Regalcare at Glen Ridge

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #2), the Facility failed to ensure they provided an environment free from safety hazards and adequate supervision to prevent an elopement. On 04/14/26 Resident #2 eloped from the Facility unbeknownst to staff. Facility staff were notified by local Hospital Emergency Department (ED) staff that he/she was there being evaluated. Staff were unaware he/she was missing from the Facility for over four hours.

Inspectors wroteBased on interview and record review, the facility failed to ensure that Minimum Data Set (MDS) assessments were transmitted within 14 days after a resident assessment was completed for six Residents (#49, #4, #10, #86, #123 and #7), out of a total sample of 34 residents.

Inspectors wroteBased on resident interviews and test tray results, the facility failed to ensure foods provided to the residents were prepared by methods that conserve palatability and are at appetizing temperatures on four of four units.

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure for one Resident (#121), out of 34 sampled residents, that his/her dignity was maintained at the highest practical level of wellbeing. Specifically, the facility failed to maintain Resident #121's dignity by failing to provide incontinence care timely resulting in Resident #121 walking around the unit with a soiled brief with his/her pants visibly wet, emitting an odor and eating a meal with a soiled brief.

Inspectors wroteBased on observation, record review and interviews, the facility failed to implement policies and procedures to protect one Resident (#101) from potential abuse, out of 34 sampled residents. Specifically, for Resident #101, who is assessed with severe cognitive impairment, the facility failed to identify a facial injury, report the facial injury to administration, and failed to implement a timely and thorough investigation of the facial injury.

Inspectors wroteBased on observations, record review and interviews, the facility failed to accurately code three Minimum Data Set (MDS) assessments, for one Resident (#144), out of a total sample of 34 residents. Specifically, the facility failed to accurately reflect Resident #144's status related to his/her left upper extremity range of motion.

Inspectors wroteBased on observation, record review, and interview, the facility failed to follow professional standards of nursing practice for one Resident (#68) out of a total sample of 34 residents. Specifically, for Resident #68, the facility failed to administer medication via the correct route as stated in the physician's orders.

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to provide activities of daily living (ADL) timely to 1 Resident (#121), out of 34 sampled residents. Specifically, the facility failed to provide incontinence care timely to Resident #121, who is assessed as incontinent and is dependent on staff for daily care, resulting in Resident #121 walking around the unit and eating his/her breakfast with a soiled brief.

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to develop a comprehensive person-centered care plan with individualized interventions for a range in motion impairment for one Resident #144, out of a total sample of 34 residents. Specifically, the facility failed to develop a care plan for Resident #144 who displayed and was assessed with an impaired left upper extremity impairment.

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to adequately maintain the nutrition and hydration status of one Resident (#22) out of a total sample of 34 residents. Specifically, for Resident #22 the facility failed to:a. Address a significant weight loss timely, andb. Implement interventions for weight loss as indicated in physician's orders.

Inspectors wroteBased on record review and interview, the facility failed to ensure recommendations from the Monthly Medication Review (MRR) conducted by the pharmacist were addressed and acknowledged by the physician in a timely manner for two Residents (#11, #81) out of five residents reviewed out of a total sample of 34 Residents.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide dental services for one Resident (#40) out of a total sample of 34 Residents. Specifically, the facility failed to provide dental care to Resident #40 for an improper fitting upper denture that was documented by facility staff.

Inspectors wroteBased on record review and interview, the facility failed to ensure medical records were completed for two Residents (#101 and #10) out of a total sample of 34 Residents. Specifically, the facility failed to:1. Ensure the medical providers (nurse practitioner and physician's) clinical encounter notes were accessible in the medical record and 2. Ensure that Resident #10's daily care performed by the Certified Nursing Assistants (CNA) was documented as completed.

Inspectors wroteBased on observation, record review and interview, the facility failed to establish and 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. Specifically,For one Resident (#54) with a wound, out of a total sample of 34 residents, the facility failed to implement Enhanced Barrier Precautions (EBP). The facility failed to handle clean linen to prevent possible contamination.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure they developed and implemented a baseline plan of care within 48 hours of his/her admission.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), who was alert, oriented, and able to make his/her needs known, the Facility failed to ensure he/she was free from physical and emotional abuse from a staff member, when on 08/26/24, although Resident #1 was asleep, the Facility's contracted Podiatrist began to provide care to his/her feet, Resident #1 woke up abruptly, was startled by the Podiatrist touching his/her feet, told the Podiatrist to stop, they became engaged in a verbal and physical altercation, during which Resident #1 was struck on the left side of his/her face and left arm. Resident #1 was transferred and evaluated in the Hospital Emergency Department for an injury to his/her left cheek. Resident #1 said as a result of the altercation, he/she was fearful and anxious about the Podiatrist being in the building.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #2), who had an ileostomy (surgical procedure that creates an opening in the abdominal wall to direct the small intestine and allow waste to exit the body), the Facility failed to ensure they provided care consistent with professional standards of practice, when on 09/23/24, although nursing was aware Resident #2 did not have ostomy appliances in place over his/her stoma, which was actively secreting stool, no additional nursing interventions were implemented to protect his/her abdominal wound, resulting in fecal matter contamination of his/her abdominal incision, excoriation of surrounding skin, and he/she required transfer and re-admission to the Hospital for treatment.

Inspectors wroteBased on observations, record review, policy review and interviews, the facility failed to provide assistance with Activities of Daily Living (ADLs), for six Residents (#63, #10, #3, #37, #94, and #2) out of a total sample of 46 residents. Specifically: 1a. For Resident #63, the facility failed to ensure incontinence care was provided for 17 hours resulting in the development of new pressure ulcers. 1b. For Resident #10, the facility failed to ensure incontinence care was provided for 17 hours resulting in the development of new pressure ulcers. 2. For Resident #3, the facility failed to provide assistance with meals as per the plan of care. 3. For Resident #37 and #94, the facility failed to provide assistance with nail care. 4. For Resident #2, the facility failed to provide assistance with facial hair removal.

Inspectors wrote3. Resident #81 was admitted to the facility in May 2021 and had a primary diagnosis of stroke. Review of Resident #81's Norton Plus Pressure Ulcer Scale dated 7/30/24, indicated a score of 15, signifying a moderate risk for the development of pressure ulcers. Review of Resident #81's Minimum Data Set Assessment (MDS) dated [DATE], indicated a Brief Interview for Mental Status score of 1 out of 15; signifying severe cognitive impairment. The MDS indicated the Resident is completely dependent on staff for all bed mobility and required substantial assistance for all other activities of daily living. The MDS indicated the Resident was at-risk for pressure injuries but had no skin wounds and required pressure relieving devices for the bed and chair. Resident #81's care plan dated as revised 6/19/24, indicated: Focus: [...]

Inspectors wrote3. Resident #63 was admitted to the facility in May 2024 with diagnoses including morbid severe obesity, type two diabetes, congestive heart failure, muscle weakness, localized edema, anemia in chronic kidney disease, and hereditary and idiopathic neuropathy. Review of Resident #63's most recent Minimum Data Set Assessment (MDS), dated [DATE], indicated Resident #63 had a Brief Interview for Mental Status exam score of 15 out of a possible 15, which indicated the Resident had intact cognition. The MDS further indicated Resident #63 is high risk for pressure ulcers, always incontinent of bowel and bladder and dependent on staff for toileting. Further review of the MDS indicated use of a pressure reducing device for his/her bed. [...]

Inspectors wroteBased on record review, interview, and observation, the facility failed to notify the physician of changes in medical status for five Residents (#81, #42, #30, #99 and #78) of 46 sampled Residents. Specifically: 1. For Resident #78 the facility failed to ensure the physician was notified when: a.) pain medication was unavailable upon admission to the facility, and for the 19 hours following admission, resulting in worsening pain; and b.) when Resident #78's scheduled pain medication ran out, resulting in worsening pain. 2. For Resident #42 the facility failed to ensure the physician was notified when they were unable to fulfill an order to obtain a culture and sensitivity of a new wound for over a week from when the order was given. 3. For Resident #81, the facility failed to notify the physician or nurse practitioner that Resident #81 had a Stage 2 pressure wound on the left calf. 4. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to protect three Residents (#5, #63, and #10) from abuse and neglect out of a total sample of 46 residents. Specifically: 1. For Resident #5, (who is cognitively impaired), the facility failed to ensure he/she was free from abuse, when the surveyor witnessed a staff member squeeze Resident #5 cheeks and force feed medications. Using the reasonable person concept, this would result in emotional distress. 2. For Resident #63 and #10, the facility failed to ensure they were free from neglect after staff failed to provide incontinence care for 17 hours, resulting in the development of a new pressure ulcers.

Inspectors wroteBased on observations, record review, policy review and interviews, the facility failed to identify and address a newly developed contracture for one Resident (#63) out of a total sample of 46 residents.

Inspectors wroteBased on interview, observation, record review and policy review, the facility failed to ensure that pain management, consistent with professional standards of practice, the comprehensive person-centered care plan, and the Resident's goals and preferences was provided for one Resident (#78) out of a total sample of 46 residents. Specifically the facility failed to: a.) ensure pain management was provided upon admission to the facility resulting in worsening pain after 19 hours without any medication available or administered and b.) provide effective pain management when Resident #78's scheduled pain medication ran out resulting in worsening pain.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure there was sufficient staffing to provide necessary treatment and care to Residents on one of four nursing units ([NAME]). Subsequently, multiple residents were not provided incontinent care for 17 hours and skin checks revealed newly developed pressure areas for two Residents (#10 and #63).

Inspectors wroteBased on observation, interview, record, and policy 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. Specifically: 1. The facility failed to ensure the clean laundry room was free from potentially infectious substances. 2a. For Resident #30, the facility failed to ensure that enhanced barrier precautions (EBP) were implemented during treatment of an open wound. 2b. For Resident #45, the facility failed to ensure that EBP was implemented during treatment of his/her feeding tube. 3. The facility failed to ensure nursing staff performed hand hygiene appropriately during the medication administration task.

Inspectors wrote3. Resident #30 was admitted to the facility in June 2024 with diagnoses including dementia, acute respiratory failure and cancer. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated that Resident #30 scored an 11 out of 15 on the Brief Interview for Mental Status exam indicating moderately impaired cognition. Further review indicated Resident #30 has three pressure areas and is at risk for the development of pressure areas. Review of the facility document titled RC Norton Plus Pressure Ulcer Scale and dated 7/9/24, indicated that Resident #30 scored a 10 indicating high risk for pressure ulcer development, Review of the doctor's orders dated August 2024 indicated an order dated 6/11/24 for Pressure relief heel boots to Bilat feet when in bed remove as needed for skin checks or patient tolerance. [...]

Inspectors wroteBased on record review, observations and interviews, the facility failed to ensure a physician's order was implemented for two Residents (#263, #81) out of a total sample of 46 residents. Specifically, 1. For Resident #263, the facility failed to ensure his/her weight was reported to the Nurse Practitioner (NP) or Medical Doctor (MD) as ordered; 2. For Resident #81, the facility failed to treat and accurately report a Stage 2 wound to the physician.

Inspectors wroteBased on observation, policy review and interview, the facility failed to ensure nursing staff stored all drugs and biologicals in accordance with accepted professional standards of practice. Specifically: 1. The facility failed to properly secure medication carts on two of four units, 2. The facility failed to properly secure treatment carts on two of four units, 3. The facility failed to properly secure the medication room on the Oak Grove Unit, 4. The facility failed to ensure opened insulin was labeled with resident's name, the prescription label, or opening and expiration dates for two medication carts on the [NAME] unit, 5a. and b. The facility failed to ensure staff stored medications and biologicals in accordance with State and Federal laws. Findings Include: [...]

Inspectors wroteBased on record review, interview and observation the facility failed to accurately document in the clinical record for six Residents (#81, #30, #16, #63, #5, #90) of 46 sampled residents. Specifically: 1. For Resident #81 the facility failed to accurately document a Stage 2 pressure injury assessment. 2. For Resident #30 the facility failed to accurately document the wearing of Prevalon boots on the treatment sheet. 3. For Resident #16 the nurse staff failed to consistently follow the Physician's orders regarding dialysis care as indicated in the Treatment Administration Record (TAR). 4. For Resident #63, the facility failed to accurately document a Stage 3 pressure injury assessment 5. For Resident #5 the facility failed to accurately document that medications had been administered when they had not. 6. [...]

Inspectors wroteBased on observation, record review and interview the facility failed to provide a dignified existence for three Residents (#50, #30 and #86) out of a total sample of 46 residents. Specifically: 1. For Resident #50 and #30 the facility failed to provide a dignified dining experience. 2. The facility failed to serve meals in a homelike atmosphere evidenced by meals served on institutional trays on the [NAME] Unit. 3. For Resident #86 the facility failed to provide privacy while toileting.

Inspectors wroteBased on record review and interviews, the facility failed to obtain informed consents for psychotropic medications explaining the risks and benefits of treatment, prior to administering psychotropic medication for one Resident (#3) out of a sample of 46 residents.

Inspectors wroteBased on observation, record review and interview, the facility failed to accommodate the needs of one Resident (#63) out of a total of 46 sampled residents. Specifically, the facility failed to provide a shower chair able to fit Resident #63, resulting in Resident #63 not receiving a shower since his/her admission.

Inspectors wroteBased on record review, policy review, and interview, the facility failed to ensure Advance Directives (written documents that instructs health care providers of the decisions for specific medical treatment if a person was unable to speak or lacked the capacity to make decisions for themselves) were consistently documented in the medical record for one Resident (#3), out of a total sample of 46 residents.

Inspectors wroteBased on record review and interview the facility staff failed to inform two out of three residents reviewed, or their representatives, with potential liability for payment for non-covered services including estimated cost of services received while accessing their Medicare benefit.

Inspectors wroteBased on observations, interviews and records reviewed, the facility failed to identify and assess the use of pillows under the fitted sheet as a potential restraint for one Resident (#23) out of a total of 46 sampled residents.

Inspectors wroteBased on record review and interview, the facility failed to effectively carry out their abuse policy related to the reporting of an alleged abuse for one Resident (#78) out of a total sample of 25 residents.

Inspectors wroteBased on record review and interview, the facility failed to report allegations of neglect related to the provision of incontinence care to the state agency as required for two Residents (#10 and #63) out of a total of 46 sampled residents.

Inspectors wrote2. Resident #63 was admitted to the facility in May 2024 with diagnoses including morbid severe obesity, type two diabetes, congestive heart failure, muscle weakness, localized edema, anemia in chronic kidney disease, and hereditary and idiopathic neuropathy. Review of Resident #63's most recent Minimum Data Set Assessment, dated 5/29/24, indicated Resident #63 had a Brief Interview for Mental Status exam score of 15 out of a possible 15, which indicated the Resident had intact cognition. The MDS also indicated Resident #63 is dependent on staff for all functional tasks. During an observation on 8/8/24, at 1:50 P.M., Resident #63 was observed laying in bed. The Resident said his/her incontinent brief had not been changed since 9:00 P.M. the night before, (a total of 17 hours without incontinence care) and that he/she was wet and uncomfortable. [...]

Inspectors wroteBased on interview and record review, the facility failed to accurately code in the Minimum Data Set (MDS) for three Residents (#28, #100 and #112) of 46 sampled residents. Specifically; 1. For Resident #28, the use of non-invasive mechanical ventilation was inaccurately coded in the MDS. 2. For Resident #100 a significant weight loss was inaccurately coded in the MDS. 3. For Resident #112 the discharge status was inaccurately documented on the MDS.

Inspectors wroteBased on record review and interview the facility failed to develop a baseline care plan that includes the instructions needed to provide effective and person-centered care for one Resident (#16) out of a total sample of 46 residents. Specifically, the facility failed to develop a baseline care plan including resident specific interventions for a Resident who requires Dialysis three times a week.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure care plans were reviewed and revised with the interdisciplinary team (IDT) as required for three Residents (#28, #16 and #77), out of a total sample of 46 residents. Specifically: 1. For Resident #28, the facility failed to ensure his/her sleep apnea care plan was revised. 2. For Resident #16, the facility failed to ensure his/her care plan was revised in May 2024 to include the dialysis plan of care, when it was not developed upon admission or with the initial comprehensive plan of care in February 2024. 3. For Resident #77 the facility failed to ensure his/her activities of daily living care plan was revised.

Inspectors wroteBased on interview and record review, the facility failed to provide routine vision services to obtain new eyeglasses for one Resident (#20) out of a total sample of 46 residents.

Inspectors wroteBased on record review and interview the facility failed to ensure a falls assessment and falls investigation were initiated timely following a fall with injury for one Resident (#103) out of a total sample of 46 residents.

Inspectors wroteBased on record review, policy review and interview the facility failed to maintain acceptable parameters of nutrition status for two Residents (#103 and #45) out of a total sample of 46 residents. Specifically: 1. For Resident #103, the facility failed to a.) obtain weekly weights as ordered and b.) address a significant weight loss timely. 2. For Resident #45, the facility failed to obtain a Registered Dietitian (RD) consult.

Inspectors wroteBased on observations, interviews, policy review, and record review, the facility failed to provide respiratory care services in accordance with professional standards of practice two Residents (#6, and #30) out of a total sample of 46 residents. Specifically: 1. For Resident #6, the facility failed to ensure his/her oxygen (02) tubing was changed; 2. For Resident #30, the facility failed to ensure oxygen tubing was changed as ordered by the physician.

Inspectors wroteBased on observations, record review, policy review and interviews, the facility failed to ensure for one Resident (#16), who required dialysis, that they received services consistent with professional standards of practice, out of a total sample of 46 residents. Specifically for Resident #16 the facility failed to ensure: a.) nursing consistently obtained the Resident's blood pressure from the correct arm to prevent harm or injury; b.) create a complete and resident specific care plan regarding Resident #16's dialysis care; and c.) nurses consistently followed the Physician orders regarding dialysis care.

Inspectors wroteBased on record review, policy review and interview the facility failed to ensure a plan of care was developed for Trauma Informed Care, with individualized interventions, for one Resident (#58) who had a history of trauma out of a total sample of 46 residents. Specifically, for Resident #58, the facility failed to develop a comprehensive trauma care plan, with individualized triggers.

Inspectors wroteBased on record review, policy review and interview, the facility failed to ensure recommendations from the Monthly Medication Reviews (MMRs) conducted by the consultant pharmacist were addressed and acknowledged by the physician in a timely manner for two Residents (#28, and #104) out of a total sample of 46 residents. Findings Include: 1. Resident #28 was admitted to the facility in July 2023 with diagnoses that included vascular dementia, chronic kidney disease, obstructive sleep apnea, heart failure and asthma. Review of Resident #28's most recent Minimum Data Set (MDS), dated [DATE], indicated he/she scored a 12 out of 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident is cognitively intact. [...]

Inspectors wroteBased on record review and interviews the facility failed to ensure that PRN [as needed] psychotropic drugs were limited to 14 days for one Resident (#3) out of a total sample of 46 residents. Specifically, for Resident #3 the facility failed to ensure his/her Lorazepam had a stop date.

Inspectors wroteBased on interview and observation for two of five sampled Residents (#45, and #90), the facility failed to ensure the pneumonia vaccinations were offered.

Inspectors wroteBased on record review and interview, the facility failed to protect residents from abuse after one Resident (#67) alleged that Nurse #15 yelled at him/her out of a total of 35 sampled Residents. Specifically, the facility failed to remove Nurse #15 after the alleged abuse resulting in Resident #67 experiencing emotional distress.

Inspectors wroteBased on interview, document review, and policy review, the facility failed to develop, implement, and maintain a Quality Assurance and Performance Improvement (QAPI) program that addressed the full range of care and services, was comprehensive and data-driven, and focused on indicators of outcomes of quality of life, care, and services to residents in the facility.

Inspectors wroteBased on record review and interview the facility failed to develop and implement policies addressing: (a) How they will use a systematic approach to determine underlying causes of problems impacting larger systems; (b) How they will develop corrective actions that will be designed to effect change at the systems level to prevent quality of care, quality of life, or safety problems. (c) how the facility will develop acceptable performance parameters and; (d) How the facility will monitor the effectiveness of its performance improvement activities to ensure that improvements are sustained.

Inspectors wroteBased on observation, record review and interview for two residents (Resident #427 and #36) out of a total sampled of 35 residents, the facility failed to implement infection control precautions. Specifically: 1) For Resident #427 who was diagnosed with Methicillin-resistant Staphylococcus aureus (MRSA), the facility failed to implement contact precautions. 2) For Resident #36, the facility failed to clean a blood pressure before or after use.

Inspectors wroteBased on record review, policy review and interview, the facility failed to implement their Antibiotic Stewardship Program (ASP) to promote and monitor the appropriate use of antibiotics.

Inspectors wroteBased on observations and interviews, the facility failed to ensure residents were treated with dignity. Specifically: 1) Staff failed to provide a dignified dining experience for residents on three of four units in the facility. 2) Staff failed to close a laptop screen in the hallway which displayed confidential medical information.

Inspectors wroteBased on records reviewed, interviews and observations for five Residents ( #177, #99, 379, #7, #22) of 35 sampled residents, the facility failed to ensure it maintained oxygen equipment, and implemented physician orders and care plans for oxygen administration. Specifically: 1) For Resident #177 the facility failed to clean the external oxygen concentrator filter. 2) For Resident #99 the facility failed to clean the external oxygen concentrator filter. 3) For Resident #379 the facility failed to obtain a physician's order for the administration of oxygen. 4) For Resident #7 the facility failed to change outdated oxygen tubing. 5) For Resident #22 the facility failed to follow the physician's order for oxygen flow rate and to date oxygen tubing.

Inspectors wroteBased on observations, interviews and policy review, the facility failed to ensure 1.) medications were labeled, and dated once opened, according to manufacturer's guidelines in one out of four medication carts sampled, 2.) a medication cart was observed unlocked and unattended, and 3.) ensured medications were stored in locked compartments on one nursing unit.

Inspectors wroteBased on resident group meeting, interview and test tray results, the facility failed to ensure foods provided to the residents were prepared by methods that conserve nutritional value, flavor, palatability and at appetizing temperatures on three of four units.

Inspectors wroteBased on observation, record review, and interview for one Resident (#85) out of a total sample of 35 residents, the facility failed to assess for self-administration of medication.

Inspectors wroteBased on records reviewed and interviews, for one Resident (#31) , who was alert, oriented and whose preference included being able to receive a shower, the Facility failed to ensure nursing staff honored his/her right to self-determination related to his/her choice of receiving a weekly shower, out of 35 sampled residents.

Inspectors wroteBased on record review and interview, the facility failed to investigate an injury of unknown origin timely for one Resident (#61) out of a total of 35 sampled Residents.

Inspectors wroteBased on observation, record review and interview, the facility failed to develop and implement the plan of care for two Residents (#7 and #427) out of a total sample of 35 Residents. Specifically, the facility failed to 1) develop a care plan for an automatic implantable cardiac defibrillator device for Resident #7 and 2) develop a communication care plan for Resident #427.

Inspectors wroteBased on observation, interview, and record review, the facility failed to apply a left hand splint per doctor's order and recommendation from physical therapy for one Resident (#67) out of a total sample of 35 Residents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide assistance with meals for one Resident (#103) out of a total sample of 35 residents.

Inspectors wroteBased on records reviewed, interviews and observations for two Residents (#99 and #103) of 35 sampled residents, the facility failed to implement interventions to prevent skin breakdown. Specifically: 1) For Resident #99 the facility failed to place Prevalon boots on his/her feet while in bed, or use a pillow under his/her left heel while sitting in a wheelchair. 2) Resident #103 the facility failed to elevate his/her feet while lying in bed.

Inspectors wroteBased on observation, record review, policy review, and interview, the facility failed to identify a possible hazard for one Resident (#19), out of a total sample of 35 residents. Specifically, Resident #19 had 16 used Lidocaine patches in his/her room.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure staff provided appropriate care and services for one Resident (#47) with a Gastrostomy tube (G-tube: a tube that is placed directly into the stomach through an abdominal incision for administration of nutrition, fluids, and medication), out of 35 sampled Residents. Specifically for Resident #47 the amount of tube feeding infused did not correspond with the rate of infusion times and the hours infused. Additionally, the facility failed to date the G-tube feeding solution bottle per policy.

Inspectors wroteBased on observation, record review and interview, the facility failed ensure intravenous medications were administered in accordance of professional standards of practice for one Resident (#72) out of a total sample of 35 residents. Specifically, for Resident #72, the facility failed to ensure nursing obtained confirmation of placement of a PICC line (peripherally inserted center catheter) prior to use and nursing did not obtain information regarding the PICC line.

Inspectors wroteBased on observations, record review, policy review, and interviews, the facility failed to ensure for one Resident (#27), who required dialysis, received such services consistent with professional standards of practice and the comprehensive person-centered care plan, out of 35 sampled residents. Specifically, the facility failed to ensure nursing implemented a physician's order and care plan for emergency equipment at the Resident's bedside (smooth clamp).

Inspectors wroteBased on record review and interview the facility failed to develop a comprehensive trauma informed care plan for one Resident (#31) out of a total sample of 35 residents.

Inspectors wroteBased on employee record review and interview, the facility failed to complete performance reviews annually for two of two Certified Nursing Assistants (CNA) reviewed, as required.

Inspectors wroteBased on record review and interview, the facility failed to ensure pharmacy recommendations were 1) reviewed by the physician as required for one Resident (#105) and 2) reviewed by the physician in a timely manner for one Resident (#5) out of a total of 35 sampled Residents. Review of the facility policy titled Medication Regimen Review, revised and dated 8/17/23, indicated the following: *Facility should independently review each resident's medication regimen directly from the resident's medical chart and with the Interdisciplinary Care Team members, resident, or Responsible Party as needed. *Facility should encourage Physician receiving the medication regimen review (MRR) and Director of Nursing to act upon recommendations contained in the MRR. [...]

Inspectors wroteBased on record review and interview for one Resident (#177) of 35 sampled residents, the facility failed to ensure a gradual dose reduction (GDR) was attempted by the physician. Specifically: On 9/22/23, Resident #177 was prescribed Clonazepam as needed (PRN) and a GDR attempt was required by 10/4/23, but a GDR did not occur until 10/11/23, seven days after the required review date.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a diet of personal preferences to one Resident (#67) out of a total sample of 35 residents.

Inspectors wroteBased on observations, record review, and interview for one Resident (#45) of 35 sampled residents, the facility failed to provide adaptive eating equipment. Specifically, the facility failed to provide adaptive eating utensils to maximize food intake for Resident #45, who lacked coordination to both hands.

Inspectors wroteBased on observation, record review and interview, the facility failed to accurately document in the medical record for one Resident (#7) out of a total sample of 35 Residents. Specifically, the facility documented that oxygen tubing was changed two times and when it was not.