Royal Gardens Healthcare

Inspectors wroteBased on interview and record review, the facility failed to provide treatment and care in accordance with the professional standards of practice for two (2) of 2 sampled residents (Resident 4 and 7) by failing to:Continue and provide wound care treatment per physician (MD) orders for Resident 4. Ensure Resident 7 was seen by a pain specialist (a doctor who has specialized fellowship training in evaluating, diagnosing, and treating acute, chronic, or cancer-related pain) from 1/16/2026 to 4/16/2026 in accordance with the MD order. Thess failures resulted in Resident 4 not receiving wound care treatment for the resident's cervical spine (the uppermost segment of the spinal column) wound for 10 days (2/8/2026 to 2/16/2026 and 2/18/2026) and had the potential to result in Resident 4's cervical spine wound worsening in condition. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their infection control policy and procedure for two (2) of three (3) sampled residents (Residents 1 and 3) by:1. Not ensuring Registered Nurse 1 (RN 1) changed gloves and performed hand hygiene (washing hands with either an alcohol based hand sanitizer or washing hands) when going from dirty to clean task during wound care treatment for Resident 3 and did not perform hand hygiene after doffing (taking off) personal protective equipment (PPE; clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) after leaving the Resident 3's room.2. Failing to disinfect blood pressure cuff (a medical device, consisting of an inflatable rubber bladder within a sleeve, used to measure blood pressure) before using it on Resident 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to accommodate the needs of one (1) of one sampled resident's by failing to ensure the call light (patient-safety device, often a button on a cord, used in hospitals and nursing homes to enable patients to alert staff for assistance, thereby preventing falls and ensuring care) was within reach (arm's length or less than) of Resident 6 on 4/15/2026. This deficient practice has the potential to delay in the necessary care and services and/or needs not being met for Resident 6.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop an individualized resident-centered are plan (a care plan that prioritizes the unique health needs and desired outcomes of the resident) with measurable objectives, timeframe, and interventions for one of two sample residents (Resident 8) to address the Resident 8's behavior of getting out of bed unassisted. This deficient practice has the potential to delay in the necessary care and services for Resident 8, which can potentially result in further falls, injury and harm.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pharmaceutical services to meet the needs of two (2) of two sampled residents (Resident 1 and 2) by failing to ensure:a. Resident 1's wrist band (a secure identification bracelet worn by residents to link them to their medical records and alert staff to specific care needs, risks, or safety protocols) was checked prior to medication administration. b. Resident 1's medication Eliquis (blood thinner) was refilled and available. c. Registered Nurse (RN) 2 explained the seven (7) medications that were administered to Resident 1. 2. Director of Staff Development (DSD) accurately reconciled Resident 2's psychotropic (a mind-altering substance that affects mood, thoughts, feelings, perception, or behavior) medication upon admission to the facility. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of three sampled residents (Resident 2) were free from physical abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish), when Resident 1 allegedly pushed a laundry cart to Resident 2. This deficient practice had the potential to negatively affect Resident 2's comfort and psychosocial (having to do with the mental, emotional, social, and spiritual effects of a disease) well-being which can lead to hospitalization and/or death.

Inspectors wroteBased on interview and record review, the facility failed to provide necessary care and treatment for one (1) of two (2) sampled residents (Resident 1) with urostomy (a surgical procedure creating a permanent opening on the abdomen to divert urine out of the body), in accordance with the facility's urostomy and self-catheterization policy by failing to:Obtain physician order for self-catheterization (a safe, routine procedure used four to six times daily to drain urine from the bladder using a flexible tube). Assess and monitor Resident 1's capability to perform self-catheterization. Maintain a daily record of Resident 1's daily fluid intake and output per Facility's Policy and Procedures (P&P). Inspect the condition of the skin around the stoma for any irritation or breakdown. Document Resident 1's time and frequency of catheterization. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe, clean, comfortable sanitary and home-like environment for four (4) of 4 sampled residents (Resident 4,6,19 and 35) reviewed for environment, by failing to ensure:The air vent (openings in buildings for air passage, essential for ventilation, air circulation, and maintaining indoor air quality) including the surrounding frame located on top of Resident 4's head of the bed does not have dust build up. The bedside table of Resident 6 was not chipped off exposing the interior wood. The bed control for Residents 6 and 19 does not have crack and rough edges. The overhead light of Resident 19 was not cracked. The television (TV) of Resident 35 was functioning. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure five (5) of five sampled residents (Resident 2, 6, 35, 10, and 31) reviewed for pressure ulcer (PU- injury to skin and underlying tissue resulting from prolonged pressure on the skin) were provided necessary treatment and services to prevent formation of PU and/ or promote healing of PU in accordance with the facility's policy and procedure and physician's order by failing to: Ensure Resident 2's low air loss mattress (LALM-are designed to distribute the patient's body weight over a broad surface area and help prevent skin breakdown) was set according to the resident's weight. On 1/21/2026, Resident 2 was observed with the LALM set at 350 pounds (lbs.- unit of measurement). Ensure Resident 6's LALM was set according to the resident's weight. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure appropriate competencies and skills sets to provide nursing and related services were completed for five (5) of 5 sampled employees in accordance with facility's policy and procedures (P&P). This deficient practice has high potential to cause an increased risk for improper resident assessments, inadequate documentation, and could negatively impact the quality of care to the residents which could lead to hospitalization or death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet the needs of two (2) of six (6) sampled residents (Resident 10 and 17) observed for medication administration as indicated on the facility policy and physician's order when:Resident 17's medications were not administered within 60 minutes of scheduled time of 9 AM on 1/22/2026. Resident 10's medications were not administered within 60 minutes of scheduled time of 9 AM on 1/22/2026. This deficient practice had the potential to prevent Residents 10 and 17 from obtaining the therapeutic level of their medications (a range in the blood that is medically effective but not dangerous), which could lead to complications and negatively impacting the residents' overall well-beingCross reference: F759Findings:1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor the use of insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) and anticoagulant therapy (a medical treatment using drugs called blood thinners to prevent or treat dangerous blood clots [thrombi] by slowing the blood's clotting process, stopping existing clots from growing, and preventing new ones from forming) for two (2) of 15 sampled residents (Residents 1, and 32) as indicated on the residents' care plan by failing to monitor: 1. Resident 1 for signs and symptoms of hypoglycemia (an abnormally low level of sugar [glucose] in the blood) and hyperglycemia (a condition where the blood glucose [sugar] levels are abnormally high), while on Insulin Lispro (Humalog, a fast-acting insulin) from 12/21/2025 to 1/23/2026. 2. a. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure its medication error rate was less than five (5) percent (%). 13 medication errors (the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order/ manufacturer's specifications / accepted professional standards and principles out of 35 total opportunities (observed administered medications) for error, to yield an overall medication error rate of 37.14 % for two (2) of six (6) sampled residents (Resident 10 and Resident 17) observed for medication administration. Licensed Vocational Nurse 2 (LVN 2) failed to administer Resident 17's medications, and Registered Nurse Supervisor 4 (RNS4) failed to administer Resident 10's medication within 60 minutes of the scheduled time of 9 AM on 1/22/2026. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper food handling and maintain the food service area in a clean and sanitary manner in accordance with the facility's policies and procedures (P&P) when: The can opener was chipped and soiled with food residue. The blender was chipped and inside the jar showed white to yellowish discoloration around the blade. The onion powder container lid was partially closed and did not have a label to indicate open and discard date. The stand mixer (used for mixing, whisking, and kneading ingredients) had peeling and chipped paint, with exposed metal on the adjustment handle. The coffee maker's spout (the part where the coffee flows out into the pot or cup) was cracked. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the call light device (one of the major communication technologies that link nursing home staff to the needs of residents) was within reach (an arm's length) of one (1) of 15 sampled residents (Resident 4). This failure had the potential to cause a delay in care for Resident 4 and prevent the resident from receiving the necessary care and services, which could lead to illness or serious injury.

Inspectors wroteBased on interview and record review, the facility failed to follow the process of investigation and report of grievance (a complaint, either oral or written, expressing dissatisfaction with service delivery or the quality of care furnished, regardless of whether remedial action is requested) for one (1) of 15 sampled residents (Resident 8) as indicated in the facility's policy and procedure by failing to document steps taken during the investigation of grievance, summarize pertinent findings or conclusion and document the date the grievance investigation result (decision) was confirmed This deficient practice had the potential to result in miscommunication and inaccurate information of the investigations which did not meet the documentation requirements for Resident 8's grievance.

Inspectors wroteBased on interview and record review, the facility failed to implement the facility's abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish) policy regarding investigating an allegation of verbal abuse (the use of oral, written, or gestured communication, or sounds, to residents within hearing distance, regardless of age, ability to comprehend, or disability) for one (1) of two (2) sampled residents (Resident 8) reviewed for abuse. This deficient practice had the potential to compromise or impede the protection of Resident 8, which could affect resident's emotional and mental wellbeing. Cross reference with F610.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of verbal abuse (the use of oral, written, or gestured communication, or sounds, to residents within hearing distance, regardless of age, ability to comprehend, or disability) for one (1) of two sampled residents (Resident 8) reviewed for abuse, within 2-hour timeframe to the State Survey Agency (SA, where state law provides for jurisdiction in long-term care facilities), the state ombudsman (advocates for residents of nursing homes, board and care homes and assisted living facilities), and local law enforcement. This deficient practice had the potential to compromise or impede the protection of Resident 8, which could affect resident's emotional and mental wellbeing.

Inspectors wroteBased on interview and record review, the facility failed to provide evidence that the alleged abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) was thoroughly investigated for one (1) of two (2) sampled residents (Resident 8) reviewed for abuse, as indicated in the facility's policy and procedure. This deficient practice had the potential to compromise or impede the protection of Resident 8, which could affect resident's emotional and mental wellbeing. Cross Reference with F607.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement a comprehensive resident-centered care plan (care plan, a formal process that correctly identifies existing needs and recognizes a resident's potential needs or risks to achieve healthcare outcomes) for one of 15 sampled residents (Resident 10) by failing to set Resident 10's Low Air Loss mattress (LAL mattress, designed to prevent and treat pressure injury/ ulcer [localized damage to the skin and underlying soft tissue caused by prolonged pressure]) according to the resident's weight. This deficient practice had the potential for Resident 10's skin to break down and develop skin impairment such as redness and pressure ulcer.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide grooming services for one (1) of 1 sampled residents (Resident 4) reviewed for activities of daily living (ADL, activities related to personal care that include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating), in accordance with the facility's policy and procedure (P&P) titled, Care of Fingernails/Toenails This deficient practice resulted in Resident 4's having unkempt and dirty fingernails, which could potentially lead to skin injury and infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide activities to support resident's choice of activity for one of two sampled residents (Resident 10) reviewed for activities as indicated on the care plan. This deficient practice had the potential to negatively impact Resident 10's physical, cognitive, emotional health, and sense of belonging.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate treatments and services to increase, prevent, or maintain range of motion (ROM, full movement potential of a joint) for one (1) of 15 sampled residents (Resident10) as indicated on the facility's Assistive Devices and Equipment policy. This deficient practice placed Resident 10 at risk for developing contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints), which could result in pain and discomfort, joint deformities, immobility, and skin breakdown.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and treatment for one (1) of two (2) sampled residents (Resident 8) reviewed for catheter (flexible tube inserted into the bladder to drain urine when a person cannot urinate naturally) by failing to monitor and empty the nephrostomy (a medical procedure in which a tube is inserted through the skin of the lower back into the kidney to drain urine when the normal flow is blocked) drainage tube in accordance with the physician's order, care plan, and the facility's Care of Nephrostomy Policy and Procedures (P&P). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one (1) of one sampled resident (Resident 17) reviewed for nutrition, who required adaptive feeding equipment (modified utensils, accessories, glasses, and plates to help improve residents' comfort and independence), was provided with built-up utensils (specialized utensils with a built-up handle designed to assist residents with limited or weakened grasping strength) during meals, as indicated in the physician's order. This deficient practice placed Resident 17 at risk for further decline in physical functioning and a decrease in self-feeding ability.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one (1) of two (2) dumpsters (a movable waste container) were closed and not overflowing, in accordance with the facility's Policy and Procedure (P&P) titled, Food Related Garbage and Refuse Disposal. This deficient practice had a potential to attract vermin (animals that are believed to be harmful, carry diseases such as rodents, parasitic worms, or insects), pests (any living thing that has a negative effect on humans), and wildlife (undomesticated animal species) which may cause disease and other health issues to residents residing in the facility, staff, and the community.

Inspectors wroteBased on interview and record review, the facility failed to maintain an accurate and complete record for two (2) of 15 sampled residents (Resident 8 and 17) as indicated in the facility's policy and procedure when.1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a minimum of 80 square feet (sq.ft. - unit of measurement) per resident in multiple resident bedrooms for 12 of 17 residents' rooms (Rooms 101,102, 104, 106, 109, 110, 111, 112, 114, 115, 116, and 117) in the facility. This deficient practice had the potential to affect the ability to provide care, safety, and a home-like environment for the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary care and services in accordance with the standards of practice for one of three sample residents (Resident 1) by failing to: Relay to Resident 1's physician and obtain an order regarding ST (Speech Therapist's- a professional who assesses, diagnoses, and treats swallowing disorders in people of all ages, helping them to have a safe eating through individualized therapy plans) recommendation to assist the resident during mealtime to enhance safe swallow. Relay to Resident 1's physician and obtain an order for ST evaluation after Resident 1 was observed and assessed to be able to feed himself without 1:1 assistance from the staff from 11/17/2025 to 12/19/2025. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain complete medical records for two (2) of 2 sampled residents (Residents 1 and 2) in accordance with the facility's policy. This deficient practice had the potential for Residents 1 and 2 not to receive the discharge information necessary for the residents' continuity of care in the community.

Inspectors wroteBased on interview and record review, the facility failed to ensure the discharge needs for one (1) of two (2) sampled residents (Resident 1) were identified by failing to ensure an oxygen concentrator (a medical device that concentrates environmental air and delivers it in the form of supplemental oxygen), portable oxygen, and nebulizer (a device for breathing mist treatment) were provided and ready for use upon resident's discharge to a Recuperative Care Center (a short-term residential care for residents who no longer require hospitalization but still need to heal from an injury or illness). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two (2) of 2 residents were seen by specialty doctor as indicated on the physician's order when the facility failed to:1. Follow up and obtain a prior authorization (process where healthcare providers must obtain advance approval from a patient's insurance company before providing certain medical services or medications), on a weekly basis, for Resident 1 to be seen by Vascular Surgery (treats diseases of the blood vessels, including arteries [blood vessels carrying oxygen rich blood away from the heart to the rest of the body], veins [blood vessels that carry blood from the body's tissues and organs back to the heart], and lymphatic vessels [network of thin tubes that collect excess fluid, called lymph, from body tissues and return to the blood stream [blood as it moves through the body's). 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to observe infection control measures for two (2) of 2 sampled residents (Resident 1 and 2) as indicated on the facility policy by failing to ensure:1. Certified Nursing Assistant (CNA) 1 performed hand hygiene (the practice of cleaning and disinfecting hands to remove harmful microorganisms) when exiting Resident 1 and 2's room. 2. Resident 1 had clinical or laboratory results for Carbapenem-Resistant Acinetobactor baumannii (CRAB - a bacterial infection caused by a drug-resistant strain of bacteria) when resident was readmitted to the facility on [DATE]. This deficient practice has the potential to spread infection to staff and other residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an accurate documentation of wound care treatment for two (2) of 2 sampled residents (Residents 1 and 2) on the residents Treatment Administration Record (TAR) in accordance with the facility's policy titled Charting and Documentation. This deficient practice resulted in the medical records inaccurate representation of care provided to Residents 1 and 2.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide special dietary need of one of two sampled residents (Resident 1) by failing to ensure Controlled Carbohydrate Diet (CCHO diet, a dietary approach designed to manage blood sugar levels) that is recommended by Registered Dietitian (RD, is a healthcare professional who specializes in food and nutrition) was communicated and order obtained from the resident's primary physician. This deficient practice placed Resident 1 at risk for developing high blood sugar that can lead to hospitalization and/ or death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe, clean, comfortable, and home like environment for six sampled residents (Residents 8, 194, 36, 18, 28, and 19) of 11 residents when facility failed to: 1. Maintain comfortable and safe temperature levels for Resident 8. 2. Maintain a working television for Resident 194. 3. Maintain a comfortable noise level for Resident 36. 4. Maintain a clean and sanitary environment by ensuring Resident 18's floor was not soiled and room did not smell like urine. 5. Maintain a clean and sanitary environment for Resident 28 by ensuring room did not smell like urine. 6. Ensure Resident 19's room did not have a chipping wall trim/molding. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement treatment for the prevention of pressure ulcer (painful wound caused as a result of pressure or friction) by failing to ensure that the low air loss mattress (LAL, mattress used for residents who are at risk for developing sores or already have pressure ulcer designed to circulate a constant flow of air for the management of pressure sores) was on the correct settings for three (3) of 3 sampled residents (Residents 30, 6, and 1), in accordance with the facility's policy and procedure (P&P) titled, Pressure Injury,. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe provision of pharmaceutical services as indicated in the facility policy by failing to ensure: 1. Medication storage freezer did not have an ice built up. 2. Medication storage room counters were free of dust. 3. Medications were stored under proper temperature control. This deficient practice had the potential for adverse reaction in the event that these medications, which were not stored under proper control temperature were administered to the residents and potential source of infection if cleanliness were not maintained.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure foods are handled, prepared, stored and distributed in a manner that prevents foodborne illness (infections or irritations of the gastrointestinal tract [a series of hollow organs joined in a long, twisting tube from the mouth to the anus] caused by food or beverages that contain harmful bacteria, parasites, viruses, or chemicals) by failing to ensure foods are labeled with date opened, use by date and/ or expiration date. These deficient practices had the potential to result in food contamination and/or foodborne illness for the residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure standard infection prevention control practices (a set of practices that prevent or stop the spread of infections and or diseases in the healthcare setting) were followed for four (4) out of fifteen sampled residents (Resident 8, 144, 44 and 22) in accordance with the facility's policy and procedure titled Infection Prevention and Control Program indicated an infection control prevention and control program (IPCP) when: 1. A urine-soaked diaper was seen sitting on top of paper towel dispenser in Room A 's communal bathroom. 2. [...]

Inspectors wroteBased on observation, interviews, and record reviews, the facility staff failed to ensure resident would not wait for 32 minutes to receive his meal tray while other residents in the same table were eating for one (1) of 15 sampled residents (Residents 25). This deficient practice violated the rights of the resident to be treated with dignity or respect.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light (device used by residents to call staff) was within reach for three (3) of 15 sampled residents (Resident 1, 6, and 5) in accordance with the facility policy and procedure. This failure had the potential for Residents 1, 6, and 5 to not be able to call for assistance, which could result in untimely delivery of care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a comprehensive person-centered care plan for one (1) of 15 sampled residents (Resident 22) for the use of antibiotic (medicines that fight bacterial infections) and anticoagulants (substance that is used to prevent and treat blood clots in blood vessels and the heart) per facility's Comprehensive Person-Centered Care Plan policy and procedure. This deficient practice had the potential for Resident 22 to not receive specific interventions to prevent decline in the resident's functional ability, not being monitored for resident's therapeutic treatment, and also may result in injury/harm and/or worsening of the resident's condition.

Inspectors wroteBased on interview, and record review, the facility failed to ensure one (1) of five (5) sampled residents (Resident 11) was free from unnecessary psychotropic drug (any medication capable of affecting the mind, emotions, and behavior) use as indicated in the facility's policy and procedure by failing to provide documented evidence that Resident 11's behavior was monitored for the use of: 1. Abilify (an antipsychotic medicine used to treat the symptoms of schizophrenia and bipolar disorder [a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration]) 2. Depakote (also used to treat acute manic or mixed episodes associated with bipolar disorder with or without psychotic features). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure its medication error rate was less than five (5) percent (%). There were 3 medication errors (the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order/manufacturer's specifications/accepted professional standards and principles) out of 29 opportunities (observed administered medications) for error which yielded a facility medication error rate of 10.34% for one (1) of 5 sampled residents (Resident 29) observed during medication administration (med pass): [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Daily Posted Nurse Staffing (Nurse Staffing Information) for 11/29/2024, 11/30/2024, and 12/1/2024 were posted in accordance with the facility's policy and procedure titled, Posting Direct Care Daily Staffing Numbers. This deficient practice had the potential for residents and visitors not to be accurately informed of the census and staffing for the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide the minimum of 80 square feet (sq.ft. - unit of measurement) per resident in multiple resident bedrooms for 12 of 17 residents' rooms (Rooms 101, 102, 104, 106, 109, 110, 111, 112, 114, 115, 116, and 117) in the facility. This deficient practice had the potential to affect the ability to provide a home like environment to the residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staffing information was posted and placed in a visible and prominent place on a daily basis. As a result, the total number of staff and the actual hours worked by the staff was not readily accessible to residents and visitors and had the potential to inaccurately reflect the actual nurses providing direct care to the residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure three of three sampled residents (Residents 1, 2 and 3) received consistent treatment to promote the healing and prevention of pressure ulcers (injury to skin and underlying tissue resulting from prolonged pressure on the skin) by failing provide treatments as ordered by physician. These deficient practices placed the Residents 1, 2 and 3 at risk of worsening of current pressure ulcers and increased chance for the development of new pressure ulcers.

Inspectors wroteBased on interview and record review, the facility failed to ensure Resident 1 was free from physical abuse (an act where one person uses their body to inflict intentional harm or injury upon another person) when struck by Resident 2 in the face. This failure resulted in preventable and unnecessary physical abuse with the potential for emotional and mental trauma for Resident 1.

Inspectors wroteBased on interview and record review, facility failed to revise the care plan (a document that outlines the facility's plan to provide personalized care to a resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs) for one of one resident (Resident 2), to include revised specific interventions for the care and safety of Resident 2 after a physical altercation with Resident 1. This failure had the potential for Resident 2 to receive care that is not revised to meet the changes in his condition and needs, which could result in decreased quality of care and safety for Resident 2 and other residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide rehabilitation (rehab, restoring function) services per physician's orders to two of three sampled residents (Resident 1 and 2) who required rehab services by failing to: 1. Ensure Resident 1's physician's orders for Occupational Therapy (OT, profession aimed to increase or maintain a person's capability of participating in everyday life activities) and Speech Therapy (ST, profession aimed to assess and provide treatment for disorders of communication, speech production, language, and swallowing) were carried out. 2. Ensure OT and Physical Therapy (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function) treatment sessions were provided five times a week per physician's orders for Resident 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to notify the physician of a change of condition for one of three sampled residents (Resident 1) when a resident did not have a bowel movement (evacuation of stool from the body) from 12/7/2023 to 12/11/2023 , as indicated in the facility policy. This deficient practice had the potential to result in the delay of needed care and services to address Resident 1's constipation (condition in which there is difficulty on emptying the bowels), which could result in fecal impaction (hard, dry stool stuck in the colon or rectum) and hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to complete the admission Minimum Data Set (MDS, a comprehensive standardized assessment and screening tool) within the regulatory time frame for one (1) of three (3) sampled residents (Resident 2) in accordance with the facility policy. This deficient practice had the potential to result in not developing a comprehensive resident centered care plan, which could negatively affect the provision of necessary care and services for Resident 2.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure two out of two sampled residents (Resident 24 and 36) were free from physical restraints (any manual method, physical or mechanical device, equipment, or material that is attached or adjacent to the resident's body; cannot be removed easily by the resident; and restricts the resident's freedom of movement or normal access to his/her body). a. For Resident 24, the facility failed to obtain a physician's order for the use of geriatric chair (Geri chair, a large, padded, and mobile reclining chair that prevented the resident from rising). There was no consent and assessment for the use of Geri chair in resident's medical records. b. For Resident 36, the facility failed to obtain a physician's order for the use of geriatric chair with the duration for the use of Geri chair. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide wound treatment for two (2) of 2 sampled residents (Resident 10 and 37) in accordance to the physicians order. 1. Resident 37 did not receive antifungal cream to his bilateral (affecting both sides) buttocks extending to perineum (the area between the anus and scrotum) and right hip moisture-associated skin damage (MASD). 2. Resident 10's calcium alginate (a highly absorptive dressing that absorbs fluids from covered wounds and form a protective gel) was not given during treatment observation on 12/09/23. This deficient practice had the potential for Resident 37 and 10's wounds to worsen and develop an infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary respiratory care services and treatment for three (3) of 3 sampled residents (Residents 28, 197, and 199). 1. The facility failed to change Resident 28's nasal cannula tubing (oxygen tubing used to deliver supplemental oxygen that is placed directly on the nostrils) every Sunday according to physician's order and failed to ensure that the nebulizer (a drug delivery device used to administer medication in the form of a mist inhaled in the lungs) face mask and tubing were placed in a bag after use. This deficient practice had the potential for the Resident to develop a respiratory infection. 2. The facility failed to follow Resident 197's physician order to receive one (1) liter of oxygen per minute (LPM) via nasal cannula continuously. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the facility was free of a medication error rate of five percent (%) or greater as evidenced by the identification of seven (7) medication errors (the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order; manufacturers specifications [not recommendations] regarding the preparation and administration of the medication or biological; accepted professional standards and principles which apply to professionals providing services) out of 29 opportunities (observed administered medications) for error, which yielded a facility medication error rate of 24 %. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe provision of pharmaceutical services when: 1. One (1) of two (2) medication refrigerators were not set within the proper temperature range, in the medication room. This deficient practice had the potential for loss of strength of the medications, and the potential for the residents to receive ineffective medication dosages. 2. The facility failed to indicate the date when the iodine (solution used to prevent and treat infections on minor scrapes and cuts) bottle was opened to readily identify when the bottle should be discarded. This deficient practice had the potential for the loss of effectiveness of iodine and for unintentional use of possible expired medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store food in a sanitary manner to prevent growth of microorganisms that could cause food borne illness (food poisoning: any illness resulting from the food spoilage of contaminated food, pathogenic bacteria, viruses, or parasites that contaminate food, as well as toxins) by failing to: 1. Store food properly when the plastic packaging of 15 frozen coffee cakes was observed broken and unlabeled 2. Date an opened jar of peanut butter 3. Ensure food items stored in two (2) of three (3) freezers were labeled 4. Ensure kitchen equipment are free of rust and black residue These deficient practices have the potential to result in the residents ingesting expired food and can result in foodborne illnesses and can lead to symptoms such as nausea, vomiting, stomach cramps and diarrhea.

Inspectors wroteBased in observation, interview and record review, the facility failed to ensure residents were provided a homelike environment for one of 16 sampled residents (Resident 28) by failing to clean the oxygen concentrator (a device that provides oxygen) handle and oxygen flow meter (a device used to measure the volume or mass of a gas or liquid). This deficient practice had the potential to negatively impact the resident's quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a care plan for intravenous (IV- administration of medicines or fluids through a needle or tube inserted into a vein) hydration (the process of adding back water to the body that has been lost in order to keep it functioning properly) comprehensive for one of 16 sampled residents (Resident 22) in accordance with the facility policy. This deficient practice had the potential for Resident 22 to not be appropriately cared for by the facility staff in providing resident-centered care and services.

Inspectors wroteBased on interview and record review the facility failed to review and revise the care plans for one (1) of 16 sampled residents (Resident 37) who has a history of falls. This deficient practice had the potential to place Resident 37 at risk for recurrent falls, which could lead to serious injury and harm.

Inspectors wroteBased on observation, interview and record review, facility failed to ensure the wander guard (used to keep track of patients) was checked according to facility's policy and procedure (P&P) for one of four sampled resident (Resident 33) who was cognitively (ability to think and reason) impaired and displayed behaviors of wandering (walking around aimlessly without a fixed plan) in the facility. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of one sampled resident's (Resident 10) urinary indwelling catheter (Foley catheter [brand name] a flexible tube [a catheter] inserted into the bladder that remains (dwells) there to provide continuous urinary drainage) order was carried out on 12/10/2023. Resident 10 did not have a urinary indwelling catheter on 12/10/2023. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one (1) of two sampled residents (Resident 22) who is fed by enteral (passing through the intestine either naturally or through an artificial opening) means received appropriate treatment and services by failing to elevate the head of the bed (HOB) while receiving formula through the gastrostomy tube (GT - a tube inserted through the abdomen that delivers nutrition directly to the stomach). This failure had the potential to place Resident 22 at risk for aspiration (inhaling small particles of food or drops of liquid into the lungs) that can lead to lung problems such as pneumonia (a lung infection) and death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet the needs of residents as indicated on the facility policy by failing to ensure the Change of Shift Narcotics (drug that produces analgesia [pain relief], narcosis [state of stupor or sleep], and addiction [physical dependence on the drug]) Reconciliation Records contained two Licensed Nurses' signatures. This deficient practice had the potential for inaccurate record of narcotic medication use and loss of accountability, which could result to drug loss, diversion, and could potentially harm the resident if ingested.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled residents (Resident 22) was ordered for psychotropic (acting on the mind) medication with an adequate indication of use. Resident 22 was ordered for Lorazepam (a medication used to treat anxiety) 0.5 milligram (mg, unit of measurement of mass) via gastrostomy tube (GT - a tube inserted through the abdomen that delivers nutrition directly to the stomach) for anxiety manifested by (m/b) increase agitation. This deficient practice had the potential to place Resident 22 at risk for unrecognized adverse reactions associated with the use of psychotropic drug.

Inspectors wroteBased on interview and record review, the facility failed to accurately document the resident's medical record for one of 22 sampled residents (Residents 21) by failing to ensure the facility have the correct physician's order in the Resident's electronic health records (eHR) for the resident's code status (describes the type of resuscitation procedures the resident would like the health care team to conduct if the resident's heart stopped beating and/or the resident stopped breathing). This deficient practice had the potential to result in confusion on the delivery of care and services during a medical emergency.

Inspectors wroteBased on interview and record review, the facility failed to ensure one (1) of 1 sampled resident (Resident 27) had adequate indication for use of antibiotic therapy as indicated on the facility policy. This deficient practice had the potential for Resident 27 to experience adverse events (undesired harmful effects), including the development of antibiotic-resistant organisms (bacteria that are not controlled or killed by antibiotics), from unnecessary or inappropriate antibiotic treatment.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide the minimum of 80 square feet (sq.ft.) per resident in multiple resident bedrooms for 11 of 17 residents' rooms in the facility. This deficient practice had the potential to affect the ability to provide a home like environment to the residents.