) hydrocodone - acetaminophen (an opioid [also called a narcotic - powerful pain-reducing medication) per the physician's order and based on the assessed numeric pain rating scale (a standard pain scale with zero being no pain and ten [10] as the worst pain one can imagine) for Resident 44. 2. Ensure the LNs followed the physician's order to administer the pain medication according to the resident's pain level for Resident 21. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring and administering of all drugs and biologicals to meet the needs of each resident during an inspection of one (1) out of two (2) medication carts, Medication Cart 1 (MC 1) reviewed under the Medication Storage and Labeling Task by: 1. Failing to accurately account for two doses of controlled medications (medications with a high potential for abuse) affecting Resident 23 in one (1) of two (2) inspected medication carts, Medication Cart (MC) 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen by: 1. Failing to ensure a bottle of salad dressing labeled with open date of 12/23/2025 was labeled with a best by date of 2/23/2026. 2. Failing to discard a bunch of parsley leaves inside a sealed plastic bag had brownish discoloration. 3. Failing to ensure a can of applesauce with dent was not placed in the shelf for dented cans. 4. Failing to ensure one (1) round shaped and 1 square shaped clean food containers were still wet and stacked in the clean and dried dishes/utensils section of the kitchen. 5. Failing to ensure eight (8) meal trays were stacked wet on the drying rack in the dishwashing room. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to enforce its policy of storing food brought in by family or visitors in a way that it was either separate or easily distinguishable from facility food when there was no designated refrigerator space for residents with leftover foods from home or outside sources. This failure had the potential to result in a decrease in the residents' food intake leading to unintentional (without trying) weight loss and frustrations among 33 of 35 facility residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections by failing to: 1. Ensure Resident 73's personal bag was not stored on the ground during a tour of the Laundry Facilities on 12/30/2025. This deficient practice had the potential to spread communicable diseases among residents, staff, and visitors. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement its policy for antibiotic (medication used to treat infection) stewardship (efforts in long-term care facilities to ensure that antibiotics are used only when necessary and appropriate [means prescribing the right drug at the right dose at the right time for the right duration]) program and infection prevention and control program for four of four sampled residents (Residents 12, 1, 33, and 41) reviewed for antibiotic use by failing to ensure:1. Failing to ensure Resident 12 meets the criteria for the use of sulfamethoxazole and trimethoprim double strength (also known as Bactrim DS, a combination of two antibiotics used to treat bacterial infections in the ear, sinus, throat, lungs, and skin) for urinary tract infection (UTI - an infection in the bladder/urinary tract). 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the residents' right to privacy and confidentiality by failing to: 1. Ensure Licensed Vocational Nurse (LVN) 2 did not leave an unattended computer screen in a public area displaying a resident`s personal clinical information and Medication Administration Record (MAR, a record of all medications taken by a resident on a day-to-day basis) for one randomly sampled resident (Resident 23). 2. Provide privacy when LVN 2 administered Resident 6's scheduled morning medications in the activity room. This deficient practice had resulted in unauthorized exposure of the resident's medical care and treatment resulting in violation of the resident's right to privacy with the potential to cause psychosocial harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignity including the right to be free from physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the resident's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) for one (1) of one (1) sampled resident (Resident 12) reviewed for physical restraints by failing to obtain a physician's order, informed consent, and complete a restraint assessment prior to placement of bed pad alarm (a pad with sensors that will alarm when a resident stands up unassisted to help prevent falls by alerting staff). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a baseline care plan for one of two sampled resident (Resident 44) reviewed for Pain Management by failing to develop a care plan that identified resident-centered interventions per facility policy and procedure (P&P) regarding Resident 44's use of as needed (PRN) hydrocodone - acetaminophen (an opioid [also called a narcotic - powerful pain-reducing medication). This deficient practice had the potential to result in miscommunication among facility staff and a delay in care or lack of delivery of care and services for the resident.

Inspectors wroteBased on interview and record review, the facility failed to ensure necessary treatment and care was provided for one of three sampled residents (Resident 43). The facility failed to: 1. Ensure licensed nurse assessed and monitored Resident 43's change of condition (COC- a sudden, clinically important deviation from a patient's baseline in physical, cognitive [ability to think, and understand] behavioral, or functional status which without immediate intervention, may result in complications or death) when Resident 43 complained of urinary symptoms. 2. Ensure Licensed Nurses notify the physician of the change of condition and carry out physician order for laboratory test ordered on 12/28/2025. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the staff providing care and services to the resident who has a feeding tube (are soft plastic tubes through which liquid nutrition travels through the gastrointestinal tract [the series of organs that food and liquids pass through as they are digested, absorbed, and leave the body as feces]) are aware of, competent in, and utilize facility protocols regarding feeding tube nutrition and care for one of one sampled resident (Resident 1) reviewed for tube feeding by failing to ensure Resident 1's water flush bag was labeled with the resident's name, room number, rate of infusion, and initials of the licensed nurse who hung the water flush bag. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respiratory care provided to residents was consistent with professional standards of practice for one of one sampled resident (Resident 1) reviewed for respiratory care by failing to ensure Resident 1's suction canister (a container used in medical settings to collect bodily fluids [like mucus, blood, or other secretions] that have been drawn out of a patient's body using a medical suction machine) was labeled with the date it was last changed. The deficient practice had the potential for residents to develop complications such as shortness of breath, desaturation (low levels of oxygen in the blood), and respiratory infections.

Inspectors wroteBased on interview and record review, the facility failed to ensure that employee files contained documentation of required performance evaluation for one of two sampled Certified Nursing Assistant (CNA) 2. This failure had the potential to negatively impact on the quality and safety of resident care delivery.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the established and alternative menu per resident preferences and facility policy and procedure (P&P) to meet resident nutritional needs by failing to provide a resident's request for a salad or cauliflower on the lunch tray on 12/29/2026 for one of three sampled residents (Resident 44) reviewed under the Food care area. This deficient practice had the potential to result in resident dissatisfaction and malnutrition.

Inspectors wroteBased on interview and record review, the facility failed to accurately update the 2025 Facility Assessment (an evaluation of the physical environment necessary to meet the needs of the residents) for two of three sampled residents (Residents 74 and 1) to reflect care, and competency (a combination of knowledge, skills, abilities, and behaviors that enable an individual to perform a task or role successfully) of staff for gastrostomy (g-tube-a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) tube medication administration. These deficient practices had the potential for the facility to not provide needs of the residents with g-tube and delay necessary care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain accurate clinical records in accordance with accepted professional standards and practices for two of two sampled residents (Resident 44 and 21) reviewed for Pain Management by failing to: 1. Ensure Licensed Vocational Nurse (LVN) 4 accurately documented in the medication administration record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) the assessed numeric pain rating scale (a standard pain scale with zero being no pain and ten [10] as the worst pain one can imagine) number for the administration of (PRN) hydrocodone - acetaminophen (an opioid [also called a narcotic - powerful pain-reducing medication) when the pain level was documented as zero on 12/17/2025 at 11 a.m. for Resident 44. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled Certified Nursing Assistant (CNA) 2 completed mandatory dementia (a progressive state of decline in mental abilities) management and abuse prevention training. This deficient practice has the potential to lead into insufficient staff training, posing significant risks for the residents, including potential injury, neglect, and abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that 17 of 25 resident rooms (Rooms 1, 2, 3, 4, 5, 12, 13, 14, 15, 16, 17, 18, 19, 22, 23, 25 and 26) met the square footage (sq - a measurement of the area of a two-dimensional space) requirement of 80 sq feet (ft-unit of length) per resident in multiple resident rooms. This deficient practice had the potential to have inadequate space for resident care and mobility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four sampled resident rooms (Room A) met the room size requirement of 80 square feet per resident in multiple resident bedrooms or obtain an approval for a room size waiver. This deficiency had the potential to result in inadequate space for resident care and mobility in Room A.

Inspectors wroteBased on observation, interview, and record review, the facility failed to:1. Remove 16 doses of morphine sulfate (a medication used to treat pain) 15 milligrams (mg - a unit of measure for mass) and 56 doses of oxycodone/APAP (a medication used to treat pain) 5/325 mg from the medication cart after the physician's orders were discontinued affecting two of three sampled residents (Residents 1 and 3.)2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1) received care in accordance with professional standards of practice to attain or maintain the highest practicable physical well-being, when Registered Nurse (RN 1) failed to: 1. Conduct an assessment after Certified Nursing Assistant (CNA 1) reported that she overheard Resident 1 state he was going to hurt himself if he was not allowed to leave the facility. 2. Timely notify the doctor regarding Resident 1's change of condition involving possible self-harm. These deficient practices had the potential to result in Resident 1 receiving inadequate care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Reorder medications five (5) days in advance of need to assure an adequate supply was on hand (current availability) as per facility policy for two (2) of four (4) sampled residents (Resident 5 and 31) observed during the Medication Administration facility task. 2. Follow-up for delivery and availability of medications for two (2) of four (4) sampled residents (Resident 5 and 31) observed during the Medication Administration facility task. 3. Remove and destroy and not use another resident's medication (Resident 18, a discharged resident) to provide Eliquis (a medication used for cerebrovascular accidents [CVA, also known as stroke, a loss of blood flow to part of the brain, which damages brain tissue]) to Resident 31 from [DATE] to [DATE]. These deficient practices resulted in: 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a medication error rate below five (5) percent (% - unit of measure) by having seven (7) medication errors out of 26 medication administration opportunities contributing to an overall error rate of 26.92% affecting two (2) of four (4) sampled residents (Resident 5 and 31) observed during the Medication Administration facility task. The medication errors were as follows: 1. Resident 5 did not receive the following medications as ordered by Resident 5's physician: - two (2) doses on [DATE] at 9 a.m. and 5 p.m. of metoprolol (a medication used to for hypertension [a condition in which the blood vessels have persistently raised pressure]) - one (1) dose on [DATE] at 8 a.m. [...]

Inspectors wrotec. During a review of Resident 1's Record of Admission, the Record of admission indicated the facility admitted the resident on 5/22/2014 and most recently readmitted the resident on 10/19/2023. During a review of Resident 1's Client Diagnosis Report, undated, the Client Diagnosis Report indicated diagnoses that included unspecified dementia (a progressive state of decline in mental abilities), spinal stenosis (a narrowing of the spinal canal in your lower back that may cause pain or numbness in your legs) cervical region (the neck), encounter for gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), and acquired absence of unspecified parts of the digestive tract. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who need respiratory care are provided care consistent with professional standards of practice for one of one sampled residents (Resident 26) reviewed under the respiratory care area by failing to ensure supplemental oxygen (O2) was administered per physicians orders, was documented in the Medication Record (MAR, - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), and was monitored while in use. This deficient practice had the potential to result in undetected changes in the resident's respiratory status resulting in a delay in care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free of any significant medication errors (means the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order, manufacturer's specifications, and accepted professional standards) by not: 1. administering two (2) doses on [DATE] at 9 a.m. and 5 p.m. of metoprolol (a medication used to for hypertension [a condition in which the blood vessels have persistently raised pressure]) to one of four residents (Resident 5) observed during the Medication Administration facility task. 2. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Remove and discard from use one expired insulin (medication used to regulate blood sugar levels) Lispro (fast-acting insulin) Kwikpen (type of injection device) for Resident 19, in accordance with manufacturer's requirements in one of two inspected medication carts (Medication Cart 2). 2. Remove and discard from use one open Aplisol (medication used to diagnose tuberculosis [a contagious infection in the lungs that is usually spread through the air]) vial for facility stock, in accordance with manufacturer's requirements and facility policy and procedures in one of one inspected medication rooms (Medication room [ROOM NUMBER]). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the established menu to meet nutritional needs by failing to follow the 10/1/2024 lunch menu when corn bread was omitted, and green beans were substituted for seasoned peas for 42 of 45 facility residents including one of one sampled residents (Resident 10) reviewed under the Food care area. This deficient practice had the potential to result in unwanted resident weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen for 42 of 45 facility residents by failing to ensure: 1. Food items in the kitchen refrigerator, in the dry storage area, and in the resident refrigerator were labeled according to facility policy. 2. Ensure two large, plastic food storage bin lids were secured in the dry storage area. 3. Ensure an open carton of almond milk, in the kitchen refrigerator, had a cap closure and was not left open. 4. Ensure a staff member's personal cup was not located in the kitchen prep area. 5. Ensure a zucchini with a mold-appearing substance was not readily available to be served in the outside Fridge #3. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections by failing to: 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote the resident rights to examine the results of the most recent survey (a survey to determine compliance with state and federal regulations) of the facility by failing to: 1. Ensure three of three (Residents 20, 26, and 24) residents knew where to locate the most recent survey results. 2. Post the most recent survey results in a place that are prominent and accessible (a place where individuals wishing to examine surveys results do not have to ask staff to see them) to residents, family members, and legal representatives of residents. These deficient practices had the potential to impede the resident's rights.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 97) was provided a homelike environment by failing to: 1. Properly secure the ceiling light's screen, leaving the screen not fully clipped in place. 2. Ensure that a chain/cord is attached to the wall light to enable Resident 97 to turn the light on and off. These deficient practices had the potential to violate the resident's right to living in a safe, comfortable, and homelike environment.

Inspectors wroteBased on interview and record review, the facility failed to send a copy of the notification of discharge to the ombudsman (a long-term care resident advocate) for one of three sampled residents reviewed under closed record review (Resident 46). This deficient practice had the potential for Resident 46 to have an unsafe discharge.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were made aware of the facility's bed-hold policy upon transfer to a general acute care hospital (GACH) for one of three sampled residents (Resident 46) investigated during closed record review when the facility failed to complete and provide the seven (7) day bed hold agreement to Resident 46. This deficient practice had the potential for the resident and/or the resident's resident representatives to not know if the resident have a room to return to after going to the GACH. Cross-reference F623 and F641.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for one of five sampled residents (Resident 3) investigated under the unnecessary medication care area and one of one sampled residents (Resident 148) investigated under the urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) or Urinary Tract Infection (UTI, an infection in the bladder/urinary tract) care area when: 1. The facility failed to develop a care plan for Resident 3's use of Eliquis (also known as apixaban, an anticoagulant medication used to prevent blood clots). 2. The facility failed to implement Resident 148's care plan for the resident's urinary catheter. These deficient practices had the potential cause a delay in care. Cross-reference F757 and F880.

Inspectors wroteBased on interview and record review, the facility failed to revise one of three sampled residents investigated under the nutrition care area when Resident 34's care plan was not updated to reflect current nutritional interventions addressing the resident's risk for further weight loss. This deficient practice had the potential to result in inconsistent implementation of the care plan that may lead to a delay in or lack of delivery of care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an environment free from accidents and hazards for one of one sampled residents (Resident 10) reviewed under the Accidents care area by failing to ensure Resident 10 did not have a bottle of Refresh eyedrops (a medication to relieve dry, burning, irritated eyes) and a bottle of clindamycin phosphate topical solution (an antibiotic, a medication that stops the growth of bacteria) readily available for self-administration and accessible by other residents while in the dining room. This deficient practice had the potential to result in resident's self-administering medications without staff knowledge potentially resulting in resident illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide nutritional care and services consistent with resident's nutritional assessment and care plan for one of three sampled residents (Resident 34) by: 1. Failing to continue obtaining the resident's weight weekly as ordered by the physician. 2. Failing to revise the resident's care plan to address the resident's weight loss. 3. Failing to complete an SBAR (Situation, Background, Assessment, Recommendation - an assessment used to facilitate prompt and appropriate communication) form for weight loss on 8/28/2024 and 9/17/2024. 4. Failing to ensure the Interdisciplinary (IDT-group of experts from various disciplines working together to treat ailment, injury, or chronic health conditions) care plan meeting was done to address the resident's weight loss. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's drug regimen was free from unnecessary drugs for one of five sampled residents (Resident 3) investigated under the unnecessary medication care area when the facility failed to ensure Resident 3's order for Eliquis (also known as apixaban, an anticoagulant [blood thinner] medication used to prevent blood clots) did not specify an indication (valid reason) for use. This deficient practice had the potential for Resident 3 to experience errors in treatment.

Inspectors wroteBased on interview and record review, the facility failed to inform the beneficiary (resident) about potential non-coverage and the option to continue services with the beneficiary accepting financial liability for those services for one of three sampled residents (Resident 3) investigated during the beneficiary notification task when Resident 3 or Resident 3' representative did not receive the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNFABN, form that provides information to beneficiaries so that they can decide if they wish to continue receiving the skilled services that may not be paid for by Medicare and assume financial responsibility). This deficient practice had the potential for a delay in care related to coverage and medical needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents receive an accurate assessment for one of three sampled residents (Resident 46) investigated during closed record review when Resident 46's Minimum Data Set (MDS, a federally mandated resident assessment tool) indicated Resident 46 was discharged to home or the community when the resident was discharged to the hospital. This deficient practice resulted in inaccurate tracking of Resident 46 and create a communication error between the facility and the Centers for Medicare and Medicaid Services (CMS). Cross-reference F623 and F625.

Inspectors wroteBased on observation, interview, and record review, the facility failed to post the total number and the actual hours worked by the licensed nurses (including registered nurses and licensed vocational nurses) and Certified Nursing Assistants directly responsible for resident care per shift on 10/1/2024 to 10/2/2024 at the nursing station. This deficient practice had the potential to keep residents and visitors unaware of the total number of staff and the actual hours worked by staff in the facility. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that 16 of 25 resident rooms (Rooms 1, 2, 3, 4, 5, 12, 13, 14, 15, 16, 17, 18, 19, 22, 23, and 28) met the square footage requirement of 80 square feet (sq. ft.) per resident in multiple resident rooms. The room sizes for these rooms had the potential to have inadequate space for resident care and mobility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, comfortable, and homelike environment to two of four sampled residents (Residents 1 and 2) by failing to ensure Resident 1 and 2 ' s room temperature was not above 81 degrees Fahrenheit (a unit of measure). This deficient practice had the potential to affect the comfort of residents and placed the residents at risk for dehydration.

Inspectors wroteBased on interview and record review, the facility failed to maintain written grievance documentation and outcome of investigation/course of action taken for one of three sampled residents (Resident 1) by failing to address Resident 1 ' s grievances related to room being hot and increased noise levels at night. This deficient practice had the potential for Resident 1 ' s grievances to go unnoticed causing frustration and distress to the resident; and had the potential to result in a delay of care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain a physician order for oxygen therapy for one of three sampled residents (Resident 1), who was receiving oxygen therapy. This deficient practice placed the resident at risk for adverse effects due to unnecessary oxygen administration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its infection control policy by failing to ensure nasal cannula (oxygen [a colorless, odorless, and tasteless gas] tubing - a medical device to provide supplemental oxygen therapy to people who have lower oxygen levels) and humidifier (medical devices used to humidify supplemental oxygen) was changed and labeled with the date of change for one of four sampled residents (Resident 1). This deficient practice had placed Resident 1 at risk for infection.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure the resident's medical record was updated to show documentation the resident and/or their responsible party was provided with written information regarding the right to formulate an advance directive (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) for one (Resident 34) of five sampled residents. 2. Ensure a current copy of the advance directive was in the resident's medical record for three (Resident 18, 199 and 200) of five sampled residents. These deficient practices violated the residents' and/or their representatives' right to be fully informed of the option to formulate advanced directives and had the potential to cause conflict with health care wishes for Resident 18, 34, 199 and 200.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident care plans (a document or agreement that lays out a resident's individual care needs and how these will be met) are implemented for three out of four (Resident 33, 23, and 6) by failing to: 1. Ensure Resident 33 and Resident 6's fingernails' free edges were free of dirt. 2. Ensure Resident 23 was provided with a communication board at bedside to facilitate ease of communication. These deficient practices resulted in failure to deliver the necessary care and services which had the potential to affect the resident`s sense of self-worth and self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper sanitation and food handling practices by: 1. Failing to ensure food items not in their original containers were labeled and dated. 2. Failing to clean and disinfect a can opener after use. 3. Failing to document on the facility's dish machine temperature and sanitizing log for 10/13/2023 at lunch. 4. Failing to ensure refrigerator and freezer temperatures were documented for the months of August 2023, September 2023, and October 2023 for Refrigerator 1 (R#1), Refrigerator 2 (R#2), and Freezer 1 (FR#1). These deficient practices had the potential to place 42 out of 46 residents living in the facility at risk for foodborne illnesses (refers to illness caused by the ingestion of contaminated food or beverages).

Inspectors wroteBased on interview and record review, the facility failed to follow its policy and procedure regarding antibiotic (medication to fight infection) stewardship (program to ensure that antibiotics are used only when necessary and appropriate to prevent unnecessary antibiotic use and combat antibiotic resistance [not effective to treat infection]) protocol for three of four sampled residents (Resident 12, 24 and 27) by failing to: 1. Ensure to complete the McGreer's (the criteria used by the facility to count true infections) criteria form once antibiotic was ordered. 2. Ensure the antibiotic stewardship surveillance form was easily and readily accessible. These deficient practices had the potential for residents to develop antibiotic resistance from unnecessary or inappropriate antibiotic use.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care in a manner that maintained or enhance a resident's dignity and respect by failing to ensure Certified Nurse Assistant 3 (CNA 3) knocked and asked permission from the resident before entering the room for one (Resident 6) of one sampled resident reviewed for dignity. This deficient practice had the potential to affect the resident`s sense of self-worth and self-esteem.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a medication was not left with a resident who was not capable of self-administering eye medication for one of three sampled residents (Resident 18). This deficient practice placed the resident at risk for unsafe medication administration and or receiving unnecessary medications.

Inspectors wroteBased on interview and record review, the facility failed to notify the resident's physician (MD 1) and their representative (RP 1) when the resident had a significant weight loss of 11% within six months for one (Resident 34) of three residents reviewed under the nutrition care area. On 03/03/2023, Resident 34 weighed 126 pounds (lbs.) On 09/28/2023, the resident weighed 112 pounds which is a -11.11 % weight loss. This deficient practice violated the resident's rights and/or representative's right to be fully informed of Resident 34's weight loss and had the potential for delay in care to address the resident's weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one (Resident 28) of three sampled residents was provided a homelike environment when Resident 28's low air loss (LAL-specialty mattress) was secured to the foot of the bed with duct tape. This deficient practice had the potential to violate residents' right to living in a safe, comfortable, and homelike environment.

Inspectors wroteBased on interview and record review, the facility failed to complete the Minimum Data Set (MDS- an assessment and care screening tool) within 14 days of the Assessment Reference Date (ARD) for two (Resident 10 and 31) of two sampled residents. This deficient practice had the potential to negatively affect the residents' plan of care and the delivery of necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to update and or revise a resident's comprehensive care plan for two (Resident 28 and Resident 34) of three sampled residents by: 1. Failing to update Resident 28's care plan related to dementia (A group of thinking and social symptoms that interferes with daily functioning) 2. Failing to update and revise Resident 34's care plan with specific interventions after the resident had a significant weight loss. These deficient practices had the potential to result in inconsistent implementation of the care plan that may lead to a delay in or lack of delivery of care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were provided a communication device to allow communication between staff and residents for two of two (Resident 23 and Resident 30) sampled residents. This deficient practice had the potential to delay Resident 23 and Resident 30's delivery of care and services due the residents not being able to communicate their needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide nutritional and care and services for one of three sampled residents (Resident 34), consistent with resident's nutritional assessment and care plan by: 1. Failing to obtain the resident's the resident's weight weekly as ordered by the physician. 2. Failing to revise the resident's care plan to address the resident's weight loss. 3. Failing to ensure an accurate nutrition screening was done on 9/28/2023. 4. Failing to complete an SBAR (situation, background, assessment, recommendation; a technique that can be used to facilitate prompt and appropriate communication) form for weight loss on 7/7/2023 and 10/5/2023. 5. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Ensure the Controlled Drug Record (CDR- accountability record of medications that are considered to have a strong potential for abuse) coincided with the Medication Administration Records (MAR) for one of three sampled residents (Resident 45). This deficient practice had the potential to result in medication error and/or drug diversion. 2. Ensure the Xarelto (can treat and prevent blood clots) 20 milligrams (mg - unit of measurement) was available during the medication administration observation on 10/04/2023 for one of seven sampled residents (Resident 200). This deficient practice had the potential to result in unintended complications related to the management of atrial fibrillation (an irregular and often very rapid heart rhythm) such as increased risk of stroke and death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident is free from significant medication error by failing to administer Xarelto (can treat and prevent blood clots) during the medication administration observation on 10/14/2023 for one of seven sampled residents (Resident 200). Xarelto was not delivered timely resulting in Resident 200 missing the dose. This deficient practice had the potential to result in unintended complications related to the management of atrial fibrillation (an irregular and often very rapid heart rhythm) such as increased risk of stroke (occurs when a blood vessel that carries oxygen and nutrients to the brain is either blocked by a clot or bursts) and death.

Inspectors wroteBased on interview and record review, the facility failed to ensure laboratory results were communicated with the medical doctor (MD) timely for one of three sampled residents (Resident 30). This deficient practice had the potential to delay necessary care and services for Resident 30.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure left over food brought from outside was stored in the refrigerator or discarded for one of one sampled resident (Resident 99). The same left-over food observed on 10/13/2023 at 7:25 p.m. was observed again on 10/14/2023 at 9:30 a.m. This deficient practice had the potential to result in foodborne illness (also called food poisoning, illness caused by eating contaminated food) for Resident 99.

Inspectors wroteBased on interview and record review, the facility failed to ensure three of four sampled (Resident 12, 24, and 27) residents' medical records were readily accessible. This deficient practice had the potential to result in confusion among interdisciplinary team IDT-a group of experts from various disciplines working together to treat a resident's ailment, injury or chronic health condition) regarding the residents' condition and what care and services were provided to the residents. Cross reference F881.

Inspectors wroteBased on observation, interview, and record review, the facility failed to observe infection control measures for one of three sampled residents (Resident 200) by failing to ensure oxygen nasal cannula tubing (device used to deliver supplemental oxygen placed directly on a resident's nostrils) was not touching the floor. This deficient practice had the potential to result in contamination of Resident 200's care equipment and risk of transmission of bacteria that can lead to infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that 16 of 25 resident rooms (Rooms 1, 2, 3, 4, 5, 12, 13, 14, 15, 16, 17, 18, 19, 22, 23, and 28) met the square footage requirement of 80 square feet (sq. ft.) per resident in multiple resident rooms. The room sizes for these rooms had the potential to have inadequate space for resident care and mobility.

Inspectors wroteBased on observation, interview and record review, the facility failed to update and revise the residents ' care plan (a document outlining a detailed approach to care customized to an individual resident ' s need) after a fall by failing to include physician ordered interventions for one of two sampled residents (Residents 1). These deficient practices had the potential to result in inconsistent implementation of the care plan that may lead to a delay in or lack of delivery of care and services.