Rinaldi Convalescent Hospital

Inspectors wroteBased on interview and record review, the facility failed to implement a follow-up process to ensure the formulation of the resident's Advance Directive (AD - a written document that states a resident's wishes regarding medical care if the resident is no longer able to make medical decisions due to a serious illness or injury) for one of six sampled residents (Resident 3). This deficient practice had the potential to result in uncertainty regarding the resident's healthcare preferences, which could lead to decisions that are inconsistent with the resident's expressed wishes. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement its policies and procedures (P&P) for ensuring the reporting of a reasonable suspicion of a crime in accordance with Section 1150B of the Act by failing to report the results of its investigation of an allegation of neglect (failure to provide necessary goods or services required to maintain a resident's physical or mental health) to the State Survey Agency (SSA) within five (5) working days of the incident for one of six sampled residents (Resident 1). This deficient practice had the potential to delay the SSA's oversight of measures necessary to ensure the protection of residents. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the proper use of low air loss mattress (LALM - a specialty bed that alternates pressure to help heal and prevent pressure ulcers/injuries [PU/PI- injuries that break down the skin and underlying tissue when an area of skin is placed under pressure]) by placing multiple layers of linens over the LALM for two of two sampled residents (Resident 1 and Resident 3), which had the potential to interfere with the pressure-redistribution function of the LALMs. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 2), who was identified as being at high risk for falls, had a landing mat (a cushioning pad placed beside the resident's bed to help absorb the impact of a fall) in place as ordered by the physician. This deficient practice had the potential to increase the resident's risk of injury in the event of a fall. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the physician was notified for one of three sampled residents (Resident 1), when Resident 1's indwelling catheter (a thin flexible tube that is placed into the bladder [a hollow, muscular organ in the lower abdomen that stores urine] and left in place to continuously drain urine into a collection bag) was observed to have sediments and cloudiness, in accordance with the facility's policy and procedure (P&P). This deficient practice had the potential to result in a delay in treatment for Resident 1 and increase the risk of urinary complications, including catheter obstruction and urinary tract infection (UTI- an infection in the bladder or urinary tract [body's drainage system for filtering blood and removing liquid waste as urine]), that can lead to worsening infection and may result in hospitalization. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that refusal of physician-ordered wound treatment was properly documented for one of three sampled residents (Resident 1), in accordance with facility policy and procedure (P&P) and professional standards of practice. This deficient practice had the potential to result in the absence of appropriate follow-up care, delayed physician notification and evaluation of the resident's condition, and may contribute to delayed wound healing, increased risk of infection, and potential decline in the resident's overall condition. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1), was wearing heel protectors (soft protective devices placed around a person's heels to reduce pressure and friction to the heels) to bilateral heels while positioned in bed. This deficient practice had the potential to increase Resident 1's risk for impaired skin integrity, skin breakdown, and the development of pressure ulcers/injuries (PU/PI- damaged to the skin and underlying tissue resulting from prolonged pressure). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care in a manner that maintained a resident`s dignity and respect to three of three residents (Resident 8, Resident 11 and Resident 2) by failing to: a. Ensure a Certified Nursing Assistant 1 (CNA 1) was not sitting in a Resident 8's room with her personal belongings while waiting for the end of her shift during a random observation. b. Ensure staff were not standing over Resident 11 while assisting with feeding. c. Ensure a staff member knocked prior to entering a resident`s room observed during resident screening. These deficient practices violated the resident's right to privacy, to be treated with dignity and had the potential to affect the residents' sense of self-worth and self-esteem.

Inspectors wroteBased on observation, interview, and record review the facility failed to promote the resident's right to be informed of and participate in their treatment for three of six (Resident 71, 102, and 75) residents observed for medication administration by failing to provide the name of medications and their indication (reason for the use of the medication) prior to administration of the medications. This deficient practice violated Resident 71, 102, and 75`s rights to make decisions regarding their medication regimen and to refuse any or all the medications.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a plan of care that summarizes a resident's health conditions, specific care and services facility staff need to provide) for two of 19 sampled residents (Resident 40, Resident 5) by: a. Failing to implement interventions for Resident 40 to help prevent and treat constipation. This deficient practice had the potential to negatively affect the delivery of care and services to Resident 40 b. Failing to develop a care plan that specifically address Resident 5's diet. This deficient practice had the potential to negatively affect the delivery of care and services to Resident 5. a. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a call light (a device used by a patient to signal his or her need for assistance) within reach for one of three residents reviewed under the environment task (Resident 11). This deficient practice had the potential to result in Resident 11 not being able to call for facility staff assistance and delay in the provision of necessary care and services that can negatively affect the residents' comfort and well-being.

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of eight sampled residents (Resident 12) was provided written information regarding their rights to refuse or accept medical or surgical treatment and to formulate an Advanced Directive (AD- a written instruction, recognized under State law, relating to the provision of health care when an individual is unable to make decisions for themselves). This deficient practice had the potential to result in the facility not honoring the residents' medical decisions regarding end-of-life care.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a homelike environment for two of two residents (Resident 15 and 82) by failing to ensure the window screen was in good repair and did not have a tear which created an opening measuring approximately 24 inches from top to bottom. This deficient practice had the potential to allow insects, dirt, and outside debris to enter the room, placing the residents at increased risk for infection and compromising their safety.

Inspectors wroteBased on interview, and record review, the facility failed to review, and update a care plan (a document outlining a detailed approach to care customized to an individual resident's need) after a resident`s Change of Condition (COC- an improvement or worsening of a resident`s condition which was not anticipated) for one of 19 sampled residents (Resident 12 ) by failing to review and revise the resident`s CP after his fall on 1/29/2026. This deficient practice had the potential to result in Resident 12 receiving inadequate care and supervision at the facility and an increased risk of recurrent falls.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary services to maintain good grooming and personal hygiene for one of one two residents (Resident 65) reviewed under the Activities of Daily Living care area by failing to ensure Resident 65's nails were trimmed. This deficient practice placed the resident at risk for skin injury and breakdown and infection.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide services that promote the prevention of pressure ulcer injury (localized damage to the skin and/or underlying tissue usually over a bony prominence) by failing to ensure that one of four sampled residents (Resident 36) had heel protectors (a specialized medical device or wearable cushion designed to prevent or treat pressure ulcers on the heel) in place as ordered by the physician. This deficient practice placed Resident 36 at risk for developing a new pressure injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services and treatments to maintain joint range of motion (ROM- full movement potential of a joint) for one of three sampled residents (Resident 10) by failing to follow physician's orders for a Restorative Nursing program (a nursing-driven service in long-term care settings that helps residents maintain or improve their functional abilities to their highest possible level) treatment to apply an inflatable therapy orthosis carrot (a soft, cone-shaped, inflatable hand splint used to treat severe finger contractures [clenched fists]). This deficient practice had the potential to cause further decline in functional mobility, ROM, and quality of life for Resident 10.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an environment that was free from accidents and hazards for two of four sampled residents investigated under accidents (Resident 12 and Resident 20) by failing to: 1. Apply landing pads (a floor pad designed to help prevent injury should a person fall) at Resident 12`s bedside as ordered by the physician. This deficient practice had the potential to place Resident 12 at risk for injuries in the event of a fall. 2. Check for placement and functionality of Resident 20`s wander management system (WMS - a wearable bracelet security technology designed to keep residents with memory issues from wandering away from safe areas) every shift from 3/5/2026 - 3/29/2026. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to: a. Ensure a resident who had a diagnosis of obstructive and reflux uropathy (a blockage in the urinary system that prevents urine from flowing freely, causing it to back up and potentially damage the kidneys. Reflux uropathy is the backward flow of urine from the bladder to the kidneys) receives appropriate treatment and services to prevent recurring urinary tract infections (UTI, common infections that happen when bacteria infect the urinary tract) by failing to keep urinary catheter (a tube that is inserted into the bladder, allowing urine to drain) tubing from forming a dependent loop (a urinary catheter dependent loop is a U-shaped sag in the drainage tubing that falls below the collection bag, creating a low point that disrupts gravity drainage. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the enteral feeding (delivers liquid nutrition directly to the stomach or small intestine via a tube for individuals unable to meet nutrient needs orally) rate was transcribed (written) on the enteral feeding formula bottle for one of one sampled resident (Resident 43). This deficient practice had the potential to place Resident 43 at risk for not receiving the correct amount of feeding formula per physician's order which could result in unintended weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Obtain a physician's order prior to administering oxygen for one of two sampled residents (Resident 99). 2. Ensure a resident's nasal canula (NC- a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) oxygen tubing was labeled with the date and time it was last changed for one of two sampled residents (Resident 99). These deficient practices had the potential to place Resident 99 at increased risk of infection, and cause complications associated with oxygen therapy. 3. Ensure a resident received continuous oxygen as ordered by the physician for one of two sampled residents (Resident 11). This deficient practice had the potential to cause Resident 11 to have shortness of breath that could lead to hypoxemia (a low level of oxygen in the blood).

Inspectors wroteBased on interview, and record review, the facility failed to ensure a resident's drug regimen was free from unnecessary medications (any medication in excessive dose, excessive duration, without adequate monitoring) for one of one sampled residents (Resident 99) by failing to monitor Resident 99 for sign and symptoms of bleeding for the use of enoxaparin sodium (an anticoagulant [blood thinner] used to prevent and treat harmful blood clots) in accordance with the facility's policy and procedure on Anticoagulation-Clinical Protocol. This deficient practice had the potential for Residents 99 to receive suboptimal (less than the highest standard or quality) care, and experience serious adverse consequences (unwanted, uncomfortable, or dangerous effects that a drug may have) possibly resulting in bleeding, hospitalization, or death.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free of any significant medication errors by failing to rotate clonidine patch (medication patch used to treat hypertension [high blood pressure- the force of the blood pushing on the blood vessel walls is too high]) administration sites for one of one sampled resident (Resident 40). This deficient practice had the potential for skin irritation and for the medication to not work as intended.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure temperatures were checked and documented for one of two refrigerators (Refrigerator 1) in Medication room [ROOM NUMBER]. This deficient practice had the potential to compromise integrity of the medications stored in medication room one refrigerator.

Inspectors wroteBased on interview, and record review, the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one of two sampled residents (Resident 36) by failing to include the resident`s diagnosis of anxiety disorder (a mental health condition characterized by excessive, persistent, and uncontrollable fear or worry that interferes with daily life) on the current diagnoses list. This deficient practice placed Resident 36 at risk of not receiving appropriate care due to inaccurate medical care information.

Inspectors wroteBased on interview and record review, the facility failed to ensure the facility arranged provisions of hospice services for one of one sampled residents (Resident 11) by failing to: 1. Ensure the hospice attending physician assessed and completed a history and physical (H&P- a comprehensive, structured evaluation performed by a clinician, combining subjective patient-reported history with objective physical exam findings to guide diagnosis and treatment). 2. Ensure the hospice agency provided training programs in hospice care for facility staff per contractual agreement. These deficient practices had the potential to negatively affect Resident 11's physical comfort, psychosocial (state of mental, emotional, and social health of an individual) well-being, and had the potential to delay or have a lack of necessary care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure medications are administered in a safe manner by failing to perform hand hygiene before and after medication administration for two of six sampled residents (Resident 71 and 102) observed during medication administration. 2. Ensure Certified Nursing Assistant 1 (CNA 1) did not place her personal purse and cell phone on the bedside table belonging to one of one sampled resident (Resident 8). These deficient practices had the potential to spread infection and cross contamination (the physical movement or transfer of harmful bacteria [germs] from one person, object, or place to another) among staff and other residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide at least 80 square feet (sq. ft. - unit of measurement) per resident in multiple resident bedrooms for five of 36 resident rooms (Rooms 101,102,104,105, and 107). rooms [ROOM NUMBERS] had two beds in each room. Rooms 104,105, and 107 had 3 beds in each room. This deficient practice had the potential to result in inadequate useable living space for all the residents and inadequate working space for the health caregivers.

Inspectors wroteBased on interview and record review, the facility failed to implement its policy and procedures (P&P), titled Abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment, resulting in physical harm, pain, or mental anguish), Neglect (failure of staff to provide necessary care), Exploitation (illegal or improper act of using a resident's funds, property, or assets for another person's profit or advantage, often involving coercion, manipulation, or fraud) and Misappropriation (deliberate misplacement, exploitation, or wrongful temporary/permanent use of a resident's belongings or money without their consent) Prevention Program by failing to conduct required pre-employment screening prior to hiring one of two sampled employees (Certified Nursing Assistant 1 [CNA 1]). [...]

Inspectors wroteBased on interview and record review, the facility failed to: 1. Obtain weekly weights as ordered for one of three sampled residents (Resident 1) 2. Ensure that staff monitored and documented intake (food and fluid consumption) and output (urine and stool amounts) in accordance with professional standards of practice and per the facility's policy and procedure (P&P) for one of three sampled resident (Resident 1), who had a gastrostomy tube (G-tube - a tube surgically inserted through the abdomen directly into the stomach to provide a way to deliver nutrition and medication when a person cannot eat or drink enough by mouth) and an indwelling catheter (a tube inserted into the bladder to allow urine to drain freely). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the significant change in status assessment (SCSA - a comprehensive assessment that must be completed when the interdisciplinary team [IDT - a group of healthcare professionals and staff from different areas who work together to create the best possible care plan for a resident] has determined that a resident meets the significant change guidelines for either major improvement or decline) Minimum Data Set (MDS - a comprehensive assessment and screening tool) was completed within the required time frame for one of three sampled residents (Resident 1). This deficient practice had the potential to negatively affect the provision of necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to follow the physician's orders dated 8/26/2025 to obtain laboratory services (any examination of materials derived from the human body for purposes of providing information for the diagnosis, prevention, or treatment of any disease or impairment of, or the assessment of the health of human beings) for one of five sampled residents (Resident 1). This deficient practice had the potential to negatively affect the provision of necessary care and services to meet Resident 1's needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control practices by failing to ensure Treatment Nurse 1 (TN 1) did not return disposable supplies to the treatment cart and did not disinfect a reusable plastic container prior to returning it to the treatment cart after completing wound treatment for one of one sampled resident (Resident 2). These deficient practices had the potential to result in cross contamination (germs are unintentionally transferred from one substance or object to another with harmful effect) resulting in the potential spread of germs placing residents, staff, and visitors at risk of being infected.

Inspectors wroteBased on interview and record review, the facility failed to provide in-service training (training intended for those actively engaged in a profession or activity) as indicated by the facility's in-service calendar for Certified Nursing Assistants (CNA) regarding behavioral health for two of two sampled CNAs (CNA 2 and CNA 3). This deficient practice has the potential to place residents who have a behavioral health diagnosis at risk for improper care and avoidable incidences.

Inspectors wrote2. During a review of Resident 12's admission Record, the admission Record indicated the facility admitted Resident 12 on 11/18/2024 with diagnoses including, but not limited to unspecified dementia (general term for a progressive state of decline in mental abilities), lack of coordination, a displaced (moved from proper or usual place) subtrochanteric (area below the trochanter [area below the neck of the femur located near the hip]) fracture of the right femur (longest and strongest bone in the body located from the hip to knee), subsequent (following) encounter for closed fracture (a broken bone that doesn't break the skin), and a history of falling During a review of Resident 12's Physician's Progress Note, dated 11/20/2024, the Physician's Progress Note indicated Resident 12 did not have the capacity to understand and make decisions and required skilled nursing services after [...]

Inspectors wrote3. During a review of Resident 12's admission Record, the admission Record indicated the facility admitted Resident 12 on 11/18/2024 with diagnoses that included, but not limited to unspecified dementia (general term for a progressive state of decline in mental abilities), lack of coordination, a displaced (moved from proper or usual place) subtrochanteric (area below the trochanter [area below the neck of the femur located near the hip]) fracture of the right femur (longest and strongest bone in the body located from the hip to knee), subsequent (following) encounter for closed fracture (a broken bone that doesn't break the skin), and a history of falling. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that pain management was provided, consistent with professional standards of practice for two of two sampled residents (Resident 22 and 10) being investigated under the pain care area when: a. Resident 22 was not assessed before and after tramadol (a controlled [a medication's use and distribution are tightly controlled because of their abuse potential or risk] medication given for pain) was administered on 2/9/2025 at 8:30am. b. Resident 10 was not assessed before and after oxycodone with acetaminophen tablet (brand name is Percocet, a narcotic pain medication) was administered on 1/21/2025 at 1:10 a.m., 1/31/2025 at 1:45 a.m., and 2/01/2025 at 2 a.m. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain accurate clinical records in accordance with accepted professional standards and practices by failing to ensure all medications administered to residents were documented in their medication administration record (MAR, a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for two of five sampled residents (Resident 22, 10) being investigated under the care area of unnecessary medications for: a. Resident 22's Xanax (controlled [a medication's use and distribution are tightly controlled because of their abuse potential or risk] medication for anxiety [feelings of fear, dread, and uneasiness]) and tramadol (controlled medication used for pain). b. Resident 10's Percocet (narcotic, controlled medication used for pain). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from any significant med errors for three of six sampled residents (Resident 72, Resident 70, and Resident 83) reviewed for unnecessary medications by failing to: 1. Administer Resident 72's Morphine Sulfate Contin (a medication used to control pain) 30 milligrams (mg- metric unit of measurement, used for medication dosage and/or amount) on 2/1/2025 as ordered by the physician. This deficient practice resulted in the resident not receiving the medication as scheduled, which can potentially lead to increased pain. 2. Hold parameters for midodrine (a medication to elevate blood pressure for those with low blood pressure) as ordered by the physician for Resident 70 and Resident 83. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when a steel scoop was left inside a bin containing a thickener powder used for residents` pureed diet (a pureed diet is needed for people who have trouble chewing or swallowing). This deficient practice had the potential to place five residents who are receiving pureed diet, out of 91 residents at risk for foodborne illnesses (refers to illness caused by the ingestion of contaminated food or beverages).

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Implement policies on transmission based precautions (TBP-a set of infection control measures used to prevent the spread infections that are transmitted through contact with infected person, their bodily fluids, or contaminated surfaces or objects) by failing to provide trash cans inside resident's rooms for used Personal Protective Equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) for one of five (5) sampled residents (Resident 72) reviewed for infection control. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a facility staff knocked and requested permission prior to entering a resident`s room for two of two residents (Resident 40 and 188) reviewed under the care area of dignity. This deficient practice violated the resident`s rights to be treated with respect and dignity which had the potential to affect the resident`s sense of self-worth and self-esteem.

Inspectors wroteBased on interview and record review, the facility failed to follow the facility's policy and procedure titled, Advance Directives (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor), for one out of the five sampled residents (Resident 16) reviewed under Advance Directives care area, by failing to maintain a current copy of the resident's advance directives in the resident's clinical record. This deficient practice had the potential for the facility to not honor the resident's medical decisions regarding end-of-life treatment and had the potential to cause conflict with Resident 16's wishes regarding health care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who required assistance with nail trimming was provided care and services to maintain good personal hygiene for one of one sampled resident (Resident 19) reviewed under Activities of Daily Living (ADLs- is a term used to collectively describe fundamental skills required to independently care for oneself, such as eating, bathing, and mobility). This deficient practice had the potential to result in a negative impact on the resident's self- esteem and self-worth due to an unkempt appearance.

Inspectors wroteBased on interview and record review, the facility failed to implement a resident centered activities program by failing to provide activities that meet the resident's spiritual or religious needs for one of one sampled resident (Resident 70) reviewed under the Activities care area. This deficient practice violated the resident`s right to receive religious services which has the potential to affect the resident`s sense of self-esteem and self-worth.

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of one sampled resident (Resident 27) received treatment and services to prevent decrease in range of motion (ROM- full movement potential of a joint) by failing to clarify Resident 27`s physician order for Restorative Nursing Assistant (RNA- nursing aide program that helps residents to maintain their function and joint mobility) exercise program. This deficient practice had the potential to place the resident at risk for further range of motion (ROM- full movement potential of a joint) decline.

Inspectors wroteBased on interview and record review, the facility failed to provide appropriate care and services to maintain acceptable parameters of nutritional status for one of one sampled resident (Resident 27) by failing to: 1. Communicate Resident 27's nutritional intake (the amount of food a person eats) percentage with the facility`s Registered Dietician (RD-a health professional who has special training in diet and nutrition). 2. Inform Resident 27`s physician regarding resident`s refusal to eat as indicated in her care plan (written guide that organizes information about the resident's care). This deficient practice had the potential to place Resident 27 at risk for weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed ensure staffing information of the actual hours worked by licensed and unlicensed nursing staffing directly responsible for resident care pers shift was posted daily on 2/11/2025 and on 2/13/2025 as indicated in the facility's policy and procedure (P&P) on Staffing, Sufficient and Competent Nursing. This deficient practice had the potential to keep residents and visitors unaware of the total number of staff and the actual hours worked by staff in the facility.

Inspectors wroteBased on interview and record review, the facility failed to monitor a resident for side effects of Trazadone (an antidepressant medication) and Xanax (an antianxiety medication) for one (Resident 72) out of five sampled residents investigated under the care area of unnecessary medications. This deficient practice had the potential to place Resident 72 t at increased risk of taking an unnecessary medication and experiencing adverse side effects.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from physical abuse (deliberately aggressive or violent behavior by one resident towards another) for one (1) of four (4) sampled residents (Resident 2) on 10/20/2024, when Resident 1 threw water at Resident 2, wetting Resident 2's face, chest, and clothes. This deficient practice resulted in Resident 2 being subjected to physical abuse by Resident 1 while under the care of the facility and had the potential to cause Resident 2 emotional harm which could result to a feeling of embarrassment, low self-esteem, and self-worth.

Inspectors wroteBased on interview and record review, the facility failed to implement their policy on acute (sudden onset) condition changes by failing to monitor a resident with hematuria (blood in the urine) for one of three sampled residents (Resident 1). This deficient practice had the potential to result in confusion in the care and services for Resident 1, which could have placed the resident at risk for not receiving appropriate care due to incomplete resident medical care information.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement infection control practices by failing to ensure contact precautions (measures that are intended to prevent transmission of germs which are spread by direct or indirect contact with the resident or the resident's environment) were implemented for one of three sampled residents (Resident 1), upon Resident 1's return to the facility on 5/26/2024 and was diagnosed with dermatitis (a skin condition that causes swelling and irritation) consistent with scabies (a contagious skin condition characterized by a rash [an area of the skin that has changes in texture or color and may look inflamed or irritated] and intense itching). [...]

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive person-centered care plan (a plan for an individual's specific health needs and desired health outcomes) for one of three sampled residents (Resident 1) with a diagnosis of dermatitis (a skin condition that causes swelling and irritation) consistent with scabies (a contagious skin condition characterized by a rash [an area of the skin that has changes in texture or color and may look inflamed or irritated] and intense itching). This deficient practice had the potential to result in a delay or lack of delivery of necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure the comprehensive care plan (a care plan is a form where you can summarize a person's health conditions, specific care needs, and current treatments) were evaluated, revised, and renewed for three of six sampled residents investigated for Comprehensive Care Plans by failing to: 1. Ensure Resident 68's care plan for risk for fall was evaluated, revised, and renewed. 2. Ensure Resident 54's care plan for impaired visual function was evaluated, revised, and renewed. 3. Ensure Resident 7's care plan for potential to impairment to skin integrity was evaluated, revised, and renewed. This deficient practice had the potential to result in residents not receiving the necessary care and services to prevent falls and further decline in visual function and skin integrity.

Inspectors wroteBased on interview and record review, the facility failed to complete a post-hemodialysis (HD, the removing of waste and excess fluid to prevent build up in the body for residents who have loss of kidney [organs that remove waste products from the blood and produce urine] function) assessment for one of one sampled resident (Resident 54) investigated under the Dialysis care area. This deficient practice placed the resident at risk for a delay in detecting complications resulting from HD.

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Remove and discard from use one discontinued medication for Resident 26 in one of two inspected medication rooms (Medication room [ROOM NUMBER]). 2. Remove two expired medications from facility stock in one of two inspected medication rooms (Medication room [ROOM NUMBER].) 3. Remove and discard from use one discontinued medication for Resident 77 in one of two inspected medication carts (Medication Cart 1). 4. Remove and discard one discontinued medication for Resident 183 in one of two inspected medication carts (Medication Cart 1.) 5. Label five inhalation (a form of a medication to be inhaled as a vapor or spray) solutions with an open date for Residents 12, 24, 62, 133 and 333 in one of two inspected medication carts (Medication Cart 2). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide dignity and respect for one of eight sampled residents (Resident 134) when Certified Nursing Assistant 4 (CNA 4) was observed standing over Resident 134 while assisting him with his meal. This deficient practice had the potential to affect a resident's self-worth and self- esteem.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a person-centered care plan (a written document that summarizes a patient's needs, goals, and care) for a resident who required scheduled and as needed pain medication for one of one sampled resident (Resident 46) investigated under the care area Pain Management. This deficient practice had the potential to result in failure to deliver necessary care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the low air loss mattress (LAL - a medical-grade mattress designed to prevent and treat skin breakdown) was set correctly in accordance with the physician's orders and manufacturer's instructions for one of four sampled residents (Resident 13) investigated under the care area Pressure Ulcer (a wound that develops when skin is damaged by constant pressure or fiction)/Injury. This deficient practice placed the resident at risk of discomfort and development of new pressure ulcers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an environment free from accidents and hazards by failing to ensure a resident did not have albuterol (medication to treat lung conditions) inhalers (a device that administers medication by breathing in) readily available for self-administration at bedside for one of five sampled residents (Resident 46) investigated under the care area Accidents. This deficient practice had the potential to result in the resident self-administering medications without staff knowledge potentially resulting in overdose (an excessive and dangerous dose of a drug) with accompanying symptoms of increased heart rate, nervousness, shakiness, tremors, or chest pain.

Inspectors wroteBased on interview and record review, the facility failed to ensure there was evidence documented in one of three sampled resident's (Resident 21) medical records of the toileting trial program (or bladder training, which can involve assisting a resident to the restroom at specific timed intervals) results as per the facility policy and procedure. This deficient practice has the potential for Resident 1 to not to achieve or restore normal bowel and bladder function.

Inspectors wroteBased on interview, and record review, the facility failed to monitor a resident's valproic acid (used to treat certain types of seizures [sudden, uncontrolled body movements that occur because of abnormal electrical activity in the brain] level (measures the amount of valproic acid in the blood) for a resident who was prescribed Depakote (medication used to prevent seizures) for one of six residents (Resident 31) investigated for unnecessary medications. This had the potential to place a resident at risk for having a seizure by having a subtherapeutic level (abnormally low amount which could indicate there is not enough medication in the body to be effective) or a toxic serum concentration (having too much medication in the body which can have unwanted and harmful side effects [a secondary, typically undesirable effect of a drug or medical treatment]).

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident who was prescribed an antipsychotic medication (a medication used to treat psychosis [a mental condition in which thought and emotions are so affected that contact is lost with external reality]) was being monitored for a specific behavior for one of six sampled residents (Resident 31) investigated for unnecessary medications. This deficient practice had the potential to result in adverse reaction (undesired harmful effect resulting from a medication or other intervention) or impairment in the resident's mental or physical condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the established menu to meet nutritional needs by failing to provide a roll (bread) for the noon meal on 2/20/2024 for two of eight sampled residents (Resident 46 and 39) investigated under the Dining Task. This deficient practice had the potential to result in unwanted resident weight loss and had the potential for residents getting disappointed with the meal experience they look forward to.

Inspectors wroteBased on observation, interview, and record review, the facility failed to honor a resident's preferences by failing to ensure the resident was served their ordered preference for low-fat milk (a type of milk that has some or all the fat content removed) for one of eight sampled residents (Resident 46) investigated under the Dining Task. This deficient practice had the potential to result in the resident having a decreased meal intake which could lead to unintentional weight loss and malnutrition (lack of sufficient nutrients in the body).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide at least 80 square (sq.) feet (ft.) per resident for five of 36 resident rooms (room [ROOM NUMBER], 102, 104, 105, and 107). The room size for these rooms had the potential to have inadequate space for resident care and mobility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe environment for 95 of 95 residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83, 84, 85, 86, 87, 88, 89, 90, 91, 92, 93, 94, and 95), staff, and visitors, by: 1. Failing to ensure that the facility's roof was free from cracks, holes and other damage that allowed water from rain to penetrate through and drip into the space between the roof and ceiling. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to protect a resident's right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) for one of five sampled residents (Resident 1) when on 1/21/2024, Certified Nurse Assistant 1 (CNA 1) witnessed Resident 2 punch Resident 1's right side of the face. This deficient practice resulted in Resident 1 being subjected to physical abuse by Resident 2 while under the care of the facility. Based on the reasonable person concept (hypothetical [suggested], average person's reaction to the actual circumstances) due to Resident 1's moderately impaired cognition (ability of think and make decisions), an individual subjected to physical abuse can have lifetime physical pain and or psychological (mental or emotional) effects including feelings of embarrassment and humiliation.