River View Post Acute

Inspectors wroteBased on interview, and record review, the facility failed to provide appropriate pharmaceutical services for one of four sampled residents (Resident 1) when, Resident 1 did not receive as needed (PRN) medications for constipation when indicated. This failure placed Resident 1 at risk for prolonged discomfort, nausea, and vomiting associated with untreated and unresolved constipation.

Inspectors wroteBased on observation, and interview, the facility failed to ensure a clean, comfortable, and home-like environment for a census of 94 when the facility baseboards had not been reinstalled after the flooring was replaced in November 2025, leaving exposed peeling drywall and holes in the walls with accumulated dust and debris. These failures had the potential to negatively affect the residents' physical and psychosocial well-being.

Inspectors wroteBased on interview, and record review, the facility failed to ensure professional standards of care were met for one of three sampled residents (Resident 1) when Resident 1 was admitted to the facility following knee replacement surgery and the facility was unable to provide Resident 1's prescribed medications. This failure had a negative effect on Resident 1's psychosocial well-being and had the potential to negatively affect her health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to timely identify a right hip fracture (a broken or cracked bone) for one of three residents (Resident 3) following an unwitnessed fall on 1/14/26, when nursing staff failed to conduct a comprehensive post-fall assessment (a thorough evaluation completed after a fall to identify possible injuries, pain, causes of the fall, and changes in the resident's condition), failed to adequately reassess Resident 3's reported hip pain and changes in condition, failed to complete required post-fall neurological monitoring (neuro checks - assessments used to identify changes in alertness, thinking, behavior, movement, sensation, and function following a fall) within required timeframes, and failed to complete a weekly summary (a routine nursing documentation that provides an overview of a resident's condition during the [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the required licensed nurses' 72-hour progress notes (post-incident monitoring and assessment) for resident-to-resident altercations was completed for all required shifts for two of two residents (Resident 1 and Resident 2) when Resident 2, who had a history of aggression and cognitive impairment, struck Resident 1 on the arm. This failure placed Resident 1 and Resident 2 at risk for emotional distress, delayed identification of injuries and changes in condition, and increased the risk for additional resident-to-resident altercations within the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure a physician-ordered anticonvulsant medication (medication to prevent a seizure [a sudden, uncontrolled surge of electrical activity in the brain]) was implemented and administered as ordered for one of three sampled residents when, Resident 1 returned from the hospital on 4/27/26 with physician instructions to resume medication for a seizure disorder and the nursing staff failed to implement the order, obtain physician order clarification, notify the physician of the medication omission, and administer the medication, resulting in Resident 1 not receiving the ordered anticonvulsant medication for approximately 25 days, from 4/27/26 through 5/21/26. [...]

Inspectors wroteBased on observation and interview the facility failed to ensure a clean, comfortable, and home-like environment for a census of 89 when: 1. Room W had peeling paint on the wall behind the trash can, 2. Room X had a shelf across from bed B, where personal items were stored, with a broken front edge with jagged edges, 3. Room Y had peeling paint on the closet doors and adjacent wall, the air vent had black discoloration around the perimeter, an electric outlet cover was pulling away from the wall, the bathroom sink was detached from the wall, an area of the bathroom wall had an approximate 10 inch by 8 inch unpainted area covered with white spackle, 4. Room Z had multiple areas of peeling, flaking paint along the wall behind the head of the bed and, 5. The back hall shower room had peeling plaster behind the shower head; [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the resident representative (RR, a person who is responsible for another person's medical and/or financial decisions) for one of three sampled residents (Resident 1) regarding a change in Resident 1's new lab tests (blood test to screen for or diagnose illness) and new medication orders. This failure resulted in Resident 1's RR being uninformed of a change in Resident 1's medical treatment and did not allow the RR to participate in medical care decision making.

Inspectors wroteBased on interview and record review, the facility failed to ensure immediate notification was made to the residents physician of a significant x-ray report for one of three sampled residents (Resident 1), when Resident 1 had a STAT (immediate) x-ray completed on 2/8/26 of the left leg that indicated a fracture (break) of the left lower leg as well as osteomyelitis (a severe infection within the bone, causing inflammation (swelling) and destruction of bone tissue) of the left lower leg and left heel. This failure resulted in delayed care and placed Resident 1 at risk for pain, suffering, and medical complications related to the identified injury and infection.

Inspectors wroteBased on staff interviews and clinical record review and facility polity review, the facility failed to ensure that a comprehensive assessment was completed for one of three sampled residents (Resident 1) when, a Licensed Nurse failed to reassess Resident 1's left foot after receiving Resident 1's x-ray results which indicated a left lower leg fracture and acute osteomyelitis of the left heel. This failure placed Resident 1 at risk for experiencing pain, suffering and further medical declines.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure garbage and refuse were properly disposed for a census of 85, when:1. A garbage dumpster lid was not closed; and,2. A trash can in the kitchen did not have a working cover lid on it. These failures had the potential to expose the residents' environment to pests, odors, or diseases.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pharmacy services were maintained for a census of 85 when:1. Non-narcotic (medications that are not opioids-not addictive) prescription medication destruction records were either not signed and/or co-signed by licensed nurses in 17 out of 24 destruction records reviewed in one of two medication rooms (Med Room Unit 1) observed; and,2. Three unidentified pills were found in a medication cup on top of a storage container beside Resident 40's bed unattended and unsupervised. This failure had the potential for drug diversion (unlawful use of prescription drug by unauthorized individuals) or misuse of prescribed medications due to unsafe disposition practices and Resident 40 not receiving important medication as prescribed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide safe and effective use of medications including administering, storing, and dispensing, of all drugs and biologicals for a census of 85 when:1. A bag for IV (intravenous, into the vein) infusion containing 0.9% normal saline (electrolyte supplement in water) and a vial of ertapenem (antibiotic for infection) one gram (a unit of measurement) connected to the bag had a label indicating DO NOT USE AFTER 12/15/25 was stored in the Med (medication) Room Unit 1 together with other active medications and available for use; and,2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety when:1. A microwave was placed in the kitchen,2. A bun toaster was dirty with black residue,3. The kitchen walls were chipped and had cracking paint,4. Multiple pots, pan, and other cooking items were flaky and had black residue buildup,5. The stove top and drip pan were dirty and had grease buildup,6. The walk-in refrigerator and freezer had ice buildup; and,7. Vents and fans were dirty in the food prep area. These failures had the potential of leading to food borne illness (an illness that comes from eating contaminated food) for the 81 residents eating facility prepared meals.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide and maintain a safe, clean, comfortable, and homelike environment for a census of 85, when:1. Resident 19's overbed headlight remained continuously on because the pull string was broken; and,2. Resident 40, and Resident 7 had chipped walls and cracked paint behind their bed frames. These deficient practices demonstrated a lack of effective systems to identify, report, and correct environmental concerns resulting in Resident 19, Resident 40, and Resident 7 not feeling supported, treated with dignity and comfort, or provided a home-like living environment.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the Preadmission Screening and Resident Review (PASARR- a service to ensure that individuals with mental illness are able to receive specialized services) Level II screening was completed for 1 of 24 sampled residents (Resident 6). This failure had the potential for Resident 6 not to receive adequate services to prevent mental health decline.

Inspectors wroteBased on interview, and record review, the facility failed to develop or revise a comprehensive care plan for 1 of 24 sampled residents (Resident 34) when a care plan (guide that healthcare workers use to ensure a resident receives the best possible care tailored to their individual needs and goals) was not developed for pain. This failure placed Resident 34's physical and emotional well being at risk.

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents received appropriate medical evaluation and treatment for a reported vision concern for 1 out of 24 sampled residents (Resident 65) when Resident 65 was not seen or examined by an ophthalmologist (a medical doctor who specializes in diagnosing and treating all eye diseases). This failure placed Resident 65 at risk for continued visual impairment, functional decline, and psychosocial distress.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 76) was provided with appropriate care and services with enteral feeding (also referred to as G-Tube feeding, gastrostomy tube feeding, the delivery of food and nutrients through a feeding tube directly into the stomach or part of the intestines) when Resident 76's enteral feeding orders were not carried out as recommended by the Registered Dietitian (RD). This failure had the potential for Resident 76 not to receive adequate enteral nutrition and hydration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a comprehensive and effective pain management for one of three sampled residents (Resident 97) when pain management interventions were not implemented when indicated. This failure had the potential for Resident 97 to experience ongoing discomfort and pain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe medication administration practices when the medication error rate was more than 5% (% or percentage-number or ratio that expressed as a fraction of 100) with a resident census of 85. Medication administration observations were conducted over multiple days, at varied times, in random locations throughout the facility. The facility had a total of 2 errors out of 26 opportunities which resulted in a facility wide medication error rate of 7.69% in 1 of 9 residents (Resident 6) observed for medication administration. These failures had the potential to result in unsafe medication use and medication errors affecting the health and well-being of Resident 6.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free of any significant medication errors (the observed or identified preparation or administration of medications or biologicals which are not in accordance with the prescriber's order, manufacturer's specifications, and accepted professional standards) for one of nine sampled residents (Resident 6) observed for medication administration by failing to follow the manufacturer's specific recommendation when an extended release (ER-means the drug is specially formulated to release the active ingredient slowly and steadily into the body over a prolonged period, typically 8 to 24 hours) medication was crushed and administered to Resident 6. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 of 24 sampled residents (Resident 3) received recommended dental services; when Resident 3 was not scheduled for dental care to adjust loose upper partials when it was identified on 9/5/25. This finding resulted in Resident 3 to have missing partials and had the potential to result in problems chewing food, weight loss, and decreased self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain acceptable parameters of nutrition for one of three sample residents (Resident 1) when Resident 1's 21-pound weight loss in a 10-day period was not recognized, addressed, or reported to the physician in a timely manner. This failure had the potential to lead to malnutrition, nutrient deficiencies, loss of muscle mass, and increased muscle weakness for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure the psychosocial well-being for one of three sampled residents (Resident 1), when the Social Services Department failed to process a referral for a psychiatric evaluation for Resident 1 in a timely manner. This failure had the potential to worsen Resident 1's feelings of sadness, loneliness, and depression.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents (Resident 2) was free from unnecessary medication when, Resident 2 was prescribed an as needed lorazepam (anti-anxiety) medication that did not have the required 14-day stop date or a note from the doctor explaining why the lorazepam did not need a stop date. This failure had the potential for Resident 2 to not be properly evaluated for the continued need of lorazepam and could result in continued use of an unnecessary medication and possible harmful side effects.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled resident's (Resident 1) Preadmission Screening and Resident Review (PASRR: required screening done before admission to identify mental illness, intellectual disability, or related conditions and ensure proper placement and services) was completed accurately when, Resident 1's diagnosis of intellectual disability (a condition that involves limitations on intelligence, learning and everyday abilities necessary to live independently) and related condition of cerebral palsy (a person's brain is injured or did not develop normally before, during, or shortly after birth) were not marked on Resident 1's PASRR. This failure had the potential for Resident 1 not being evaluated and able to receive the care and services appropriate for the resident's needs.

Inspectors wroteBased on interview and record review, the facility failed to provide the needed behavioral health care and services (treatments that support a person's mental and emotional well-being) for one of three sampled residents (Resident 1), when Resident 1's psychotherapy (talking treatment that helps a person manage emotions, behaviors and stress) sessions scheduled two times per week were missed on two occasions, and the facility failed to ensure timely follow-up or alternative interventions. This failure put Resident 1 at risk for worsening mental health symptoms, social withdrawal, and decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure a reasonable accommodation of needs were honored for one of four sampled residents (Resident 2) when the facility did not have a mechanical lift sling (soft fabric padded sling that wraps around the body and attaches to a mechanical lift to assist in a transfer from one location to another) available to transfer Resident 2 out of bed. This failure caused Resident 2 to not attend the activities of her choice and had the potential to negatively impact Resident 2's quality of life and psychosocial well-being. A review of Resident 2's admission RECORD, indicated, she was admitted to the facility in mid 2022. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an allegation of abuse was reported to the Department timely for one of three sampled residents (Resident 1) when Resident 1 alleged certified nursing assistant (CNA) 3 forcefully grabbed her legs on 8/2/25 but the incident was not reported to the Department until 8/7/25. This failure resulted in a delay in the abuse investigation process and decreased the facility's potential to protect Resident 1 and other residents in the facility from physical and psychosocial harm. A review of Resident 1's admission RECORD, indicated, she was admitted to the facility in late 2024 with diagnoses which included bipolar disorder (a mental health condition that causes changes in a person mood, energy, and ability to function). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure appropriate notification was provided for one of four sampled residents (Resident 1) when, Resident 1's responsible party (RP, health care decision maker) was not informed of Resident 1's allegation of abuse. This failure had the potential to affect the ability of the RP to be informed of and participate in Resident 1's plan of care.

Inspectors wroteBased on interview and record review, the facility failed to ensure care plan interventions were implemented for two out of three sampled residents (Resident 1 and Resident 2) when, Resident 1 and Resident 2's care plan intervention of alert charting (documentation of assessments completed after an incident occurs to monitor for negative affects to health or well-being) was not completed for Resident 1 after an allegation of abuse was made and for Resident 2 after a verbal altercation occurred. This failure had the potential for Resident 1 and Resident 2 to have unassessed care needs that could negatively impact their health and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe and comfortable homelike environment for two of seven sampled residents (Resident 6 and Resident 7) when:1. Resident 6 and Resident 7 requested their room doors be kept closed due to the disruptive behavior of another resident (Resident 3) in the hallway outside of their rooms; and2. Resident 7 did not stay in the activities room for activities due to another Resident (Resident 3) yelling and cussing at everyone. These failures removed Resident 6 and Resident 7's right to a dignified homelike environment, with the potential to result in a negative psychosocial outcome.

Inspectors wroteBased on interview and record review, the facility failed to provide a safe environment and adequate supervision for one of seven sampled residents (Resident 1) when Resident 1 fell from her wheelchair in the facility's smoking area, unsupervised, at 12:25 a.m. on 12/11/25. This failure resulted in a broken nasal bone (broken nose), a nosebleed, and subarachnoid hemorrhage (bleeding in the area between the brain and the thin tissues that cover and protect it) for Resident 1.

Inspectors wroteBased on interview and record review the facility failed to protect the rights of one of three residents (Resident 1) when Resident 1 was not provided routine showers. This failure caused Resident 1 to feel upset with not having his care needs met and had the potential to negatively impact his psychosocial well -being.

Inspectors wroteBased on observation and interview the facility failed to maintain a safe, clean, comfortable, sanitary and homelike environment for the two unsampled residents (Resident 4 and Resident 5) who shared a bathroom, when their toilet seat was contaminated with residue from a bowel movement (BM). This failure created an unsanitary environment and placed the residents at risk of injury and/or infection. Findings. During an observation on 4/25/25, at 10:24 AM, in the bathroom between Resident 4 and Resident 5 ' s rooms, a clump of brown bowel movement was observed smeared on the toilet seat. During an observation on 4/25/25, at 11:05 AM, housekeeper (HSK) 1 was observed mopping the floor of Resident 4 ' s room. [...]

Inspectors wroteBased on observation and interview the facility failed to provide a safe and hazard free environment for one of three sampled residents (Resident 2) when wheelchairs, a recliner, and an overbed table were stored in Resident 2 ' s bedroom. These failures had the potential to obstruct Resident 2 ' s access to his room, personal belongings, and created a potential risk of fall or injury to Resident 2.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection prevention and control practices for a census of 91 residents when: Urinals (a urine collection container), wash basins, kidney basins (used for tooth brushing), personal grooming items, and bedpans (a container to collect stool and/or urine for a person while in bed), were not labeled and stored in a sanitary manner. This failure increased the risk of infectious diseases to spread for residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure treatment was provided to meet the needs of one of five residents (Resident 1), receiving wound care when: 1. Resident 1 was to be evaluated by a podiatrist (specializes in foot disorders) and interventional radiology (studies and treats disease) within 1-2 weeks following his discharge from the hospital to the facility, and the facility did not arrange for this; 2. The facility did not consult with the physician regarding removal of Resident 1's right foot surgical sutures, which were in place from his admission on [DATE] to discharge on [DATE]; and, 3. The facility did not follow up on a recommendation Resident 1 required an evaluation for further surgery, and Resident 1 was discharged without this communicated. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain standards of infection prevention and control for 9 out of 89 residents residing in the facility when the Certified Nursing Assistant (CNA) assigned to their care wore a loosened gauze dressing on her right hand. This failure had the potential to spread infection to the nine residents in her care and those residents who were not assigned to her but were assisted by the CNA .

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure respiratory care was provided in accordance with professional standards of practice for three of eleven sampled residents (Resident 53, Resident 90, and Resident 30) receiving oxygen therapy when: 1. Resident 53 received oxygen therapy without a physician's order, 2. Resident 53 and Resident 90 did not have a care plan developed for oxygen use; and, 3. Resident 30's nasal cannula (NC- flexible tubing that sits inside the nostrils and delivers oxygen) was labeled with a date which was expired and Resident 30's oxygen humidifier bottle (a plastic bottle filled with water which moistens the oxygen) was not labeled with a date of when it was changed. These failures had the potential to result in negative health impacts for the residents. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe medication storage practices in two out of four medication carts and two out of two medication storage rooms when: 1. Expired, unlabeled, and undated prescription medications were stored in the active storage areas of medication cart 2, 2. Undated prescription medications were stored in the active storage areas of medication cart 4, 3. Undated and discontinued prescription medications were stored in the active storage areas of the two medication storage rooms; and, 4. Containers of over the counter (OTC) liquid medications with dry, crusty debris around their rims and sides were stored in the active storage areas of medication carts 2 and 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe food production in accordance with professional standards for food safety for the 91 residents who received facility prepared meals when: 1. Opened food packages and/or containers were not labeled with an open date, 2. Spoiled and expired food products were not removed, 3. Kitchen equipment and food contact surfaces were not cleaned; and, 4. A partially consumed bottle of drinking water was found on a shelf with food items in the dry food storage area. These failures had the potential to put residents eating facility prepared meals at risk for foodborne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 of 29 sampled residents (Resident 1) was provided with alternate methods of communication and entertainment when Resident 1's physical limitations prevented the use of a cell phone or tablet device. This failure had the potential to negatively impact Resident 1's psychosocial well-being.

Inspectors wroteBased on observation and interview, the facility failed to accommodate the needs of 1 of 29 sampled residents (Resident 1) when Resident 1's call light (device used to contact staff for assistance) was not within her reach. This failure placed Resident 1 at risk of falls and unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's right to be free from physical abuse for 1 of 29 sampled residents (Resident 33) when Resident 33 was assaulted by Resident 20 and witnessed by Certified Nurse Assistant (CNA) 7 on 8/3/24. This failure had the potential to cause physical injury, and could negatively affect Resident 33's psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 of 29 sampled residents (Resident 19) was free of restraints (any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move or access any part of his/her body) when; Resident 19 was observed trying to get up from his Geri chair (geriatric wheelchair, a comfortable, fully reclining chair with wheels) which was reclined with the chair footrest placed in an elevated position, and Resident 19 could not freely get out of the chair. This failure resulted in Resident 19 not being able to move freely and had the potential to affect Resident 19's dignity, and to cause an avoidable injury to him.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a resident specific care plan (provides direction on the type of nursing care the resident may need based on their health, medication, behavioral, and psychosocial needs) for 3 of 29 sampled residents when: 1. Resident 32 did not have a care plan developed for the dialysis (procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) services she was receiving, 2. Resident 197 did not have a care plan developed for splint care to the left arm; and, 3. Resident 46 did not have a care plan developed after an altercation involving Resident 23 (unsampled). These failures had the potential for care needs not being met for Resident 32, Resident 46, and Resident 197. [...]

Inspectors wroteBased on interview, and record review, the facility failed to update or revise the comprehensive care plan for 2 of 29 sampled residents (Resident 83 and Resident 71) when: 1. Resident 83 had a documented change in condition related to a skin wound or ulcer (an open sore caused by a break in the skin); and, 2. Resident 71's smoking care plan was not updated. This failure had the potential to result in Resident 83 and Resident 71 not receiving adequate and appropriate care and services necessary to reach their highest practical physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow a physician's order for 1 of 29 sampled residents (Resident 197) when Resident 197's orthopedic referral was not carried out in a timely manner. This failure placed Resident 197 at risk to not receive immediate and appropriate treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure vision care was provided to 1 of 29 sampled residents (Resident 46) when, Resident 46 complained of worsening eyesight and requested to be seen by an ophthalmologist (physician who specializes in eye and vision care), and the facility did not assist her in obtaining vision appointments. This failure had the potential for Resident 46 to develop worsening eyesight and had the potential to negatively impact her activities of daily living and quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 of 29 sampled residents, (Resident 83) received consistent treatment to promote the healing and prevention of pressure ulcers (localized damage to the skin and/or underlying tissue, as a result of pressure or pressure in combination with friction) when Resident 83's physician order for heel protectors (devices that help reduce the risk of pressure damage to the heels of patients by completely offloading the heel) was not followed. This deficient practice placed Resident 83 at risk for worsening his current pressure ulcer and increased the chance for the development of new pressure ulcers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the provision of care and services to assure 1 of 29 sampled residents (Resident 74) maintained his highest level of range of motion (ROM, the full movement potential of a joint) when: 1. Resident 74's order for Restorative Nurse Assistant (RNA) services (care to improve or maintain the functional mobility of residents) was not implemented; and, 2. Resident 74 did not have a care plan developed for his arm and hand contractures (shortening or hardening of muscles, tendons or other tissue leading to deformity and rigidity of joints). These failures placed Resident 74 at risk of a decline in ROM and worsening contractures.

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure 1 of 29 residents (Resident 12) had appropriate fall precaution measures in place when, Residents 12's bedside table was not in reach and two fall mats (used to cushion a fall) were not in place next to Resident 12's bed and were not included in Resident 12's care plan. This failure had the potential for Resident 12 to be injured during a fall.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain a physician's order for an indwelling foley catheter (a flexible, sterile tube inserted externally into the bladder to drain urine in a collection bag outside of the body) for one of three sampled residents (Resident 1) with an indwelling foley catheter. This failure placed Resident 1 at risk of a catheter- associated urinary tract infection (CAUTI- infection caused when germs enter the body through a urinary catheter), skin breakdown, and discomfort.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 297) who received intravenous (IV) therapy (infusion of liquid medication directly into the vein) was provided services consistent with professional standards of practice when Resident 297's IV tubing (thin flexible plastic tubing that connects the IV infusion bag to the residents IV access site) was lying on the floor during administration of the medication and Resident 297's IV infusion bag was not labeled with the date, time, and initials of the staff who administered the medication. These failures had the potential to adversely affect Resident 297's health and safety, including an increased risk of developing a new or worsening infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to practice appropriate infection prevention and control measures for a census of 93, when 1 of 29 sampled resident's (Resident 90) urinal was unlabeled. This failure had the potential for spread of infection if Resident 90's urinal was used by another resident. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a safe environment for one of three sampled residents (Resident 2), when a blanket was caught in the wheel of a chair used to transport Resident 2 from the shower, causing the chair to stop abruptly and tip forward. This failure resulted in Resident 2's fall on 7/25/24, with a fracture to her left medial malleolus (bony bump on the inner side of the ankle) and left fibula (leg bone between the knee and ankle), increased pain, and decreased mobility, with the potential for skin breakdown and other negative health outcomes.

Inspectors wroteBased on interview and record review, the facility failed to ensure professional standards of practice were followed for one of seven sampled residents (Resident 1) when Resident 1 did not receive his medication as prescribed, and the physician was not informed the medication was unavailable for administration. This failure may have contributed to Resident 1 ' s increased seizure activity and hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) was evaluated promptly for injury following an incident of alleged abuse by Resident 2. This failure placed the victim, Resident 1, at risk for physical injury and/or psychosocial harm to not be identified and treated timely and appropriately by facility staff.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure: 1. A full-time, qualified Certified Dietary Manager (CDM) or Registered Dietician (RD) was employed to oversee the daily operations of the kitchen and food preparation for 82 residents who received food from the kitchen. 2. One of 28 Residents sampled (Resident 50) received nutritional assessments on admission and quarterly from the RD. These failures had the potential to effect food safety and sanitation for the 82 residents receiving facility prepared food and placed Resident 50 at risk of impaired nutritional status which could further compromise her medical status.

Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety for a total of 82 residents who received facility prepared foods when: 1. The ice machine contained a yellow substance around the ice chute area (where prepared ice comes out and lands in an ice storage bin), a pink substance was found on the lip of the ice bin (held prepared ice), specks of a black and pink substance were found inside the upper portion of the ice machine (contained the mechanical working parts), the ice machine filter was covered with a thick layer of a gray colored debris, and the ice machine was not cleaned correctly and at regular intervals (last cleaned 3/20/23); 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident's rights to be treated with dignity were honored for three of twenty-eight sampled residents (Resident 36, Resident 57, and Resident 186) when: 1. Certified Nursing Assistant (CNA) 3 did not provide professional care to Resident 36, Resident 57, and Resident 186, 2. CNA 3 limited their availability to provide care to Resident 57; and, 3. Staff was unaware that Resident 39 preferred only female staff to care for her. These failures had the potential to negatively impact the residents' psychosocial well-being and physical health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a comprehensive person-centered care plan (tool that outlines the plan of action that will be implemented during a patients' care) for six of twenty-eight sampled residents (Resident 25, Resident 28, Resident 32, Resident 39, Resident 43, and Resident 33) when: 1a. Multiple pressure injuries (PI-injuries to skin and underlying tissue resulting from prolonged pressure on the skin) that were identified did not have their own separate or dedicated care plan developed for Resident 25, 1b. An activities of daily living (ADL-refer to people's daily self-care activities) care plan was not developed for Resident 28, 2a. An anticoagulant (medication to prevent blood clots) care plan was not developed for Resident 32 to address monitoring side-effects of the medication, 2b. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respiratory care provided was consistent with professional standards of practice for three of twenty-eight sampled residents (Resident 32, Resident 43, and Resident 288) when: 1. Oxygen therapy was provided without a physician order for Resident 43; and, 2. The oxygen flow rate was not followed per physician order for Resident 32 and Resident 288. These failures placed Resident 32, Resident 43, and Resident 288 at risk for respiratory distress and inadequate treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe medication storage practices for a census of 85 when: 1. One of two treatment carts was left unlocked, 2. Staff's personal belongings were stored in two of two medication storage rooms, 3. Opened and unlabeled multi-dose medication vials were stored in one of two medication rooms, 4. Opened and unlabeled medications were stored in two of four medication carts; and, 5. An expired ointment medication was stored in one of two treatment carts. These failures had the potential to contribute to medication error, unsafe medication use, and storage.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure reasonable accommodation of needs were honored for two of twenty-eight sampled residents (Resident 16 and Resident 33) when: 1. Resident 16 was not provided with an appropriate call light device per resident need; and 2. Resident 16 and Resident 33's call lights were not within reach. These failures had the potential for Resident 16's and Resident 33's needs to go unmet with the potential to cause physical and/or psychosocial harm.

Inspectors wroteBased on interview and record review, the facility failed to accurately code the Minimum Data Set (MDS- a resident assessment tool used to guide care) for one of twenty-eight sampled residents (Resident 5) when, Resident 5's MDS Section I for Active Diagnoses dated 6/15/23 was marked with schizophrenia (a serious mental illness that affects how a person thinks, feels, behaves, and relates to others) but did not have a schizophrenia diagnosis on admission. This failure had the potential for Resident 5 to receive inappropriate care due to an inaccurate diagnosis.

Inspectors wroteBased on interview and record review, the facility failed to develop all of the identified components of a baseline care plan, within 48 hours of admission as required, to address resident-specific care needs for two of twenty-eight sampled residents (Resident 288 and Resident 50) when; 1. Resident 288's oxygen use care plan was not created; and 2. Resident 50's tube feeding (used to provide nutrition to people who cannot obtain nutrition by mouth) and psychiatric behavior care plans were not created. This failure had the potential to results in unmet oxygen use needs for Resident 288 and unmet psychiatric behavior monitoring and tube feeding needs for Resident 50.

Inspectors wroteBased on interview and record review, the facility failed to provide ongoing activities based on resident needs and preferences for one of twenty-eight sampled residents' (Resident 16) when, Resident 16 was not provided with in room activities at least three times a week. This failure had the potential to effect Resident 16's psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 16) with limited range of motion (ROM) received care and services to maintain or improve mobility when; 1. Resident 16 was not provided with all ordered ROM services; and 2. ROM services were not documented as completed over a three-week period for Resident 16. These failures removed the opportunity to potentially improve ROM and had the potential to result in a decline of ROM for Resident 16.

Inspectors wroteBased on interview and record review, the facility failed to assess the nutritional status for one of twenty-eight sampled residents (Resident 50), when Resident 50's nutritional assessment was not completed by the registered dietitian (RD). This failure had the potential for Resident 50 to lose weight, become dehydrated, or develop skin breakdown which could result in a decline of health status for Resident 50. A review of Resident 50's admission RECORD, indicated, she was admitted to the facility in early 2023 with diagnoses which included, dysphagia (difficulty swallowing), cerebral infarction (stroke-damage to the brain from interruption of its blood supply). [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure direct care staffing information was posted in a prominent place as required for a census of 85. This failure prevented the residents and visitors to view the hours and number of direct care staff providing care to the residents of the facility on a daily basis.

Inspectors wroteBased on interview and record review, the facility failed to provide appropriate social services support following a grievance made about treatment for one of twenty-eight sampled residents (Resident 57) when, there was no social services follow-up provided for Resident 57 after Resident 57 reported a concern with treatment provided by a staff person. This failure had the potential for Resident 57 to not achieve the highest practicable mental and psychosocial well-being.

Inspectors wroteBased on interview, and record review, the facility failed to ensure monitoring for a high-risk blood thinning medication (A medication used to prevent blood clots with potential side effects of abnormal bleeding) was completed daily for 1 of 19 residents (Resident 32) who received blood thinning medication. This failure had the potential to result in undetected adverse effects that could occur when blood thinning medications were administered.

Inspectors wroteBased on interview and record review the facility failed to ensure one of four sampled residents (Resident 50) antipsychotic (medication used to treat mental distress) medication regimen was safely managed when the facility failed to monitor Resident 50 for behaviors related to her schizophrenia (a disorder that affects a person's ability to think, feel and behave clearly) diagnosis. This failure had the potential for Resident 50 to receive unnecessary antipsychotic medications with potential side effects.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that dietary assistant (DA) 1 had the appropriate competencies and skills to carry out the duties of the kitchen when DA 1 incorrectly monitored the water temperature of the dishwasher and did not follow the instructions on the dishwashing temperature log. This failure had the potential to spread food born illness to the 82 residents who received meals from the kitchen.

Inspectors wroteBased on interview, and record review, the facility failed to maintain complete and accurate medical records for two of twenty- eight sampled residents (Resident 10 and Resident 39) when the hospice (specialized end-of-life care for all residents with an advanced, life-limiting illness) agency's nurse progress notes were not contained in the clinical record. This failure had the potential to not provide sufficient information that reflected the condition, care and services provided for Resident 10 and Resident 39.