River City Post Acute

Inspectors wroteBased on interview and record review, the facility failed to provide pain management in accordance with professional standards and resident centered care plan for two of four sampled residents (Resident 1 and Resident 2) when:1a. Resident 1's pain medication was not administered consistently as ordered; and,1b. Resident 2's physician order to hold pain medication when the respiratory rate (RR) is below 18 was not followed. These failures increased the risk for Resident 1 not to receive adequate pain control and for Resident 2 to experience adverse effects such as drowsiness and slow or shallow breathing.1a. [...]

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from verbal abuse by facility staff for one of four sampled residents (Resident 1) when Certified Nursing Assistant (CNA) 1 called Resident 1 a faggot. This failure resulted in Resident 1 not being free from abuse and had the potential for Resident 1 to feel disrespected, afraid, and angry. Resident 1 was admitted [DATE] with diagnoses that included prostate cancer (uncontrolled growth of cells in a gland below the bladder), muscle weakness, chronic pain and major depressive disorder (persistent sadness, hopelessness, and a loss of interest in activities). A review of Minimum Data Set (MDS, an assessment tool), dated 6/4/26, indicated Resident 1 had intact memory. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection control and prevention practices for a census of 171, when, inside room [ROOM NUMBER], which was on Enhanced Barrier Precaution (EBP, infection control measures that require healthcare staff to wear gowns and gloves during high-contact activities for residents), the following were found: 1. Used gloves was discarded on the floor;2. Used pieces of gauze packets were discarded on the floor;3. Used gown was halfway discarded in the garbage bin;4. Several wound treatment supplies including normal saline, gauze, and treatment liner-sheets were left exposed and unattended at the windowpane;5. Urinal with urine was left on top of the overbed table near the resident's eyeglasses and television remote;6. Overbed table had scattered whitish colored sand-like-substances; and 7. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision during shower when the staff left one of three sampled residents (Resident 1) unattended. Resident 1 was at high risk for falls. This failure resulted in Resident 1's fall.

Inspectors wroteBased on interview and record review, the facility failed to ensure safety interventions were provided for one of three sampled residents (Resident 1), when a two-person assist was not implemented according to Resident 1's plan of care when transferred from the bed to the wheelchair. This failure resulted to Resident 1's fall with injury and had the potential to result in further falls and injuries.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from physical abuse by another resident for one of five sampled residents (Resident 1), when Resident 2 punched Resident 1 in the face and head. This failure caused Resident 1 to have a small laceration to the corner of his eye and a bruise on the back of his head.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure services provided met professional standards of quality for one (Resident 1) of five sampled residents when Resident 1's Peripherally Inserted Central Catheter (a thin, flexible tube inserted into a peripheral vein in the arm and threaded to a large vein near the heart to administer medications such as antibiotics) dressing was not changed per physician orders. This failure had the potential to cause infection for Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of 36 sampled residents (Resident 12 and Resident 3) were free from chemical restraints (the use of medications to manage resident's behaviors or restrict their freedom) when:Resident 12 was treated with quetiapine (Seroquel, a psychotropic medication used to treat mental illness) without an adequate indication for its use, andResident 3 received quetiapine without supporting evidence of a bipolar disorder (a mental disorder characterized by mood swings alternating between emotional highs and lows) diagnosis. These failures resulted in Resident 12 and Resident 3 continuing to receive unnecessary psychotropic medications, increasing their risk of unwanted side effects such as drowsiness. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide needed care and treatment according to professional standards of practice for three of 36 sampled residents (Resident 15, Resident 90 & Resident 156) when:Resident 15 did not receive bowel care as ordered. This failure resulted in Resident 15 experiencing abdominal discomfort from constipation. 2. Resident 90 did not receive physical therapy as ordered by the physician. This failure had to the potential for Resident 90 to experience a decline in mobility 3. Wound care nurse failed to follow physician orders for Resident 156 during wound care treatmentThis failure had the potential for Resident 156's wounds to worsen.1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents receive necessary care to maintain their highest practicable physical and psychosocial well-being for one of 36 sampled residents (Resident 79), when Resident 79, who required podiatrist care (a specialized physician who managed foot health, including cutting and trimming toenails) was observed with long yellow toenails. This failure had the potential to affect Resident 79's foot health contributing to injury and/or infection and negatively impact Resident 79's psychosocial well-being. A review of the admission record indicated the facility admitted Resident 79 in 2024 with multiple diagnoses, including diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control) and generalized weakness. A review of the most recent quarterly Minimum Data Set (MDS: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one out of 36 sampled residents (Resident 46) received the appropriate services needed to maintain acceptable parameters of nutritional status when: 1. Significant unplanned weight loss of 12.4 lbs (pounds, a unit of measurement), 9.1 percent (%) occurred from January 31, 2026, to February 28, 2026. 2. The recommendation made during the Interdisciplinary Care Conference (IDT) conducted on February 20, 2026, of adding an Oral Nutritional Supplement (ONS) for Resident 46 was not ordered or implemented. These failures placed Resident 46 at risk for nutrional decline and further unplanned weight loss. 1. A review of Resident 46's Facesheet, indicated he was admitted to the facility in January 2026, with diagnoses that included: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate did not exceed 5% for 2 of 3 sampled residents (Residents 4 and 104). For Resident 4, a licensed nurse did not administer the resident's multivitamin in accordance with the Physician Orders. For Resident 104, a licensed nurse did not administer the resident's:a. folic acid, an essential vitamin for cell growth and red blood cell formation; andb. calcium, a mineral important for strong bones and overall health, as ordered by the physician. As a result, 3 errors were identified out of 31 opportunities for error during the observation of medication administration; the facility medication error was 9.68%.1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its policy and procedure for a census of 162 when:Three bottles of atropine eye drops, medication used to treat various eye conditions, 1% (percent, unit of measure), requiring room temperature storage, were stored in the refrigerator, creating a potential risk for drug degradation and reduced effectivenessOpened inhalers (used to administer medication by breathing in) in the medication cart were not dated, which put residents at risk of receiving expired or outdated medication1. During a concurrent observation and interview with Licensed Nurse (LN) 13 on [DATE] at 2:25 p.m. in Medication Room Hall 1, three bottles of atropine 1% were stored in the refrigerator at 38 degrees F (Fahrenheit, unit of measure for temperature) per refrigerator thermometer. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food was stored in a sanitary manner when:1. Multiple cups, bowls and a large colander were found stored upright and exposed to the air, dust and splatter in the kitchen and when, 2. The activities refrigerator had no working thermometer, foods were not dated when opened, and chocolate ice cream drippings and debris were observed on the bottom of the freezer. These failures increased the risk for food borne illness. 1. During an initial tour observation on 3/3/26 at 8:19 a.m., two large trays of coffee cups, a nest of 6 mixing bowls and colander were stored upright on a bottom shelf in the kitchen open to air, dust and splatter. During a concurrent observation and interview on 3/3/26 at 8:20 a.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were implemented for 8 sampled residents (Resident 95, Resident 56, Resident 54, Resident 17, Resident 153, Resident 126, Resident 133, and Resident 173) and residents who use shower room in hallway 6 and 7 when: 1. Resident 95 had a visibly blood-soiled dressing left on arteriovenous fistula site (AVF; a surgically created connection between an artery and a vein, usually in the arm, that allows easy access to the blood stream for dialysis-a treatment that uses a machine to clean waste and extra fluid from the blood when a person's kidneys were no long able to do it) and 2. There were unsanitary conditions in the showers of hallway 6 and 7, and 3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care in an environment that maintained and enhanced residents' dignity and respected their individuality, when a white board at the Nursing Station of Hall 6 identified two residents by their room numbers referring them as FEEDERS.This failure had the potential to compromise residents' dignity by exposing residents' care needs. During an observation on 3/3/26 at 4:05 p.m., a white board on the wall at the Nursing Station of Hall 6 had two resident rooms that were labeled as FEEDERS.During a concurrent observation and interview on 3/4/26 at 3:15 p.m., with Licensed Nurse 3 (LN 3) and LN 4, a whiteboard in Hallway 6 listed two resident rooms as FEEDERS. LN 3 & LN 4 stated, staff wrote important information on white board and updated it daily. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to allow two of 36 sampled residents (Resident 19 & Resident 153) to make choices about aspects of their life in the facility that are significant to them when:The facility did not offer or assist Resident 19 to eat in the dining room for breakfast, andThe facility failed to allow Resident 153 to keep snacks in his room. These failures had the potential to affect Resident 19 and Resident 153's mental health and overall wellbeing. 1. During an observation on 3/3/26, at 9:00 a.m., Resident 19 was sitting in bed with his breakfast tray on his bedside table. During an interview on 3/3/26, at 9:00 a.m., with Resident 19, Resident 19 stated, he ate his breakfast in bed and would rather eat in the dining room. [...]

Inspectors wroteBased on interview and record review the facility failed to complete a Minimum Data Set (MDS: a federally mandated, standardized, and comprehensive assessment tool used in nursing homes to evaluate the functional, medical, and psychological status of residents) assessment for one of four sampled residents (Resident 142) when Resident 142 was discharged on 9/22/25 and facility staff did not complete the Discharge MDS assessment. During a review of Resident 142's facesheet, facesheet indicated, Resident 142 was admitted on [DATE], and discharged from the facility on 9/22/25. During a concurrent interview and record on 3/5/26, at 1:51 p.m., with MDS Nurse 2 (MDS 2), Resident 142's Medical record was reviewed. The Medical record indicated, Resident 142 did not have a discharge MDS assessment completed. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 36 sampled residents (Resident 18) received a required mental health evaluation for an identified mental disorder. This failure had the potential to result in Resident 18 not receiving needed mental health care and services. A review of the admission record indicated the facility admitted Resident 18 in 2025 with multiple diagnoses, which included bipolar disorder (a mental health disorder characterized by extreme mood swings, alternating between emotional highs and lows). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and/or implement a comprehensive care plan for two of thirty-six sampled residents (Resident 46 and Resident 88) when: 1. Resident 46's communication board care plan was not implemented by staff. 2. Resident 88 did not have a Care Plan that indicated he needed to wear a helmet when out of bed. These failures placed Resident 46 at the risk of care needs not being met and Resident 88 at risk of fall and injury. 1. A review of Resident 46's Facesheet, indicated he was admitted to the facility in January 2026, with diagnoses that included: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to arrange needed services for one of thirty-six sampled residents (Resident 88) when Resident 88 did not receive neurology (physician focused on treating disorders of the nervous system including the brain) or neurosurgical (surgical specialty focused on treating disorders of the nervous system including the brain) follow up services after admission to the facility. This failure placed Resident 88 at risk for increased disability and decreased functional status. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one of 36 residents (Resident 4), received necessary assistance with tooth brushing and mouth care in accordance with the resident's assessed needs, care plan, and facility policy. This failure resulted in ongoing poor oral hygiene, decayed dentition, and unmet assessed Activity of Daily Living (ADL) needs for Resident 4. A review of Resident 4's admission record indicated Resident 4 was originally admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide activities to one of 36 sampled residents (Resident 156) when the facility failed to provide activities meaningful to Resident 156 and according to the activities schedule. This failure had the potential to negatively affect Resident 156's mental health and wellbeing. During an interview on 3/4/26, at 8:42 a.m., with Resident 156, Resident 156 stated, she wishes she could get out of bed earlier so she can attend activities. Resident 156 stated, activitiy staff used to offer coffee at 10 am, but they offer that anymore. Resident 156 stated, look at the schedule posted on the wall and see if they offer those activities. Resident 156 further stated, When the state is here, everything is perfect. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide supervision for one of thirty-six sampled residents (Resident 88) to ensure Resident 88 wore a protective helmet when out of bed. This failure placed Resident 88 at serious risk for injury, including intracranial hemorrhage (bleeding inside the skull) from falls or accidents. A review of Resident 88's admission Record indicated Resident 88 was admitted to the facility in April 2024 with multiple diagnoses including cerebral infarction (blockage of a blood vessel in the brain causing cell death), hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body), and intracerebral hemorrhage (bleeding inside the brain). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respiratory equipment was maintained in accordance with professional standards of practice for one of 36 sampled residents (Resident 193) when Resident 193's nasal cannula (NC; a medical device with two prongs that is connected to an oxygen source to deliver supplemental oxygen directly into the nostrils) was not labeled with the date it was first applied. This failure had the potential to result in unsanitary delivery of oxygen to Resident 193 and an increased risk of infection. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs) were maintained for one of 162 residents when prescription medications were stored in a medication cart without a resident specific prescription label with an increased risk of medication error or drug diversion. Inspection of the medication cart 2 in hall 7 with Licensed Nurse (LN) 11 on 3/4/26 at10:30 a.m. revealed the bottom drawer of the cart contained used prescription medications without resident specific pharmacy label. These medications included two blister packs of apremilast, medication used to help calm body's overactive immune system. During an interview on 3/4/26 10:35 a.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect one of three sampled residents (Resident 1) from mental and emotional abuse when Resident 1's visitor/caregiver displayed anger by physical aggression in Resident 1's room and was verbally aggressive to Resident 1. This failure had the potential for Resident 1 to experience mental anguish and psychosocial distress. A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility in March 2025 with multiple diagnoses including neuromuscular dysfunction of the bladder (loss of bladder control due to nerve damage), protein calorie malnutrition (decreased protein and calorie intake causing weight loss and nutritional deficiencies), dysphagia (difficulty swallowing), and congestive heart failure (heart does not pump blood as efficiently as it should). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to report suspected abuse for one of three sampled residents (Resident 1) to The Department within the regulatory timeframe, when Resident 1's visitor/ caregiver was reported as abusive and the incident was not reported until two days later. This failure resulted in a delay of an investigation of abuse which had the potential for abuse to continue causing increased emotional distress or mental anguish for Resident 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection control practices for two of three sampled residents (Resident 1 and Resident 2) who had indwelling urinary catheters (a soft tube inserted into the bladder to drain urine into bag outside the body) when:CNA 1 removed his gloves, put on a new pair of gloves without washing hands, and then provided care to another resident. CNA 2 adjusted Resident 2's urine drainage bag without wearing gloves. These deficiencies had the potential to result in catheter-associated urinary tract infections (CAUTIs) for Resident 1 and Resident 2.

Inspectors wroteBased on observations, interviews and record review, the facility failed to protect one of five sampled residents (Resident 3's) right to be free from verbal abuse when Licensed Nurse 2 (LN 2) cursed and yelled at him. This failure caused Resident 3 to feel humiliated, fearful and intimidated. During a review of Resident 3's admission Record (AR), the AR indicated that Resident 3 was admitted to the facility in December 2025 with diagnoses that included Hemiplegia (severe loss of strength), Hemiparesis (weakness), and Depression (serious mental health condition). During a review of Resident 3's Progress Notes (PR), dated 1/12/26, The PR indicated that Resident 3's Brief Interview for Mental Status (BIMS, tool to assess cognition) score was 13 out of 15 which suggested Resident 3 was cognitively intact. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure services provided met professional standards of quality for one of five sampled residents, Resident 4's change of condition when: 1. There was no signed documentation of a physician telephone order (TO, verbal orders given by physician over the phone) of naloxone on file for Resident 4 that was given on [DATE], 2. There was no documentation of naloxone administration on Resident 4's Medication Administration Record (MAR), used to document medications taken by patient); and3. The Assistant Director of Nursing (ADON) did not follow the facility's policy and procedures for the administration of Naloxone which included giving repeated doses and calling 911. These failures had the potential to have resulted in a lack of continuity of care and the delay of critical interventions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accommodate the exercise of resident/resident representative's rights for one out of 11 sampled residents (Resident 5) when facility did not respond timely to Resident 5's representative request of Resident 5's personal belongings. This failure resulted in Resident 5 not having access to his personal belongings and had the potential for Resident 5 to experience undignified existence.

Inspectors wroteBased on interview, and record review, the facility failed to exercise the resident representative's right for one out of five sampled residents (Resident 5) when Resident 5 signed the facility's admission agreement, consent for treatment and release of information, and consents for facility services while Resident 5 was not oriented to person, place, date and time and did not have the capacity to make medical decisions. This failure has the potential to result in Resident 5 and Resident 5's representative to not fully understand the facility's admission agreement, treatment options, and other services that would be provided to Resident 5.

Inspectors wroteBased on interview and record review, the facility failed to ensure one out of five sampled residents (Resident 1) was free from significant medication error when Resident 1 did not receive his prescribed antiseizure medications (used to treat epilepsy and other seizure disorders by altering electrical activity in the brain) in accordance with the physician's order and standards of practice. This failure had the potential for Resident 1 to experience seizure activity (a sudden, uncontrolled electrical disturbance in the brain that can cause a range of symptoms, such as muscle stiffening, shaking, or altered sensations) and other seizure related complications which could negatively affect the resident's health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a call light within reach for two of five sampled residents (Resident 1 and Resident 2). This failure had the potential to result in unmet care needs and compromise the residents safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement the proper transmission-based precautions (TBP-additional infection control measures used in healthcare settings to prevent the spread of infectious diseases that are transmitted through specific routes) when there was no correct signage posted on the door for one of three sampled residents (Resident 3) who was observed to be positive for Covid-19 (a respiratory illness caused by the SARS-CoV-2 virus). This failure had the potential to increased risk of infection transmission for a facility census of 167 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect one of four sampled residents (Resident 1) from abuse when Resident 2 spit on Resident 1 in the face during a verbal altercation. This failure had the potential for Resident 1 to experience fear or distress.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff answered call lights (device used by residents to signal his or her need for assistance from staff) in a timely manner for three of 4 sampled residents (Resident 3, Resident 4, and Resident 1). These failures had the potential to result in resident's care needs not being met and placed residents' safety at risk.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure services provided meet professional standards of quality for one of 4 sampled residents (Resident 1) when:1. Resident 1's order for the immobilizer sling (a device used to restrict arm and shoulder movement to aid in the healing process after an injury) was not followed; and2. Resident 1's order for supplemental oxygen was not followed and updated according to residents' needs. These failures increased the risk for Resident 1 to experience increased pain, worsening of injury and be given supplemental oxygen that was not needed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a call light was within reach for one of 4 sampled residents (Resident 2). This failure had the potential to not meet the needs and placed Resident 2 at risk for safety.

Inspectors wroteBased on observation, interview and record review the facility failed to provide a safe and protective environment for one of three sampled residents (Resident 1), when Resident 1 was hit on the side of his face by Resident 3. During a record review of Resident 1's Face Sheet (FS), the FS indicated Resident 1 was admitted to the facility in early 2025 with diagnoses which included cerebral infarction (condition where a part of the brain is damaged or dies due to a lack of blood supply), hemiplegia (a condition characterized by weakness or paralysis affecting one side of the body), and aphasia (language disorder that affects a person's ability to communicate or speak). [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure physician's order was followed in accordance with the professional standards of practice for one of three sampled residents (Resident 3), when the physician was not notified of Resident 3's blood sugar level. This failure had the potential for Resident 3 to receive inaccurate and inadequate care. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide adequate monitoring and supervision for one of four sampled residents (Resident 1), when Resident 1 left the facility without notifying staff. This failure resulted in Resident 1 leaving the facility unsupervised and increased her risk for harm and injury.

Inspectors wroteBased on interview and record review the facility failed to provide adequate supervision to ensure safety when Resident 1 eloped from the facility for a census of 157. This failure had the potential to result in serious injury or death for Resident 1.

Inspectors wroteBased on observation and interview, the facility failed to maintain acceptable infection control practices when four shower rooms were observed unsanitary for a census of 165. This failure had the potential for the shower rooms to harbor infectious organisms and spread them to the residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow professional standards of practice when they failed to follow physician orders for two of six sampled residents (Resident 1 and Resident 2). These failures had the potential to result in poor residents ' health outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure interventions consistent with resident needs were implemented for one of three sampled residents (Resident 1) when Resident 1 sustained a fracture of the 4th right finger from a fall and interventions to support and stabilize the finger to prevent worsening were not implemented in a timely manner. This failure resulted in delay in the management of Resident 1 ' s fracture.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident ' s right to be free from physical abuse by a resident for one of five sampled residents (Resident 1) when facility staff witnessed Resident 3 hit Resident 1 on the head. This failure resulted in Resident 1 not being free from abuse and had the potential for Resident 1 to be injured.

Inspectors wroteBased on interview and record review the facility failed to follow their policy and procedures (P&P) to ensure Resident 1's responsible party received written notification, including the reason for the change, before a room change was initiated for one of two sampled residents (Resident 1). This failure violated Resident 1 and Resident 1's Responsible Party's (RP) right to receive written notice of the room change and had the potential to result in confusion for Resident 1 and dissatisfaction with his living arrangements.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure resident safety for one resident (Resident 1) out of a census of 158 when Resident 1's care plan was not implemented correctly and consistently, and facility did not know Resident 1's whereabouts. This failure resulted in Resident 1 missing and eloping from the facility and reduced the facility's potential in keeping Resident 1 safe from harm.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents received care which met professional standards for one of three sampled residents (Resident 2) when physician ' s order to apply soft heel lift boots (soft boots used to relieve pressure against the heels) was not implemented. This failure had the potential for the development or worsening of pressure injury (damage to skin and underlying tissues when continuous pressure cuts off blood flow to the area).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the infection prevention and control program guidelines and practices were maintained for a census of 163, when uncovered disposable razors on top of an overfilled sharps container (used to safely dispose of hypodermic needles and other sharp medical instruments,) inside the residents shower room in nursing station seven was not properly disposed and replaced timely by staff. This failure had the potential to result in transmission, spread of infection, and caused harm for the residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure professional standard of care was provided for one of three sampled residents (Resident 3), when the physician's order for fluid restriction (a diet which limits the amount of daily fluid consumption) was not followed. This failure placed Resident 3 at risk for dehhdration or fluid overload.

Inspectors wroteBased on observation, interview and record review the facility failed to provide adequate supervision to prevent elopement for one of two sampled residents (Resident 2). This failure had the potential for Resident 2 to be injured or harmed, as he was able to leave the facility without staff being aware.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide intravenous (IV, the administration of substances directly into a vein) care in accordance with professional standards of quality for two of six sampled resident's (Resident 2 and Resident 3) when Resident 2 and Resident 3 did not have physician orders for IV flushes (used to clear out IV lines after medication is used and to prevent blockages in the line). This failure had the potential for the residents to not receive the full dose of medication ordered, to receive the incorrect type or amount of IV flush and increased the risk for a blockage in the IV line.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide safe, sanitary care for two of six sampled resident's (Resident 2 and Resident 3) intravenous (IV, the administration of substances directly into a vein) care when the Peripherally Inserted Central Cather (PICC, a thin flexible tube inserted into a vein in the upper arm that extends into a large vein near the heart) dressings were not changed, and IV tubing was not dated. These failures increased the risk of infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) were cared for in a manner which promoted their dignity when CNA 1 spoke to Resident 1 with a rude and upset tone while helping during toileting. These failures had the potential to negatively impact residents' psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain infection control practices for a census of 171 when: 1. No Enhanced Barrier Precautions (EBP, involves use of gown and gloves during high contact resident care designed to reduce transmission of Multi Drug Resistant Organisms [MDRO, bacteria resistant antibiotics]) were in place for Resident 99, Resident 115, and Resident 31, and, 2.the facility staff failed to sanitize a blood pressure cuff between residents. These failures increased the risk for infections:

Inspectors wroteBased on interview and record review, the facility failed to develop comprehensive care plans for two of 37 sampled residents (Resident 87 and Resident 161) that included measurable objectives and timetables to meet the resident's medical and nursing needs. This failure created the potential for inaccurate care.

Inspectors wroteBased on interview and record review, the facility failed to ensure care was provided in accordance with professional standards for 1 of 37 sampled residents (Resident 72) when Resident 72 did not receive dialysis as prescribed. This resulted in Resident 72 being transferred to the emergency room (ER).

Inspectors wroteBased on interview and record review, the facility failed to complete annual performance evaluations (PEs) for two of two sampled certified nursing assistants (CNA 1 and CNA 2). This failure increased the risk of residents to receive poor-quality care from the CNAs.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow infection control practices when the cook failed to wear a beard restraint in the kitchen for a census of 165 Residents when: cook's facial hair was not covered with a beard restraint while preparing food. This deficient practice had the potential to cause the transfer of harmful bacteria and hair into food served to residents living at facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the walk-in freezer in safe operating condition when ice buildup was noted on the ceiling and back wall of the freezer. This had the potential to affect the safety and quality of the food served for 165 of the residents eating facility prepared meals.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident bedrooms met the minimum requirement of 80 square feet per resident. There were 13 rooms with three occupants in each room for a census of 171, were below the minimum requirement of 80 square feet per resident. This failure increased the potential for inadequate personal space for the residents in these rooms. During an observation and concurrent interviews conducted on 11/18/24 at 12:03 p.m. rooms [ROOM NUMBER] were observed to be neat, with sufficient space for residents' personal effects. There was ample room for entrance, way out, maneuvering of equipment in and out of the rooms, and access to the bathrooms. No validated issues or concerns regarding the lack of space for delivering care were verbalized by any of the residents in these rooms. During an interview on 11/18/24 at 12:08 p.m. [...]

Inspectors wroteBased on interview and record review, the facility failed to protect one out of four sampled residents' (Resident 4) right to be free from physical abuse by a resident (Resident 1) when Resident 1 yanked, tugged, and shook Resident 4's hair backwards. These failures resulted in Resident 4 getting hurt, being scared, and experienced emotional distress, and had the potential for Resident 4 and all residents in the facility to experience physical and/or psychosocial harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a sanitary environment for food preparation and service for a census of 156 residents when rodent droppings were observed in the kitchen and the dry food storage area. This failure had the potential to contaminate food served to residents causing food-borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose of trash and garbage properly when outside garbage dumpsters were uncovered for a census of 156 residents. This failure had the potential to attract rodents and insect pests resulting in an unsanitary and uncomfortable environment for residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary means of communication for one of four sampled residents (Resident 1), when staff did not use translation services including phone translation services and Resident 1 was not provided with a communication board (an alternative communication device with symbols and pictures to help people with limited English communicate). This failure had the risk potential for Resident 1's care needs to be unmet leading to inadequate care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a comfortable and sanitary environment for one of four sampled residents (Resident 1), when Resident 1's privacy curtain had a brown crusted stain on it and the top drawer of the bedside dresser had insect fragments, stains, and solid particle matter on the bottom of the drawer. This failure resulted in an unsanitary and uncomfortable environment for Resident 1 with the risk potential for infection or harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to revise the Care Plan for one of four sampled residents (Resident 1), when Resident 1's Care Plan did not accurately reflect the feeding assistance provided. This failure had the potential for Resident 1 to receive incorrect feeding assistance not in accordance with her wishes.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of three sampled residents (Resident 1) and (Resident 2), were free from abuse, when Resident 2 was seen hitting Resident 1 on the arm, afterwhich Resident 1 turned and threw his coffee on Resident 2. This failure increased the potential for physical and psychosocial injury.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain one of three sampled resident's (Resident 1) assistive devices in working condition when the resident's hearing aids were inoperable. This failure resulted in Resident 1 being unable to communicate and feeling frustrated.

Inspectors wroteBased on observation and interview the facility failed to prepare, distribute and serve food in accordance with professional standards for food service safety when: 1. Dietary aide (DA) 1 used her non-sterile, gloved index finger and thumb to prepare the food thermometer for insertion into the food. 2. Trash can not covered near food, a glove laying on the floor, a small sink next to the prepared food not clean. 3. Resident 2's breakfast tray was taken out of the dirty tray cabinet and given to Resident 2. These failures had the potential for residents receiving food from the facility kitchen, in a census of 167, to be exposed to food-borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide meals at a safe and appetizing temperature for three out of three random residents (Residents 1, Resident 2, and Resident 3) when, meals were served cold. This failure had the potential for poor food intake, nutrient deficits, and undesirable weight loss for residents eating facility prepared meals.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper infection prevention and control practices for one of four sampled residents (Resident 3) when staff stored five unlabeled bedpans (a device used as a receptacle for urine and/or feces) and one unlabeled, uncleaned bedside commode bucket (a device used as a receptacle for urine and/or feces) under the sink in Resident 3's bathroom. This failure had the potential to increase the spread of infection.

Inspectors wroteBased on interview and documentation review, the facility failed to provide food at an appetizing temperature when three residents (Resident 3, Resident 4, and Resident 5) complained that hot foods were consistently served cold, staff were aware of the complaints, and residents brought up the food temperature issue during the resident council meeting and yet unresolved for a census of 165. This failure resulted in the residents' preference consistently not being honored, therefore, Resident 5 feeling disrespected and Resident 3 and Resident 4 settling for having hot food cold.

Inspectors wroteBased on observation, interview and documentation review, the facility failed to provide a functioning call light system for two of three sampled residents (Resident 1 and Resident 2) when neither the light above their room nor the call light panel at the nursing station were working when the residents put the call lights on. This failure compromised the major communication link for staff to meet the needs of the residents and placed the residents at risk for safety.

Inspectors wroteBased on interview and record review the facility failed to ensure one of four residents (Resident 1) was free from abuse when facility staff witnessed Resident 2 punch Resident 1 in the face. This failure resulted in Resident 1 to sustain a laceration and bruising under his left eye.

Inspectors wroteBased on interview and record review, the facility failed to ensure comprehensive care plans (plans that summarize specific care needs and treatments) were developed for one of four sampled residents (Resident 1), when the facility identified Resident 1 as exit seeking. Care plans were not created until after Resident 1 eloped (run away secretly) from the building. This failure resulted in no written interventions being available for staff to follow which could have reduced the risk of Resident 1 leaving the building and being lost for eight hours.

Inspectors wroteBased on interview and record review, the facility failed to provide adequate monitoring and supervision for one of four sampled residents (Resident 1), when Resident 1 left the facility without notifying staff. This failure caused Resident 1 to be lost for eight hours and increased the risk for harm.

Inspectors wroteBased on observation, interview, clinical record and policy review, the facility failed to ensure 1 of 3 sampled residents (Resident 1) had access to his motorized wheelchair (MWC) when they failed to provide a place to store it within the facility premise. This failure resulted in Resident 1 not being able to have mobility within the facility or outside the facility.

Inspectors wroteBased on observations, interview and record review, the facility failed to ensure a homelike environment was provided for two of 31 sampled residents (Residents 12 and 39) when there was no running hot water in their bathroom. This failure resulted in resident 12 and 39 not having access to hot water to wash their hands.

Inspectors wroteBased on observation, interview and record review, the facility failed to employ staff with appropriate competencies for a census of 157 when: 1. [NAME] 1 was unable to demonstrate knowledge of fire safety measures; and 2. [NAME] 1 did not know how to calibrate the thermometer used to check the temperature of cooked food. This failure had the potential to cause a fire that could result in serious injury or substantial property loss, and inaccurate temperature readings of food that may cause rapid growth of pathogenic microorganisms (an organism causing disease to a person), resulting in foodborne illness (infection caused by bacteria, viruses and parasites).

Inspectors wroteBased on observation, interview and record review, the facility failed to serve meals at a safe and appetizing temperature for 10 out of 31 sampled residents (Resident 99, Resident 7, Resident 92, Resident 139, Resident 64, Resident 22, Resident 209, Resident 74, Resident 150 and Resident 50) whose meals were delivered and served cold. This failure had the potential for decreased meal intake which could potentially result in weight loss due to lack of proper nourishment that could negatively impact the resident's quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that nutritional supplements on two of four inspected medication carts (med cart 1 and med cart 2) were labeled with a date and time when opened and kept at proper temperatures. This failure decreased the potential for residents to receive the full nutritive value of their supplements.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to provide 80 square feet of space per resident in rooms 26, 34, 35, 42, 43, 44, 46, 47, 48, 49, 50, 51, and 53. This failure increased the potential for inadequate personal space for the residents in these rooms for a census of 157.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 31 sampled residents (Resident 129) was provided with an appropriate call light system to call staff when she needed assistance. This failure had the potential for the resident's needs not being met.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure the intravenous (IV) tubing was labeled with the date and time for 1 of 31 sampled residents (Resident 208). This failure had the potential to result in an infection for Resident 208.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure infection prevention and control program guidelines and practices were maintained for one of four sampled residents (Resident 1), when the isolation contact precautions cart was set up with no personal protective equipment (PPE) available for staff use. This failure had the potential to result in transmission and spread of infection for a vulnerable population.

Inspectors wroteBased on observation, interview and record review, the facility failed to protect one of 4 sampled residents (Resident 1) from verbal and physical abuse when Resident 2 physically assaulted Resident 1 and caused multiple injuries and used derogatory language towards him. Additionally, Resident 2 had in the recent past assaulted two other residents (Resident 3 and Resident 4). This failure resulted in Resident 1 sustaining injuries to his left ear, left side of face, left eyebrow and right 3rd finger, and had increased the potential to negatively impact Resident 1's psychosocial well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to protect one of 3 sampled residents (Resident 1) from verbal and physical abuse when Resident 2 physically assaulted him and used derogatory language towards him. This failure resulted in Resident 1 having a headache and had the risk potential to negatively impact his psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a clean environment was maintained for a census of 164 residents, when facility shower rooms were observed to be unsanitary. These failures had the potential to compromise the health, safety, and dignity of residents by increasing the risk of transmission-based infection in an unsanitary and uncomfortable environment.