Reunion Plaza Senior Care and Rehabilitation Cente

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary services to maintain personal hygiene for 1 of 5 residents reviewed for ADLs (Residents #1.)1. The facility failed to reposition Resident #1 at least every two hours on the 6/10/26 10:00 PM to 6:00 AM (6/11/26) shift.2. The facility failed to ensure LVN F provided appropriate incontinent care to include cleansing Resident #1's skin to his front and back private areas on 6/11/26.3. The facility failed to ensure CNA E turned Resident #1 to cleanse urine from his skin on the back side of his body or to check under the pad for wetness on 6/16/26.4. The facility failed to ensure CNA C provided appropriate incontinent care to include cleansing Resident #1's skin to his front and back private areas or turning Resident #1to check his under pad for wetness on 6/17/26. [...]

Inspectors wroteBased on observation, interview, and record review, 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 for 1 of 6 residents (Resident #1) reviewed for infection control practices.1. The facility failed to ensure LVN D wore a gown and gloves while providing direct care to Resident #1, who was on EBP, while performing PEG tube care on 6/11/26.2. The facility failed to ensure LVN D did not place paper towels that had fallen onto the floor back into Resident #1's bed on 6/11/26.3. The facility failed to ensure LVN F wore a gown and gloves while providing direct care to Resident #1, who was on EBP, while performing incontinent care or flushing his PEG tube on 6/11/26.4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the right to personal privacy was provided for 1 of 6 residents (Resident #1) reviewed for resident rights. The facility failed to ensure CNA A and CNA B pulled the curtain and covered Resident #1's genitalia while providing a bed bath on 6/17/26. This failure could place residents at risk of humiliation, diminished quality of life, loss of dignity, and self-worth.

Inspectors wroteBased on observations, interviews and record review the facility failed to ensure residents with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 of 4 residents (Resident #1) reviewed for pressure injury. The facility failed to ensure Resident #1 was turned/repositioned at a minimum of every two hours on 6/08/26. The facility failed to ensure Resident #1 had boot style heel protectors on both feet at all times per the physician orders on 6/08/26. [...]

Inspectors wroteBased on observations, interviews, and record review, 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 for 1 of 4 residents (Resident #1) reviewed for infection controlThe facility failed to ensure the Treatment Nurse A and ADON C wore appropriate PPE (gown and gloves) while performing wound care on Resident #1 on 05/07/26. Resident #1 was on Enhanced Barrier Precautions also known as EBP (an infection control strategy implemented in nursing homes to reduce the spread of multidrug-resistant organisms also known as MDROs). This failure could place any resident at the facility at risk for cross-contamination and the spread of infection.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that residents who need respiratory care are provided with such care, consistent with professional standards of practices for 1 of 1 resident (Resident #5) reviewed for respiratory care related to tracheostomy care.1. The facility failed to ensure LVN A, who worked for a staffing agency, had the needed competencies/knowledge to care for Resident #5 with a tracheostomy prior to attempting to perform tracheostomy (surgical procedure creating an opening (stoma) into the neck into the trachea (tube-windpipe- that allowed air to pass to and from lungs) to establish an airway)) care and suctioning on 2/25/26 and required surveyor intervention for the safety of the resident.2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pain management was provided to residents who require such services consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 4 resident reviewed for pain management. (Resident #21) The facility failed to ensure Resident #21 had effective pain management by failing to administer routine pain medication timely. This failure could place residents at risk for increased pain and decreased quality of life.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to have sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population for 7 (Resident #4,#2,#47,#77,#78,#90 and #104) of 16 residents reviewed for nursing services. The facility failed to have sufficient staff available to provide resident ADL care routinely. This failure could put residents at risk of not receiving necessary care and supervision to maintain their highest practicable physical, mental, and psychosocial wellbeing. Findings Included: 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food safety requirements.1. The facility failed to label and securely store a large white opened bag containing tan/brown granulated particles (identified as breadcrumbs by [NAME] LL) on 2/23/26.2. The facility failed to ensure DA MM wore a beard covering to cover facial hair while in the kitchen or a mask on 2/23/26 and 2/24/26.3. The facility failed to ensure [NAME] NN performed hand hygiene after pulling up her mask multiple times while preparing pureed (smooth pudding-like) foods on 2/24/26.4. [...]

Inspectors wroteBased on observation, interview, and record review 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 for 13 of 34 residents (Resident's #7, #17, #18, #22, #26, #29, #31, #41, #51, #66, #71, #83, and #85) reviewed for infection control practices.1. The facility failed to ensure facility staff followed infection control protocol during a COVID-19 outbreak at the facility.2. The facility failed to ensure the staff had access to the required PPE supplies for COVID positive rooms on 100 hall, on 02/23/2026, 02/24/2026, and 02/25/2026.3. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that the residents and/or representatives had the right to participate in the development and implementation of his or her person-centered plan of care, and to ensure that the planning process facilitated the inclusion of the residents and/or representatives for 5 (Resident #4,Resident #21, Resident #51, Resident # 81, and Resident #90) of 18 residents reviewed for care plans. The facility failed to ensure the IDT, Resident #4, Resident #21, Resident #51, Resident #81, and Resident #90, were involved in the review of the comprehensive assessment and were able to discuss their individualized care needs for services to include their need for medical and nursing care, medications, therapy, psychological and dietary needs. [...]

Inspectors wroteBased on interview and record review, the facility failed to consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility for 6 out of 6 anonymous residents during a confidential meeting. The facility failed to ensure the resident council grievances for call light timing and showers were promptly resolved. This failure could place residents at risk for a decreased quality of life and feeling as their voice was not heard.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure necessary services to maintain grooming and personal hygiene were provided for 7 of 18 residents dependent on staff reviewed for ADLs. (Resident #2, Resident #4, Resident #47, Resident #77, Resident #78, Resident #90, and Resident #104) 1. The facility failed to ensure Resident #2, Resident #4, Resident #77, Resident #78, Resident #90, and Resident #104 received scheduled baths in February of 2026. 2. The facility failed to ensure Resident #4, and Resident #47 were groomed and shaved. These failures could place residents at risk of not receiving care or services, decreased quality of life, embarrassment, and decreased self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to refrain from utilizing the DON as a charge nurse only when the facility has an average daily occupancy of 60 or fewer residents for reviewed for nursing services. 1. The DON worked as a charge nurse or CNA 6 times in January 2026 2. The DON worked as a charge nurse or CNA 4 times in February 2026 This failure could place residents at risk by leaving nursing staff without supervisory coverage and leaving essential DON functions undone.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, and dispensing of routine drugs and biologicals to meet the needs of each resident for 1 of 7 resident's reviewed for pharmacy services. (Resident #1) The facility failed to administer Resident #1's physician ordered Debrox ear drops from 02/24/2026 to 02/26/2026. This failure could place residents at risk for medication errors and adverse effects from medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident received and the facility provided food and drink that was palatable, attractive, and at a safe and appetizing temperature for 7 of 19 residents (Resident #2, Resident #4, Resident #9, Resident #21, Resident #33, Resident #61, Resident #81) and 7 anonymous residents reviewed palatable food. 1. The facility failed to ensure residents received food that was palatable. 2. The facility failed to ensure residents received food with an appetizing appearance, texture, and appropriate temperature. These failures could place residents at risk of weight loss, altered nutritional status, and diminished quality of life. Record review of a Resident Council Meeting Form dated 09/30/25 indicated, .Food sometimes served cold on the halls.1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to promote resident self-determination through support of family choice for 1 of 19 residents reviewed for resident rights. (Resident #78)The facility failed to place Resident #78's shoes on his feet daily as requested by family. The facility failed to get Resident #78 up out of bed daily as requested by family. These failures could place dependent residents at risk for feelings of depression, lack self-determination and decreased quality of life. Record review of an undated face sheet revealed Resident #78 was [AGE] years old and admitted to the facility on [DATE] with diagnoses which including quadriplegia (paralysis affecting all four limbs and the torso, typically caused by cervical spinal cord injury), seizures, and high blood pressure. [...]

Inspectors wroteBased on interview and record review the facility failed to provide the resident access personal and medical records pertaining to him or herself, upon an oral or written request, in the form and format requested by the individual, if it is readily producible in such form and format (including in an electronic form or format when such records are maintained electronically, or, if not, in a readable hard copy from such other form and format as agreed to by the facility and the individual, within 24 hours (excluding weekends and holidays) and allow the resident to obtain a copy of the records or any portions thereof upon request and 2 working days advance notice to the facility for 1 of 7 residents (Resident #105) reviewed for access of records. [...]

Inspectors wroteBased on interview and record review, the facility failed to assess each resident quarterly (every 3 months) using the MDS form specified by the state and approved by CMS for 1 of 19 residents (Resident #20) reviewed for assessments. The facility failed to ensure Residents #20's quarterly MDS assessment was completed within 3 months from the previous assessment. This failure could place residents at risk of not receiving necessary care or receiving inappropriate care for their conditions.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a Baseline Care Plan that included the instructions for resident care needed to provide effective and person-centered care for 3 of 12 residents reviewed for new admissions. (Resident #100, Resident #101, and Resident #103). The facility failed to develop a Baseline Care Plan for Resident #100's urinary catheter (tube inserted into the bladder to drain urine) within 48 hours of admission. The facility failed to develop a Baseline Care Plan for Resident #101 and Resident #103 within 48 hours of admission. This failure could place residents at risk of not receiving care and services to meet their needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for 1 of 13 (Resident #91) residents reviewed for quality of care. The facility failed to ensure a neurology referral was implemented for Resident #91, when it was ordered on 12/10/2025. These failures could place residents at an increased risk for a decreased quality of care, neglect, and decreased self-esteem.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents who were incontinent of bladder and bowel received appropriate treatment and services to prevent urinary tract infections for 1 (Resident #90) of 12 residents reviewed for incontinent care. The facility failed to provide timely incontinent care for Resident #90 using appropriate techniques. This failure could place residents at risk for urinary tract infections, pain, and skin breakdown.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 1 of 2 residents (Resident #31) reviewed for enteral tube management. The facility failed to ensure LVN O did not push Resident #31's medications by gastrostomy tube during medication administration on 02/24/2026. This failure could place residents with gastrostomy tube at risk for complications from medication administration such as stomach cramping or damage to the tube lining.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5 percent. There were 7 errors out of 32 opportunities, resulting in a 21.88 percent medication error rate for 2 of 7 residents reviewed for medication error. (Resident's #20, #34) The facility did not ensure the following:1. Resident #20's Vitamin D3, magnesium oxide, multivitamin with minerals, B-12 methyl, and Vitamin C were administered on 02/24/2026.2. Resident #34's esomeprazole magnesium (for indigestion) and Bisacodyl suppository 10 mg was administered on 02/25/2026. These failures could place residents at risk for adverse reactions or ineffective dosage related to inaccurate drug administration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 8 resident reviewed for physical environment (Resident #4). Resident #4's electrical bed remote had a short and would only let the head up. The remote would not let the head down or control the foot of the bed or the bed height. This deficient practice could result in decreased comfort, pain, the resident developing skin issues or deterioration of current wounds.

Inspectors wroteBased on observation, interviews and records reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 4 (Resident #4, Resident #21, Resident #23 and Resident #34) of 18 residents reviewed for care plans. 1. The facility failed to ensure Resident #4 had a complete comprehensive care plan.2. The facility failed to ensure Resident #21 had a care plan for high-risk medications (antianxiety, antidepressant, and opioid).3. The facility failed to ensure Resident #23 had a complete comprehensive care plan.4. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents were free from accident hazards for 3 of 8 residents reviewed for accidents (Resident #1, Resident #2, and Resident #3.) Resident #1 had a fall on the facility van, Van Driver A did not call 911 for assistance, and he did not report the incident to the facility. The resident was not sure of the date or time frame, and the facility could not provide a time frame. Resident #2 complained of Van Driver A's unsafe and erratic driving. Resident #3 was not strapped into the van correctly and her wheelchair tipped over backward which caused her to hurt her head, hand, and arm. This noncompliance was identified as PNC (past non-compliance) Immediate Jeopardy. The noncompliance was corrected prior to entrance. This facility failure placed Residents at risk for serious injury.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that respiratory care was provided consistent with professional standards of practice for 2 of 6 residents reviewed for respiratory care. (Resident #1 and Resident #2)1. The facility failed to ensure Resident #1's oxygen concentrator (takes air from the surroundings, extracts oxygen and filters it into purified oxygen for resident to breathe) air intake area (mouth of the oxygen concentrator bringing in the air that will be processed) was not covered in gray fuzzy dust and hair-like particles.2. The facility failed to ensure Resident #1 received the physician's ordered amount of oxygen of 2 LPM by nasal cannula.3. The facility failed to ensure Resident #2's oral suction catheter was stored properly. These failures could place residents at risk of respiratory complications or respiratory infection.

Inspectors wroteBased on observations, interviews, and record review 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 for 2 of 9 residents (Residents #2 and Resident #3) reviewed for infection control practices.1. The facility failed to ensure CNA A and CNA B did not contaminate Resident #2's clothing, draw pad, bedding, pillows, and feeding tube pole after performing incontinent care.2. The facility failed to ensure CNA A and CNA B donned (put on) a gown while performing incontinent care on Resident #2, who was on Enhanced Barrier Precautions (EBP).3. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 2 of 3 residents reviewed for quality of care (Resident #289 and Resident #290). 1. The facility failed to ensure Resident #289 did not elope from the facility on 9-12-24. 2. The facility failed to ensure Resident #290 did not elope from the facility on 8-31-24 and 9-5-24 . The noncompliance was identified as PNC. The Immediate Jeopardy (IJ) began on [DATE] and ended on [DATE]. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for injury or harm.

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary medications (is a medication used: In excessive doses (including duplicate therapy); or for excessive duration; or without adequate monitoring; or without adequate indication for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued) for 3 of 5 residents (Resident #33, Resident #65, and Resident #80) reviewed for unnecessary medications. 1. The facility failed to ensure Resident #33 had the correct diagnoses on entered orders for the use of diabetes mellitus medications. 2. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure that residents were free of significant medication errors for 1 of 18 residents (Residents #80) reviewed for pharmacy The facility failed to ensure Resident #80 Amlodipine, Carvedilol, Hydralazine, and Losartan were not administered when her blood pressure and/or pulse were outside of the ordered parameters on 11/03/24, 11/06/24, and 11/10/24. This failure could place residents at risk of medical complications and not receiving the therapeutic effects of their medications.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the menus met the nutritional needs of residents and were followed for 2 of 2 meals (the lunch meals on 12/2/24 and 12/3/24) reviewed for nutritional adequacy. The facility did not serve the posted lunch menu of breadstick and iced cinnamon raisin bars on 12/02/24. Cook Q did not follow the recipe for cheesy rice by using sliced cheese instead of shredded cheese per the recipe on 12/03/24. The facility did not follow the soup recipe on 12/03/24 by serving canned mushroom soup instead of homemade soup. The facility failed to use the appropriate size serving scooper for the pureed chicken, tomatoes and okra and potatoes and ground chicken for the lunch meal service on 12/03/24. The facility failed to ensure [NAME] Q scooped full serving sizes during the lunch meal on 12/03/24. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature for 7 of 86 residents (Resident #77, Resident #52, Resident #83, Resident #50, Resident #74, Resident #62, and Resident #40), 1 of 1 family member (Resident #63), and 1 of 1 meal (Lunch meal) reviewed for food and nutrition services. The facility failed to provide palatable food served at an appetizing temperature or taste to Resident #77, Resident #52, Resident #83, Resident #50, Resident #74, Resident #62, and Resident #40, and a family member of Resident #63, who complained the food was served cold, was bland, over, or undercooked and did not taste good. This failure could place residents who ate food from the kitchen at risk of weight loss, altered nutritional status, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure food stored in the kitchen refrigerator was labeled and dated on 12/02/24. 2. The facility failed to ensure cookware stored in the pantry and main kitchen area did not have carbon build up on 12/02/24. 3. The facility failed to ensure containers of cornmeal and sugar were properly sealed on 12/02/24. 4. The facility failed to ensure cornmeal was not spilled on the dry pantry floor on 12/02/24. 5. The facility failed to ensure 3 white bins, storing metal lids, did not have food particles in them on 12/02/24. 6. [...]

Inspectors wroteBased on observations, interviews, and record review, 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 for 2 of 3 residents (Resident #63 and Resident #65) reviewed for infection control. The facility failed to ensure, on 12/04/24, CNA E and CNA L, changed their gloves and performed hand hygiene appropriately while providing catheter care to Resident #65. The facility failed to ensure, on 12/04/24, CNA F, changed her gloves and performed hand hygiene appropriately while providing incontinent care to Resident #63. These failures could place residents at risk of exposure to cross-contamination and infections.

Inspectors wroteBased on interview, and record review the facility failed to treat each resident with respect and dignity and provide care in a manner that promotes maintenance or enhancement of his or her quality of life for 1 of 1 resident (Resident #57) reviewed for resident rights. The facility failed to ensure CNA S treated Resident #57 with respect and dignity when CNA S left Resident #57 exposed to the hallway after leaving her room. These failures could place residents at risk for diminished quality of life, loss of dignity, and self-worth.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or others for 1 of 6 residents (Resident #35) reviewed for reasonable accommodations of needs. The facility failed to ensure Resident #35 had a call light within reach. This failure could place residents at risk of possible falls, major injuries, hospitalization, and unmet needs.

Inspectors wroteBased on interview, and record review the facility failed to post in a place readily accessible to residents, and family members and legal representative of residents, the results of the most recent survey including any plans of correction without identifying information about complainants or residents for 2 of 2 survey results binders reviewed. The facility failed to ensure the most recent abbreviated standard survey results, exit date 08/15/24, was posted in the survey results book. This failure could place residents at risk of not being aware of past and current violation findings from state surveys and investigations conducted in the facility.

Inspectors wroteBased on interview, and record review, the facility failed to ensure individuals with mental health disorders were provided an accurate Preadmission Screening and Resident Review (PASRR) Screenings for 1 of 4 residents (Resident #76) reviewed for PASRR. The facility failed to refer Resident #76 for PASRR review following new mental illness diagnosis of major depression disorder (mood disorder that causes persistent sadness and loss of interest) on 05/13/24. This failure could place residents at risk of not receiving needed assessments (PASRR Evaluation), individualized care, and specialized services to meet their needs.

Inspectors wroteBased on observation, interviews and records reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident to ensure the comprehensive care plan described the services and interventions to be used to attain and maintain the resident's practicable physical, mental, and psychosocial well-being for 2 (Resident #63 and Resident #80) of 18 residents reviewed for care plans. The facility failed to ensure Resident #63, per her care plan intervention, had a pillow placed in her wheelchair due to leaning on 12/02/24 and 12/03/24. The facility failed to document/monitor Resident #80's oral intake per her care plan intervention due to her altered nutritional status in November 2024. These failures could place residents at risk of not having their individualized needs met, and a decline in their quality of care and life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, personal and oral hygiene for 1 of 5 residents (Resident #80) reviewed for ADL (activities of daily living) care. The facility failed to ensure Resident #80 was gotten out of bed in November 2024. This failure could place residents who required assistance from staff for ADLs at risk of not receiving care and services to meet their needs which could result in feelings of poor self-esteem, decrease socialization and skin breakdown.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received care, consistent with professional standards of practice, to prevent pressure ulcers based on the comprehensive assessment for 1 of 5 Residents (Resident #65) whose record were reviewed for skin integrity. The facility failed to ensure Resident #65's pressure-relieving mattress (is designed to distribute the patient's body weight over a broad surface area and help prevent skin breakdown) was on the correct settings. This failure could place residents at risk for developing pressure ulcers and could contribute to developing avoidable pressure ulcers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that each resident who was incontinent of bowel/bladder and each resident with an indwelling catheter received appropriate treatment and services to prevent urinary tract infections, for 2 of 5 residents (Resident #65 and Resident #63) reviewed for quality of care. The facility failed to ensure CNA E and CNA L provided peri care/catheter care per the facility's policy for Resident #65 on 12/04/24. The facility failed to ensure, on 12/04/24, Resident #63 did not have feces on her thigh and brown stained creases on the legs portion of her brief. These failures could place residents at risk for urinary tract infections.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrated that this was not possible or resident preferences indicated otherwise for 1 of 3 residents (Resident #81) reviewed for nutrition. 1. The facility failed to follow the dietician's recommended tube feeding for Resident #81 to receive Glucerna 1.5 at 60 ml/hr beginning 9/14/24. 2. The facility failed to follow the dietician's recommendation of weekly weights beginning 11/15/24 for Resident #81. 3. The facility did not follow up on Resident #81's 9.12% weight loss in 3 months. These failures could place residents at risk for malnourishment, weight loss, skin breakdown, and decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate administering of all drugs and biologicals, to meet the needs of 1 of 18 residents (Residents #80) reviewed for pharmacy services. The facility failed to ensure Resident #80 had accurate and new readings for each administration of Hydralazine (is used to treat high blood pressure) on 11/01/24, 11/02/24, 11/06/24, 11/07/24, 11/11/24, 11/15/24, and 11/16/24. This failure could place residents at risk for inaccurate drug administration.

Inspectors wroteBased on interview and record review, the facility failed to ensure each residents' drug regimen was free from unnecessary psychotropic drugs (without adequate behavior monitoring and diagnosis) for 2 (Resident # 65 and Resident #80) of 5 residents whose medications were reviewed. The facility failed to ensure Resident #65 had an appropriate diagnosis on entered order for her prescribed Escitalopram (is commonly used to treat depression and anxiety). The facility failed to ensure Resident #80 had behavior monitoring for her prescribed Venlafaxine (is used to treat major depressive disorder, anxiety, and panic disorder), Divalproex (is used to treat seizure disorders, certain psychiatric conditions (manic phase of bipolar disorder and to prevent migraine headaches), and Mirtazapine (is an atypical antidepressant and is used primarily for the treatment of a major depressive disorder).

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure each resident receives and the facility provides food that accommodates residents' food preferences for 1 of 18 residents (Resident #77) reviewed for food preferences and the accommodation of resident's meal choices. The facility failed to honor Resident #77's preference for boiled eggs at breakfast on 12/03/24, 12/04/24, and 12/05/24. The facility failed to obtain Resident #77's meals choice for each meal. These failures could result in a decrease in resident choices, diminished interest in meals, and weight loss.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident's person-centered comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 4 of 12 residents (Residents #18, #6, #8, and #10), reviewed for care plans. 1. The facility failed to revise and update Resident #18's care plan following physically aggressive behaviors against another resident. No interventions for aggressive behavior were listed on the behavior care plan. 2. The facility failed to revise and update Resident #6's care plan with interventions following a fall with major injury. The care plan did not include Resident #6's hip fracture or interventions for the care of the hip fracture. 3. [...]

Inspectors wroteBased on record review, and interview, the facility failed to treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for 1 of 12 residents reviewed for resident rights. (Resident #32) The facility failed to promote self-determination for Resident #32 by not allowing her to make healthcare decisions for herself when on 06/16/2024, LVN M, who was an agency nurse, refused to call an ambulance for Resident #32 because she felt Resident #32 was medically stable at the facility. This failure could place residents at risk for decreased quality of life, decreased self-esteem and increase anxiety.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents were free from abuse for 2 of 27 residents (Resident #1 and Resident #3) reviewed for resident abuse. 1. The facility failed to ensure Resident #1 was free from abuse when on 11/02/2023 CNA H shook Resident #1's wheelchair when pushing into the bathroom for incontinent care. 2. The facility failed to ensure Resident #3 was free from abuse when on 6/20/24 CNA J forcefully pushed Resident #3's wheelchair with her in it, from the doorway of her room to the doorway of another room across the hallway (approximately 13 foot). These failures could place residents at risk of physical harm, mental anguish, and/or emotional distress.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement an effective discharge planning process for 1 of 15 residents (Resident #32) reviewed for care plans. The facility failed to prepare Resident #32 to effectively transition to post-discharge care and the reduction of factors leading to preventable readmissions. These negative findings could cause a resident to have an unsafe living environment upon discharge.

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents received adequate supervision and assistance devices to prevent accidents for 1 (Resident #14) of 6 residents reviewed for quality of care. The facility failed to ensure Resident #14 had supervision that prevented him from going outside and falling causing a hematoma and abrasion to his head. This failure could result in residents experiencing accident, injuries, and diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to ensure residents were free of any significant medication errors for 1 of 12 residents reviewed for medications. (Resident #32) The facility failed to ensure Resident #32's IV antibiotic (meropenem) was initiated per MD orders to begin on 06/07/2024. These failures could cause prolonged illness and increased recovery time for residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene were provided for 2 of 6 (Resident #2 and Resident #3) residents reviewed for ADLs. The facility did not provide scheduled showers for Resident #2 and Resident #3. These failures could place residents at risk of not receiving services/care and decreased quality of life. Findings Include: 1. Record review of the face sheet dated 12/01/23 indicated Resident #2 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses including diabetes, weakness, hypertension (elevated blood pressure), and acute kidney failure (a condition where the kidneys suddenly cannot filter wastes from the blood). [...]

Inspectors wroteBased on observation and interview the facility failed to ensure all drugs were stored in a locked compartment, only accessible by authorized personnel for 2 of 4 (600 Hall Nurse/Medication and the Treatment Cart) medication carts and 1 of 2 (LVN G) nurses observed for medication storage. The facility did not ensure the medication carts were secured and unable to be accessed by unauthorized personnel. The facility failed to ensure medications were not left at the nurse's station unattended. These failures could place residents at risk for not receiving drugs and biologicals as needed, medications being used passed their effective or expiration date, and a drug diversion.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide respect, dignity and care in a manner and in an environment that promoted maintenance or enhancement of quality of life for 1 of 7 residents reviewed for resident rights. (Resident #1) The facility did not ensure the window blinds were closed during incontinent care exposing Resident #1. This failure could place residents at risk for diminished quality of life, loss of dignity and self-worth.

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 for 1 of 3 staff (CNA A) viewed for infection control. The facility failed to ensure CNA A changed gloves and perform hand hygiene while providing incontinent care. These failures could place residents and staff at risk for cross-contamination, spread of infection and could potentially affect all others in the building. Findings Include: 1. During an observation on 11/30/23 at 1:47 p.m. CNA A was performing incontinent care on Resident #1. CNA rolled up a dirty draw sheet, did not change gloves, then grabbed clean rag and wiped Resident #1's side off. [...]

Inspectors wroteBased on interview and record review the facility did not notify the physician of a significant change in the physical condition for 1 of 22 resident reviewed for notification of change. (Resident #151) The facility did not notify the physician when Resident #151, who had a history of Acute Respiratory Failure with hypercapnia (too much carbon dioxide in the body), had an oxygen saturation of 88% on [DATE] at approximately 6:30 p.m., had difficulty breathing, and would not keep on their Bipap (non-invasive ventilation breathing support administered through a face mask) mask . The resident was found unresponsive at 11:10 p.m. and expired at the facility. The facility failed to have a Physician Notification Policy. These failures resulted in the identification of an Immediate Jeopardy (IJ) on [DATE] at 5:21 p.m. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that respiratory care was provided consistent with professional standards of practice for 6 of 22 residents reviewed for respiratory care. (Resident #151, Resident #26, Resident #3, Resident #5, Resident #29, and Resident #67) The facility failed to monitor Resident #151 to ensure he kept his Bipap (non-invasive ventilation used for breathing support administered through a mask) mask on. The facility failed to notify the physician of a low oxygen saturation of 88% and the Resident #151 would not keep his Bipap mask on. The facility failed to obtain and monitor Resident #151's vital signs. The facility failed to follow Resident #151's readmission orders from the hospital for the use of Bipap. The facility did not ensure Resident #26's oxygen concentrator filter was free from gray like substances. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 2 of 6 residents (Resident #27 and Resident #361) reviewed for pressure injury. The facility failed to ensure Resident #27 low air loss mattress (is designed to distribute the patient's body weight over a broad surface area and help prevent skin breakdown) was on the correct settings. The facility failed to ensure Resident #27 had dressing on his back wounds. The facility failed to ensure the WCN loosening Resident #27's dressing, before removing, from his heel wound to prevent bleeding. The facility failed to ensure Resident #27 was turned and repositioned every 2 hours. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food safety requirements. The facility failed to ensure the plastic zipper bag labeled cocoa powder was securely closed. The facility failed to ensure the plastic trash-like bag labeled salt was securely closed. The facility failed to ensure there was not an uncovered unlabeled small cup of white granular substance left on the dry storage shelf. The facility failed to ensure the plastic trash-like bag labeled light brown cane sugar was securely closed. The facility failed to ensure the plastic bag labeled cheese was securely closed in the cooler. These failures could place residents at risk of foodborne illness and food contamination.

Inspectors wroteBased on observation, interview, and record review the facility failed to treat each resident with respect and dignity and provide care in a manner that promotes maintenance or enhancement of his or her quality of life for 2 of 3 residents (Resident #72, and Resident #201) reviewed for resident rights. The facility failed to ensure LVN SS treated Resident #72 with respect and dignity. The facility failed to ensure CNA HH treated Resident #72 with respect and dignity. The facility failed to cover the foley catheter urine drainage bag with a privacy bag for Resident #201 while she was out of her room in public view. These failures could place residents at risk for diminished quality of life, loss of dignity, and self-worth.

Inspectors wroteBased on interviews and record review, the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care and provide the resident and their representative with a summary of the baseline care plan that included goals of the resident, summary of medications and dietary instructions, and services and treatments within 48 hours of admission for 4 of 10 residents reviewed for baseline care plans. (Resident #94, Resident #352, Resident #358, and Resident #361) 1. The facility failed to develop a baseline care plan with initial goals and the minimum healthcare information necessary to provide person-centered care within 48 hours of admission for Resident #94, Resident #352, Resident #358, and Resident #361. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain dressing, bathing, and bed mobility were provided for 4 of 24 residents reviewed for ADLs (Resident #22, Resident #29, Resident #45, and Resident #79.) The facility failed to provide Resident #29 with timely incontinence care. The facility failed to assist Resident #22 with daily dressing. The facility did not provide scheduled showers for Resident #22, Resident #45, and Resident #79. These failures could place residents at risk of not receiving services/care and decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the DON served as a charge nurse only when the facility had an average daily occupancy of 60 or fewer residents for 10 shifts in the last 90 days. The census was 96. The DON worked as a charge nurse or CNA 3 times in August 2023 The DON worked as a charge nurse or CNA 3 times in September 2023. The DON worked as a charge nurse or CNA 4 times in October 2023. This failure could place residents at risk by leaving nursing staff without supervisory coverage and leaving essential DON functions undone.

Inspectors wroteBased on interview, and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate administering of all drugs and biologicals, to meet the needs of 1 of 24 residents reviewed for pharmacy services. (Residents #83) The facility failed to provide Resident #83 with dronabinol 5mg and megace 40mg for multiple days in September and October 2023 due to medications not being available. This failure could place residents at risk for inaccurate drug administration and cause Resident #83 increased pain and weight loss.

Inspectors wroteBased on interview and record review, the facility failed to ensure, based on the comprehensive assessment of a resident, residents who had not used psychotropic drugs were not given these drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for 2 of 5 residents (Resident #5, Resident #6) reviewed for unnecessary psychotropic medications. The facility failed to limit Resident #5's Lorazepam (anti-anxiety) prn medications to 14 days and the prescribing practitioner did not provide a rationale for extended use. The facility failed to have an appropriate diagnosis or indication of use for Resident #5's Lorazepam. The facility failed to document Resident #5's behaviors to justify administration of Lorazepam and effectiveness of administration. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that it was free of medication error rate of 5 percent or greater. The facility had a medication error rate of 18.92%, based on 7 errors out of 37 opportunities, which involved 4 of 7 residents (Resident #18, Resident #50, Resident #25, and Resident #39) reviewed for medication administration. The facility failed to administer Resident #18's loratadine (used to temporarily relieve the symptoms of hay fever [allergy to pollen, dust, or other substances in the air] and other allergies.) as ordered on 10/31/23. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections for 6 of 22 residents reviewed for infection control. (Resident #19, Resident #64, Resident #27, Resident #94, Resident #352, and Resident #358) The facility failed to clean Resident #19's room after she had a nosebleed. The facility failed to ensure Resident's # 64's wheelchair was free of soiled adult briefs. The facility failed to ensure WCN NN practiced infection control measures by changing gloves after touching items during a wound dressing change for Resident #27. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that the residents had the right to participate in the development and implementation of his or her person-centered plan of care, and to ensure that the planning process facilitated the inclusion of the residents and/or representatives for three (Resident #26, #35, #83) of five residents reviewed for care planning. The facility failed to ensure the IDT, Resident #26, Resident #35 and Resident #83, and the POA/RP of Resident #26, Resident #35, and Resident #83 were involved in the review of the comprehensive assessment and were able to discuss their individualized care needs for services to include their need for medical and nursing care, medications, therapy, psychological and dietary needs. The failure could affect residents by placing them at risk for not receiving adequate or individualized care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 3 of 22 residents (Resident #3, Resident #7, and Resident #27) reviewed for reasonable accommodations. The facility failed to ensure Resident #3, Resident #7 and Resident#27 call lights were within reach. This failure could place residents at risk for unmet needs.

Inspectors wroteBased on interview, and record review the facility failed to ensure assessments accurately reflected the resident status for 3 of 22 residents (Resident # 5, Resident #29, and Resident #361) reviewed for MDS assessment accuracy. The facility failed to code Resident #5's use of oxygen on her MDS. The facility failed to code Resident #29's use of oxygen and being on hospice services. The facility failed to accurately reflect Resident #361 had a pressure ulcer on his admission MDS assessment. These failures could place residents at risk for not receiving care and services to meet their needs.

Inspectors wroteBased on interview and record review the facility failed to incorporate the recommendations from the PASRR level II determination and the PASRR evaluation report into a resident's assessment, care planning, and transitions of care for 1 of 1 resident's (Resident #75) reviewed for PASRR. The facility failed to submit NFSS forms timely for Resident #75. This failure could place residents identified at a level II for PASRR evaluation at risk for their specialized services not being provided in a timely manner.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet each resident's medical, nursing, mental and psychosocial needs for 1 of 2 residents reviewed for care plans. (Resident# 29) The facility failed to implement the care plan intervention to report to Resident #29's provider, of his blood glucose levels (is a test that mainly screens for diabetes by measuring the level of glucose (sugar) in your blood) that were less than 100 per the physician orders. This failure could place residents at risk of not having individual needs met and cause residents not to receive needed services.

Inspectors wroteBased on observation, interview and record review, the facility failed to complete a discharge summary that included but is not limited to, (i) A recapitulation of the resident's stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results. and resident's follow up care and any post-discharge medical and non-medical services for 1. (Residents #202) of four residents reviewed for discharge planning. 1. The facility failed to complete a recapitulation of Resident #202's stay. 2. The facility failed to ensure Resident #202 had a physician prescribed wheelchair, bedside commode, and shower transfer bench when he was discharged home alone. This failure could place residents at risk of decreased socialization, depression, impaired skin integrity and increased fall risk.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide resident with limited range of motion appropriate treatment and services to increase range of motion and to prevent further decrease in range of motion for 1 of 3 residents reviewed for limited range of motion (Resident #75). The facility failed to provide restorative therapy for Resident #75's contracture. The facility failed to provide physical therapy for Resident #75's contracture. The facility failed to provide occupational therapy for Resident #75's contracture. These failures could place resident who had contractures at risk of not attaining or maintaining their highest level of physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 2 of 34 residents (Resident #76 and Resident # 18) reviewed for adequate supervision. The facility failed to store, supervise, and distribute Resident #76's smoking materials. The facility failed to ensure CNA CC and CNA DD safely transferred Resident #18 The facility failed to ensure CNA CC and CNA DD locked the shower chair wheels before transferring Resident #18. The facility failed to ensure CNA CC and CNA DD used a gait belt to transfer Resident #18. This failure could place residents at risk for injury, harm, and impairment or death.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 of 7 residents (Resident #27) reviewed for appropriate treatment and services to prevent urinary tract infections (an infection in any part of the urinary system, the kidneys, bladder, or urethra (is a hollow tube that lets urine leave your body)). The facility failed to ensure Resident #27's indwelling catheter (drains urine from your bladder into a bag outside your body) remained free of dependent loops (a configuration of catheter tubing where the drainage tubing dips below the entry point into the catheter bag) and had a leg strap to anchor catheter to his leg. This failure could place residents at risk for urinary tract infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were offered sufficient fluid intake to maintain proper hydration and health for 2 of 3 resident (Resident #3, Resident #6) reviewed for hydration. The facility failed to ensure Resident #3 and Resident #6 hydration was within reach. This failure could place residents at risk for dehydration (occurs when your body loses more fluid than you take in), electrolyte imbalance (occurs when certain mineral levels in your blood get too high or too low), and infections.

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary medications (is a medication used: In excessive doses (including duplicate therapy); or For excessive duration; or Without adequate monitoring; or Without adequate indication for its use; or In the presence of adverse consequences which indicate the dose should be reduced or discontinued) for 1 of 5 residents (Resident #29) reviewed for unnecessary medications in that: [...]

Inspectors wroteBased on interview and record review, the facility failed to promote antibiotic stewardship by ensuring the appropriate use of antibiotic therapy and providing written rationale, by the provider, when an antibiotic was used despite criteria, to determine the appropriate use of an antibiotic for 1 of 4 residents reviewed for antibiotic use. (Resident #29) The facility failed to ensure Resident #29's urinalysis (is a test that examines the visual, chemical, and microscopic aspects of your urine) with a culture (checks urine for germs (microorganisms) that cause infections) was collected prior to antibiotics starting. The facility failed to ensure Resident #29 Cefdinir (is used to treat bacterial infections in many different parts of the body) has an appropriate diagnosis for indication of use. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program to keep the facility free of pest for one (room [ROOM NUMBER]) of 6 rooms reviewed for pests. The facility failed to treat room [ROOM NUMBER] for roaches. These failures placed residents at risk for the potential spread of infection, cross-contamination, food-borne illness, and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure communication with and access to services inside the facility as mandated by the PASRR program were coordinated for 1 (Resident #2) of the 3 residents reviewed for resident rights. The facility failed to communicate with and coordinate therapy services that as mandated by the PASRR program for Resident #2. This failure placed residents at risk for diminished quality of life, and loss of dignity and self-worth.

Inspectors wroteBased on interview and record review, the facility failed to promote resident self-determination through support of family choice for 1 of 6 residents reviewed for resident rights. (Resident #1) The facility did not place Resident #1's tennis shoes on his feet daily per family requested. This failure could place dependent residents at risk for feelings of depression, lack self-determination and decreased quality of life.

Inspectors wroteBased on interview and record review the facility failed incorporate the recommendations from the PASRR level II determination and the PASRR evaluation report into a resident's assessment, care planning, and transitions of care for one out of one resident (Resident #2) reviewed for PASRR. The facility failed to submit NFSS forms timely for Resident #2. These failures could place residents identified at a Level II for PASRR Evaluation at risk for their specialized services not being provided in a timely manner.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary services to maintain personal hygiene for 1 of 6 residents reviewed for ADLs. (Resident #1) The facility failed to provide incontinent care to keep Resident #1 clean and dry. The facility failed to provide scheduled baths/showers for Resident #1. These failures could place residents who required assistance from staff for ADLs at risk of not receiving care and services to meet their needs which could result in poor care, risk for skin breakdown, feelings of poor self-esteem, lack of dignity and health.

Inspectors wroteBased on interview, and record review, the facility failed to provide residents with limited range of motion appropriate treatment and services to increase range of motion and to prevent further decrease in range of motion for 1 of 5 residents reviewed for range of motion. (Resident #1) The facility did not provide restorative therapy for Resident #1's contractures. This failure could place residents who had contractures at risk of not attaining/or maintaining their highest level of physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that respiratory care was provided consistent with professional standards of practice for 1 of 7 residents reviewed for respiratory care. (Resident #1) The facility failed to ensure Resident #1's suction tip catheter (suction equipment used for oral suctioning) was properly stored. These failures could place residents at risk of respiratory complications or respiratory infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate administering of all drugs and biologicals, to meet the needs of 1 of 7 residents reviewed for pharmacy services. (Resident #1) The facility failed administer all scheduled medications to Resident #1. This failure could place residents at risk for inaccurate drug administration and side effects from missed doses of medication.