Ridgeway Post Acute

Inspectors wroteBased on observation and interview, the facility failed to ensure the rights of three of 18 sampled residents (Residents 11, 12, and 23) were considered when nursing staff did not inform them of the medications being administered during their medication administration process. This failure limited the residents' ability to participate in their care, ask questions, and make informed decisions regarding the medications they received. 1. A review of Resident 11's admission record (facility demographic) indicated she was admitted to the facility in January 2026 with medical diagnosis which included malignant neoplasm of the vulva (cancer that originates in the external female genitalia) and acute diastolic (congestive) heart failure (when the heart muscle becomes stiff and does not relax). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect four of 18 sampled residents' (Resident 47, Resident 62, Resident 69, and Resident 87) personal privacy when: 1. Resident 87's document, titled, Resident Functional Status Checklist, was posted on a dresser stored in a public facility hallway, 2. Resident 69's electronic medical record was left open and visible on a computer screen located on top of a medication cart in a public facility hallway, and; 3. The alternate meal requests for Resident 62 and Resident 47, which included protected health information, were disposed of in the regular kitchen trash without undergoing shredding or proper destruction procedures. These deficient practices had the potential to result in unauthorized disclosure of residents' protected health information and violated their right to personal privacy. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to store food in a sanitary manner for a census of 74 residents when:1. A kitchen staff member prepared food without the required facial hair covering,2. The kitchen and food storage floors had blackened debris on painted, worn, and tiled surfaces, 3. Opened food containers requiring refrigeration were improperly stored on shelves in the food storage room,4. Raw poultry in the refrigerator was not properly labeled with preparation and expiration dates,5. Food items were opened, undated, and missing use by dates in the food storage area,6. Daily kitchen cleaning was not documented; the log had missing entries, and the kitchen equipment and environment were not clean,7. Expired paper test strips were used to test the sanitation solution concentration in the red buckets,8. [...]

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of abuse to the Department for one of 18 sampled residents (Resident 2). This had the potential to result in harm and continued risk of abuse to Resident 2 and other residents of the facility as a result of the Department being unable to initiate an investigation timely. Record review of Resident 1's admission record (facility demographic) indicated he was admitted on [DATE] with medical diagnoses which included left femur fracture (broken thigh bone) and chronic obstructive pulmonary disease (a progressive lung condition that makes it difficult to breathe). [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and revise care plans for one of 18 sampled residents (Resident 6) when:1. Resident 6 did not have a care plan that addressed a re-occurring infection and the ongoing administration of antibiotics (a medication used to treat or prevent bacterial infections) treatment, and;2. Resident 6 did not have a care plan that followed a change of condition. These failures had the potential to result in inadequate management of Resident 6's health needs, leading to possible worsening of the infection, delayed recovery, or other complications due to the lack of appropriate care planning for ongoing antibiotic treatment and changes in condition. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide services in accordance with professional standards of practice when:1. 72-hour monitoring was not performed as required for one of 18 sampled residents (Resident 34) following a change of condition (COC), and;2. Two Licensed Nurses (LN C and LN D) did not know how to check the function of the wander guard (an electronic wander management system) for a census of 74 residents. These failures had the potential to result in harm to residents by compromising their safety and well-being, as the lack of required 72-hour monitoring after a change of condition could delay the detection and response to health issues for Resident 34, and the inability of two licensed nurses to check the function of the wander guard system could put residents at risk of elopement or wandering without proper safeguards in place. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to accurately document the controlled drug inventory count for a census of 74 residents when:1. The inventory count was not signed off every incoming and outgoing shift by nursing staff (Licensed Nurse [LN] or Registered Nurse [RN]),2. The total number of medication cards (medication blister card, a multi-compartment medication packing system) was recorded with mathematical errors, and;3. The forms were illegible. These failures increased the facility's potential for diversions (the unlawful removal or misuse of prescription or controlled substances from their intended path, from manufacturer to patient) and led to a lack of accountability for inaccurately documented controlled drugs. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure an abuse allegation between Residents 1 and 2 was reported to the state licensing/certification agency (the state) within 2 hours. This failure could put the residents at significant risk for continued harm, which could lead to severe physical and psychological trauma.

Inspectors wroteBased on interviews and record reviews, the facility failed to notify the Long Term Care Ombudsman (ombudsman, an advocate for residents of nursing homes, board and care centers, and assisted living facilities) for one out of two sampled residents (Resident 3) when Resident 3 was discharged from the facility and admitted to the hospital on [DATE] and again on 8/12/25. This failure put Resident 3 at risk for unsafe discharge.

Inspectors wroteBased on interview, observation and record review, the facility failed to provide a comfortable, homelike environment for one of four sampled residents (Anonymous Witness 1) when, after repeated complaints, the facility continued to use a floral-scented air freshener near Anonymous Witness 1's bedroom. This deficient practice resulted in Anonymous Witness 1 experiencing headaches and episodes of throat irritation and had the potential to offend or harm other residents of the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident 1) of four samples residents was treated with dignity and respect when Licensed Nurse 1 (LN 1) made a humiliating comment to Resident 1 in front of residents and staff. This failure resulted in Resident 1 feeling embarrassed and humiliated.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide one of three sampled residents (Resident 1) a homelike environment when the window sill and blinds were in need of repair and there was peeling paint on a wall in his room. These failures had the potential to negatively impact Resident 1's comfort and create an environment that was not homelike.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure one out of three sampled residents (Resident 1) was provided foot care, including timely toenail trimming when Resident 1's toenails were allowed to grow too long. This failure resulted in Resident 1 acquiring cellulitis (a skin infection that causes swelling and redness) and ingrown toenails (occurs when the edge of the toenail grows into the surrounding skin, causing pain, redness, and swelling) to all toes, which led to the physician to perform matrixectomy (a surgical procedure that removes the growth area of an ingrown toenail) of all toenails on 4/10/25. This failure also resulted in Resident 1 experiencing pain and fear of further pain due to the long and ingrown toenails and the long wait before a physician could provide care for his toenails.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure two out of three sampled residents (Resident 2 and Resident 3) received services to maintain grooming and personal hygiene (the practices and habits that maintain cleanliness and promote health by preventing the spread of germs and disease) when: 1. Residents 2 and Resident 3 were not provided regular nail trimming and nail care , and 2. Resident 3 did not receive showers or bed baths as scheduled. These failures could result in discomfort, potential skin impairments, and infection.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure a pain management plan was developed for one out of three sampled residents (Resident 1) who was at a high risk of experiencing pain when he had ingrown toenails (occurs when the edge of the toenail grows into the surrounding skin, causing pain, redness, and swelling) and after he underwent matrixectomy (a surgical procedure that removes the growth area of an ingrown toenail) to of all his toenails on 4/10/25. This failure resulted to Resident 1 experiencing pain on his toes from the ingrown toenails and after the matrixectomy procedure to all toes.

Inspectors wroteBased on observation, interview and record review, the facility failed to promote and enhance the sense of well-being for two residents (Resident 1 and Resident 6) of four sampled residents when facility staff did not verify Resident 1 and Resident 6 wore their own clothing. This failure resulted in Resident 1 showing up to a family party during the holidays wearing women ' s clothes and Resident 6 feeling disrespected and sad.

Inspectors wroteBased on interview and record review, the facility failed to ensure three residents (Resident 1, Resident 2 and Resident 4) of four sampled residents who lost personal items at the facility had their items located, replaced or reimbursed. These failures had the potential to result in feelings of frustration, loss of control, and uncertainty, which could have affected the residents ' comfort at the facility.

Inspectors wroteBased on interview and record review, the facility failed to follow physician's orders for one resident (Resident 1) of two sampled residents when licensed nurses did not communicate Resident 1's treatment orders written by a Wound Care Physician Assistant (PA - a licensed medical professional whose duties include ordering labs, medications, and treatments) for a wound on the left heel to the Attending Physician (a physician who is responsible for a patient's care in a hospital or skilled nursing facility) for approval and a signature. This failure decreased the facility's potential to ensure Resident 1's wound care treatments were ordered and carried out.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure food safety and sanitation guidelines were followed when: 1. Proper handwashing was not followed in the kitchen; 2. The proper cool down process of food and Temperature Control for Safety (TCS) process were not monitored; 3. The facility's thawing process for food was not followed; 4. The potential for cross contamination was not prevented; 5. Cleaning cloths were not placed in sanitizing solution between use; 6. Hair restraints were not utilized; 7. Food storage guidelines were not followed; 8. Food preparation equipment and utensils were not clean and kept in good working order; 9. Kitchen cleaning equipment was not stored properly; 10. Kitchen equipment and the environment were not clean; 11. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents were treated with dignity and respect when: 1. A staff member was observed standing while assisting a resident with meals; and, 2. Three staff were observed speaking a language other than English by the dining room of the facility during lunch hour. These findings had the potential for residents to experience feelings of sadness, frustration, and helplessness for a census of 76 residents.

Inspectors wroteBased on interview and record review, the facility failed to promptly respond and ensure resolutions for concerns brought-up during resident council meetings for a sample of 13 residents. This failure had the potential to result in unresolved patient care concerns, and feelings of frustration and loss of control for the residents of the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to post the location of the survey results in a easily noticeable manner. This failure decreased the facility's potential to honor the rights of 76 residents to examine the facility's survey results.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, and comfortable environment for residents when: 1. Two of three shower rooms were being used as storage; and, 2. The facility's smoking area dirty and unkempt. These failures made the shower rooms and smoking area uncomfortable and not a homelike environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide its residents a safe and functional environment free of accident hazards when water temperatures measured above 120 degreed Fahrenheit (F) in two showers and seven resident rest room faucets. These failures increased the risk of scalds or burns from hot faucet water and showers for a census of 76 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pharmaceutical services to meet residents needs for three of nine residents (Residents 39, 46 and 53) when: 1. Licensed Nurse A (LN A) did not identify Resident 39 prior to administering his morning medications on 9/24/24. 2. Resident 39's physician's order and Medication Administration Record (MAR) for a Lidocaine Patch (a topical medication for pain relief) did not follow the medication's package insert instructions for use. 3. The LN B administered a different resident's Metformin (a medication to treat diabetes/high blood sugar) to Resident 46. 4. The LN B administered Tylenol (a pain medication) to Resident 46 but did not document the medication administration on Resident 46's MAR. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1) Remove an unsampled discharged resident's medication from the medication cart and medications for four residents (Resident 25, Resident 69, Resident 27, and Resident 10) were not placed in their proper storage; and, 2) Maintain the temperature in the medication room between 68 degrees Fahrenheit (F) and 77 degrees F. These failures resulted in Resident 46 being administered Resident 27's medication and decreased the facility's potential to appropriately store medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the following: 1. The Certified Dietary Manager (CDM) ensured kitchen staff were competent in their job specific duties; and, 2. The Registered Dietitian (RD) did not have adequate oversight of the kitchen functions. These failures decreased the facility's potential to provide safe food handling and santiation for 76 residents who received preared food from the kitchen.

Inspectors wroteBased on observations, interviews, and record review the facility failed to: 1. Follow the recipe for Pacific Rim Pork Roast and Carrots with Parsley and 2. Ensure the resident meals were flavorful, appetizing, and cooked meat was tender for 76 residents who were served food from the kitchen. This deficiency decreased the facility's potential to serve palatable food and could lead to unintended weight loss due to reduced oral intake.

Inspectors wroteBased on interview and review, the facility failed to ensure facility staff and resident visitors were educated on safe food handing practices and food brought to the facility from the outside for resident consumption had the option to be heated. These failures had the potential for unsafe food handling which could lead to food borne illness and resident preferences not honored regarding food temperature for 76 residents who resided in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a sanitary storage area when one dumpster was overflowing with trash and its lid was unable to be closed, and the immediate area was strewn with trash and dirty resident equipment. This failure increased the potential to harbor and breed pathogens (organisms causing disease) and attract pests (insects and rodents).

Inspectors wroteBased on observation, interview and facility document and policy and procedure review, the facility failed to ensure essential equipment was maintained in proper working order when the ice machine was not clean and the manufacturer's guidelines were not followed. This failure had the potential for equipment to not function the way it was intended.

Inspectors wroteBased on observation and interview, the facility failed to ensure resident food preferences were honored for one resident (Resident 4) of 18 sampled residents when Resident 4 disliked pasta but was served pasta for lunch. This failure decreased the facility's potential to honor residents' preferences.

Inspectors wroteBased on interview and record review, the facility failed to honor the rights of one of two residents (Resident 5) when Resident 5 ' s medical decision-maker, Family Member 2 (FM2) was not asked or notified before starting to give Resident 5 a new pain medication MS (morphine sulphate) Contin (a long-acting pain medication made with morphine, an opiate). This failure resulted in Resident 5 becoming over sedated (state of calmness, relaxation, or sleepiness), requiring naloxone (a medication that reverses the potentially deadly effects of opiate toxicity), when he was administered a new medication before FM2 had been given a chance to consider the risks and benefits or permission for them to give it to him.

Inspectors wroteBased on interview and record review, the facility failed to follow up on a stat (immediately, urgent) laboratory (lab, a facility that provides controlled conditions in which scientific or technological research, experiments, and measurement may be performed) order for one of two sampled residents (Resident 5) when a stat urinalysis (UA, a basic test that examines the contents of a urine sample to identify conditions that may need treatment) and culture and sensitivity (C&S, a lab test that checks which bacteria are in the urine and which antibiotic will kill the bacteria) specimen for Resident 5 was rejected by the lab on 7/15/24 and a new urine specimen was not collected. [...]

Inspectors wroteBased on observation, interview and records review, the facility failed to ensure one Unlicensed Staff (Unlicensed Staff B) wore an N95 respirator to care for COVID-19 positive residents. This failure can result to the spread of infection to other facility residents and staff and cause an outbreak of COVID-19 in the facility further endangering the lives of the already frail elderly residents of the facility.

Inspectors wroteBased on observations, interviews and records review, the facility failed to ensure call lights (an alerting device for nurses or other nursing personnel to assist a patient when in need) was accessible to four of four sampled residents (Resident 1, 2, 3 & 4). This failure kept the residents' needs uncommunicated to the staff, potentially placing them at risk for neglect and harm.

Inspectors wroteBased on observations, interviews and records review, the facility failed to revise and implement a Fall and Elopement Care Plan for four of five sampled residents (Resident 1, 3, 4 and 5). These failure had the potential for facility staff to provide inadequate care and supervision to ensure the health and safety needs of the Residents were met. (Reference F600 & F689)

Inspectors wroteBased on observations, interviews and records review, the facility failed to update the Elopement (an unauthorized departure of a patient from an around-the-clock care setting) Risk Observation/ Assessment and failed to provide oversight supervision to ensure a safe environment to one of two sampled residents (Resident 5), when facility staff were aware of Resident 5 ' s attempt of leaving the facility unsupervised. These failures resulted to Resident 5 leaving the facility repeatedly without staff supervision, putting her at risk for serious physical harm or even death.

Inspectors wroteBased on interviews and records review, the facility failed to ensure its transfer or discharge policy was implemented for one of three sampled residents (Resident 1), when Resident 1 was discharged from the facility while being treated at the hospital and the Long-term Care Ombudsman (a person who investigates, reports on, and helps settle complaints) was not notified of the discharge. This failure prevented Resident 1 to exercise his right to appeal the facility's decision to be discharged and prevented the Ombudsman from advocating for Resident 1's best interest during the discharge process.

Inspectors wroteBased on interviews and records review, the facility failed to ensure notices of the bed hold policy were provided to two of three hospitalized residents (Resident 1 and Resident 2). This failure resulted in Resident 1 and Resident 2 not being informed they could return to the facility after hospitalization, and if they needed to submit payment to reserve a bed. Resident 1 During a review of the Face sheet (A one-page summary of important information about a resident) indicated Resident 1 was admitted on [DATE], with diagnosis including but not limited to Malignant Neoplasm (another term for a cancerous tumor [cancer cells form a lump or growth] of Rectum (end part of the large intestine that connects the colon to the anus); Colostomy Status (an operation that creates an opening for the colon, or large intestine, through the abdomen); [...]

Inspectors wroteBased on interviews and records review, the facility failed to allow one of two sampled residents (Resident 1) to return to the nursing facility, when Resident 1 was ready to be discharged from the hospital and wanted to return to the nursing facility. This failure had the potential to cause psychosocial (pertaining to the influence of social factors on an individual's mind or behavior) harm for Resident 1 from displacement (the act of forcing somebody/something away from their home or position).

Inspectors wroteBased on interviews and record reviews, the facility failed to report to the State (the centralized, law-making, law-enforcing, politically [NAME] institution in society) and the Ombudsman (a person who investigates, reports on, and helps settle complaints) an allegation of abuse for one out of two sampled residents (Resident 2) when Resident 1 threatened to kill Resident 2. These failures could potentially put the facility residents ' safety at risk and could result to ongoing abuse.

Inspectors wroteBased on observation, interview and records review, the facility failed to ensure effective kitchen oversight by the Registered Dietitian (RD) and designated Dietary Manager as evidenced by findings associated with meal production and meal distribution, food safety and sanitation, safe/functional environment, and staff orientation and training. This failure had the potential for putting 64 of 66 residents at nutritional risk or further compromising their nutritional status.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow the approved menu and physician diet orders when one Confidential Resident and Resident 52 complained of meal portions, five (5) of 64 residents (Resident 50, Resident 34, Resident 28, Resident 41, and Resident 51) on small portion diet, and one (1) unidentified resident on double entree diet were served the same portion of food like all the other residents who were on regular portion diet. This failure could result in undesirable changes of nutritional status, impaired healing, or poor well-being of residents in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to prepare food to conserve flavor and palatability (tastiness) for 4 unsampled residents (Resident 14, Resident 52, and two confidential residents) and 7 of 64 resident (Resident 53, Resident 45, Resident 48, Resident 18, Resident 16, Resident 160, and Resident 43) who were on pureed diet, when pureed entrée was served salty to taste. This failure could lead to weight loss and decline in nutritional status of residents in the facility.

Inspectors wroteBased on observation, interview and records review, the facility failed to ensure kitchen staff practiced safe food handling to prevent potential food contamination when an opened bag of all purpose flour was not transferred to a clean container with a lid after it was opened. These failure could potentially result to food contamination and outbreak of foodborne illness among residents of the facility.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to implement measures to reduce the risk of disease and infection transmission when: 1. Licensed staff were unable to identify appropriate transmission based precautions in caring for two out of two sampled resident (Resident 53 and 46) who had ESBL (Extended Spectrum Beta-Lactamase, an enzyme found in strains of bacteria and is spread by direct contact with the infected persons' bodily fluids); and 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow up on the resident's reported missing personal items and ensure the residents aware of the Theft and Loss policy for three (Resident 37, 211 and 35) out of six sampled resident's personal belongings from theft/loss. These failures resulted in residents stating they felt frustration, grief and confusion regarding the facility's lack of care and respect to their personal items.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure that the required notice and communication posting with the State Survey Agency (SSA) can be read and understood by the residents without staff assistance for three confidential residents and three out three sampled residents (Residents 1, 14 and 56). This failure had resulted to residents not having an access to this contact Information should they need to file a complaint with the State Survey Agency and had the risk for residents to feel like their welfare and autonomy does not matter.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure that the residents were aware on how to formally file a grievance for three out of 12 sampled residents (Residents 24, 35 and 211). This failure had the potential to result in residents unresolved grievance, leaving residents feeling angry and frustrated.

Inspectors wroteBased on observation, interview and record review, the facility: 1) Failed to protect one resident (Resident 41) from verbal abuse when she was subjected to sexual and inappropriate comments by 2 male residents (Resident 1 and Resident 2) and 2) Failed to protect one resident (Resident 21) from profane comments from Resident 1. These failures caused Resident 41 to feel uncomfortable and creepy, contributed to Resident 21 appearing upset, and caused potential for emotional distress and suffering, which in turn could cause decreased ability for Resident 41 and Resident 21 to attain or maintain their highest practicable psychosocial well-being. Findings 1) Review of Resident 1's medical record revealed he was a male resident with a BIMS (assessment tool) score of 8 (moderate cognitive impairment). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to timely report three allegations of abuse involving Residents 1, Resident 2, Resident 41, and Resident 21 to the State Survey Agency. These failures prevented the State Survey Agency from conducting independent abuse investigations on behalf of Resident 41 and Resident 21 and potentially negatively impacted the psychosocial well-being of all four residents. These failures also had the potential to result in re-occurrence abuse. Findings 1) Review of Resident 1's medical record revealed he was a male resident with a BIMS (assessment tool) score of 8 (moderate cognitive impairment). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to investigate three allegations of abuse involving Residents 1, Resident 2, Resident 41, and Resident 21. These failures prevented the facility from determining the root cause of the incidents and from assessing the victims for potential negative outcomes; these failures potentially prevented the facility from protecting the victims from further abuse and potentially negatively impacted the psychosocial well-being of all four involved residents. Findings 1) Review of Resident 1's medical record revealed he was a male resident with a BIMS (assessment tool) score of 8 (moderate cognitive impairment). [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility 1) Failed to implement the interventions to reduce the fall risk and hazards for one out of one sampled resident (Resident 12), which had the potential to result in serious injuries, including fractures and broken bones; and 2) Failed to adequately supervise one resident (Resident 1), who had a history of aggression, when he pulled 2 televisions off the walls in his room and the incident was not documented. This caused potential harm to Resident 1 and Resident 49 (Resident 1's roommate) when the televisions were pulled from the wall and caused potential for inability to track Resident 1's behaviors when the incident was not documented in his, or Resident 49's, medical records.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the respiratory care equipment was labeled with due dates for changing the tubing and humidifiers for 2 of 8 residents (Resident 161 and 162). This failure could lead to oxygen tubing and humidifiers not being changed. Residents were then placed at risk for infection if the tubing is contaminated or the humidifier water gets contaminated.

Inspectors wroteThe facility failed to maintain accurate medical records on two (Resident 1 and Resident 6) out of two sampled residents when: 1) Resident 1 had two outbursts of pulling television sets out of their wall mounted brackets and there was no documentation in the medical record regarding the event and 2) Resident 6 had nursing documentation indicating her toenails were short and clean when observed the toenails on both feet had been overgrown and full of dry flaky skin. These failures resulted in inaccurate medical records which either did not include important changes in condition or inaccurate nursing assessments which could potentially endanger each resident

Inspectors wroteBased on observation, interview and record review, the facility failed to provide necessary services to maintain good grooming and personal hygiene for 1 of 8 residents on hall 2 (Resident 161) who did not get a shower or have hair washed for 10 days. This failure had the potential to lower a resident's self-esteem and leave resident at risk for infection.

Inspectors wroteBased on interview and record review, the facility failed to follow Physician orders to prevent and treat constipation for 1 of 8 Residents on hall 2 (Resident 18). This failure resulted in Resident 18 having a bout of constipation, which caused Resident 18 moderate pain and discomfort and put her at risk for tearing of the mucous membrane and forming hemorrhoids from being constipated.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide necessary foot care treatment for one (Resident 6) of one sampled resident when the facility did not have a process for ensuring residents had appropriate foot care. This failure resulted in Resident 6 having significantly overgrown toenails.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure that one out of one sampled resident (Resident 49) who requires dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) received care consistent with professional standards of practice when there was no assessment of the Resident 49's left arm for bruit (a rumbling or swooshing sound of a dialysis fistula usually heard with a stethoscope) or thrill (a vibration felt on the overlying skin ) every four hours after dialysis treatments as stated on the facility's Nurses Dialysis Communication Record form. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a safe and sanitary environment in the kitchen as evidence by cracked and broken linoleum/tiles on the kitchen floor. This failure could cause trips and falls among the kitchen staff and cause dirt to build up on the floor attracting cockroaches and rodents.