Royal Vista Care Center

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) for three (3) of three sampled residents (Residents 1, 2 and 3) were followed in accordance with the facility's policy and procedure when:1. The facility staff failed to disinfect the shower chair used by Resident 1 before placing the shower chair back in the shower room for the next resident's use. 2. The facility staff used wet wipes meant for hygienic purposes to clean the shower chair used by Resident 2 instead of the Environmental Protection Agency (EPA, an independent federal agency tasked with protecting human health and the natural environment) approved disinfectant wipes.3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a resident centered fall care plan (document that outlines the facility's plan to provide personalized care to a resident based on the resident's needs) for one (1) of two (2) sampled residents (Resident 4), who had a prior incidents of seizure activity. This deficient practice had the potential to result in physical injuries to Resident 4 from the facility's inability to recognize unique personal triggers or warning signs to provide environmental safety protocols specific to the resident's diagnosis of seizure disorder (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness).

Inspectors wroteBased on observation, interview and record review on 5/7/2026 the facility failed to report an alleged abuse to the State Agency (SA) within two (2) hours after Resident reported an alleged abuse to the facility, for one of two sampled residents (Resident 1). This deficient practice led to delay of investigation and potentially put Resident 1 and other residents in the facility for ongoing and other abuse.

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 two (2) of three (3) sampled residents (Residents 1 and 3) with suspected (believed to have due to signs and symptoms and/ or exposure to confirmed) and confirmed (a doctor had officially identified) cases of scabies (is a highly contagious skin infestation caused by tiny, burrowing mites) in accordance with the facility's policy and procedure by failing to:1. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure three (3) of five sampled residents (Resident 7, 2 and 68) reviewed for unnecessary (any drug when used without adequate monitoring, and without adequate indication for use) psychotropic drugs (any medication capable of affecting the mind, emotions, and behavior) were free from unnecessary psychotropic drugs as indicated in the facility's policy and procedure by failing to:1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a Level 1 Preadmission Screening and Resident Review (PASRR, initial screening for all applicants to Medicaid-certified nursing facilities [meets federal and state standards for care and is approved to receive payment from Medicaid {a government health insurance program that provides free or low-cost coverage to eligible low-income individuals and families} for services provided to eligible residents] for possible serious mental disorder [MD, a health condition characterized by clinically significant alterations in thinking, mood, or behavior associated with distress and/or impaired functioning], intellectual disability [ID, a condition characterized by significantly subaverage intellectual functioning and substantial limitations in adaptive behavior] or a related condition, which is completed prior to admission to a [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two (2) of 2 sampled residents (Resident 3 and 38) reviewed for Activities of Daily Living (ADL - activities such as bathing, dressing and toileting a person performs daily) were provided care and services to maintain good grooming and personal hygiene by failing to:1. Ensure Resident 38's nails were trimmed and not long and jagged (an uneven, rough, or broken free-edge fingernails). This deficient practice resulted in multiple scattered reddened scratch marks on Resident 38's right arm.2. Ensure shower was provided for Resident 3 in accordance with residents' shower requests. This deficient practice had the potential to result in a negative impact on Resident 3's quality of life and self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three (3) of four (4) sampled residents (Resident 2, 3, and 42) reviewed for pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) were provided necessary treatment and services in accordance with the facility's policy and procedure (P&P) and physician's order by failing to ensure:1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures to ensure the accurate acquiring, administering of drugs and biologicals to meet the needs for four (4) of four sampled residents (Residents 38, 2, 82, and 67) reviewed and observed for medication administration, in accordance with the facility's policy and procedure (P&P) by failing to:Correctly administer Combivent Respimat (medication used to treat and prevent tightening of the airway in adults) for Resident 38 as indicated in the package insert (a document included in the package of a medication that provides information about the medication and its use) This deficient practice had the potential for Resident 38 to experience shortness of breath and difficulty breathing. 2a. Administer 16 medications within 60 minutes of scheduled time of 9 AM for Resident 2. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure its medication error rate was less than five (5) percent (%). 18 medication errors (the observed or identified preparation or administration of medication or biologicals which is not in accordance with the prescriber's order/manufacturer's specifications/accepted professional standards and principles) out of 36 opportunities (observed administered medications) for error which yielded a facility medication error rate of 50% for four (4) of 4 sampled residents (Residents 38, 2, 82, and 67) observed for medication administration (med pass). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two (2) of four sampled residents (Residents 38 and Resident 2) were free from significant medication errors (error which causes the resident discomfort or jeopardizes his or her health and safety) by failing to: Correctly administer Combivent Respimat (medication used to treat and prevent tightening of the airway in adults) for Resident 38 as indicated in the package insert (a document included in the package of a medication that provides information about the medication and its use) This deficient practice had the potential for Resident 38 to experience shortness of breath and difficulty breathing. 2. Ensure the extended-release formulation of divalproex, metoprolol, and Aspirin were not crushed, compromising the slow release of the medications for Resident 2. [...]

Inspectors wroteBased on observation, interview, and review, the facility failed to label and store drugs in locked compartments as indicated in the facility's Policy and Procedure (P&P) by failing to ensure: One unopened insulin (a hormone that works by lowering levels of sugar in the blood) pen was stored inside the refrigerator instead of inside Medication Cart 1 (MC 1) per manufacturer's guidelines. This deficient practice had the potential for loss of efficacy of the insulin medication. 2. One opened Ipratropium-Albuterol Solution (a medication that treats shortness of breath by opening the air passages in the lungs) foil packet, with an open date of 2/1/2026 and expired 7 days after opening, was removed from MC 1 as indicated in the facility's policy and procedure (P&P). 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper food handling practices and maintain the food service area in a clean and sanitary manner in accordance with the facility's policies and procedures (P&P) by failing to ensure:1. All personnels in the kitchen wore hair and or beard nets.2. Multiple food items were stored in a manner that prevents foodborne illness (illness that comes from eating contaminated food) for residents.3. Staff personal items were not placed inside the kitchen refrigerator. 4. Kitchen staff did not touch the rim of multiple glasses of water with bare hands during tray line preparation. These deficient practices have the potential to result in foodborne illness in a population of 80 residents who consume the food prepared by the facility every day.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the standard infection prevention control practices (a set of practices that prevent or stop the spread of infections and or diseases in the healthcare setting) in accordance with the facility's policy and procedure when:1.a Licensed Vocational Nurse 2 (LVN 2) failed to change gloves and perform hand hygiene during medication administration to Resident 2.1.b LVN 3 failed to sanitize medication tray (equipment includes durable plastic, divided trays designed to organize, transport, and dispensing pills and syringes in clinical or home settings) after putting in the dirty lancet (a small, disposable, double-edged needle or blade used to prick the skin-usually on the finger-to obtain a tiny blood sample for checking blood sugar levels) and failed to perform hand hygiene in between tasks during medication [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two (2) of five (5) sampled residents (Residents 72 and 4), in the infection control care area, were provided education or a Vaccine Information Statements (VIS- information sheets produced by the Center of Disease Control and Prevention [CDC] that explain both the benefits and risks of a vaccine [medications used to prevent diseases usually given by injection or by mouth] to vaccine recipients) for influenza (the flu- a contagious respiratory virus) and pneumococcal (a serious, often fatal infection caused by Streptococcus pneumoniae bacteria) vaccinations per facility policy. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two (2) of five (5) sampled residents (Residents 72 and 4), in the infection control care area, were provided education or a Vaccine Information Statements (VIS- information sheets produced by the Center of Disease Control and Prevention [CDC] that explain both the benefits and risks of a vaccine [medications used to prevent diseases usually given by injection or by mouth] to vaccine recipients) for the Covid-19 (a highly contagious respiratory illness caused by the SARS-CoV-2 virus) vaccine per the facility's policy and procedure. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents' medical records were updated to show documentation that advance directives (a legal document indicating resident preference on end-of-life treatment decisions) were discussed upon admission and written information were provided for one (1) of two (2) sampled residents and/or responsible party (Resident 78), in the advance directive care area. This deficient practice violated Resident's 78 and/or the responsible party's (RP) right to be fully informed of the option to formulate their advanced directives and had the potential to cause conflict with the residents' wishes regarding health care.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a safe, comfortable wheelchair for one (1) of two (2) sampled residents (Residents 38) reviewed for environmental concerns by failing to ensure the resident's wheelchair's left armrest pad was free from peeling and cracks and the wheelchair had a right padded armrest. This deficient practice had the potential to affect Resident 38's safety and comfort when sitting in the wheelchair.

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor 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) from 5/3/2025 up to 2/11/2026 for one (1) of 18 sampled residents (Residents 3) on Insulin aspart (Novolog, is a rapid-acting, man-made version of human insulin), as indicated on the care plan (CP). This deficient practice had the potential for Residents 3 not to receive treatment in the event of a hypoglycemic and hyperglycemic episode, which could lead to complications, harm, hospitalization, or death.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of one sampled resident (Resident 72) from the vision/hearing care area, maintained a scheduled ophthalmology (the specialized field of medicine that focuses on the health of the eye appointment). This failure resulted in a delaying preoperative appointment with the potential risk for a delay in necessary treatment and evaluation including surgery.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a fall risk identifier, frequent visual checks and caregiver education were implemented for one (1) of 1 sampled resident (Resident 78), for the accidents care area, as indicated in Resident 78's care plan (a document that outlines the facility's plan to provide personalized care to a resident based on the resident's needs) and the facility's policy and procedure. This failure had the potential for Resident 78 to experience preventable falls, injury or accident hazards.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of 18 sampled residents (Resident 78) who was incontinent (loss of control) of bladder, was provided a bladder retraining and/or toileting program (helps manage incontinence [involuntary loss of urine or stool] by training the bladder to hold more urine and reducing the frequency of bathroom visits) in accordance with the resident care plan (a document that outlines the facility's plan to provide personalized care to a resident based on the resident's needs) and the facility's policy and procedure titled Bowel and Bladder Program. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store the nebulizer (a small device that turns liquid medicine into a mist or fine spray) mask in a clean plastic bag when not in use for one (1) of 1 sampled resident (Resident 55) reviewed for respiratory care services, as indicated on the facility policy and procedure (P&P). This deficient practice had the potential to contaminate the nebulizer and place Resident 55 at risk for respiratory infectionFindings:During a review of Resident 55's admission Record, the admission Record indicated Resident 55 was admitted to the facility on [DATE] with diagnosis that included chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to manage the pain timely and effectively for one of two sampled residents (Resident 4) reviewed for pain by not administering Cyclobenzaprine (is a medication used to treat muscle spasms) on 1/13/2026 and 1/20/2026 as indicated on the physician's order and facility policy. This deficient practice had the potential for unmanaged pain in Resident 4's left thigh which could negatively affect the resident's overall well-being and quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor the fluid intake for one (1) of 1 sampled resident (Resident 92) reviewed for dialysis in accordance with the care plan and facility policy. This deficient practice had the potential to place the resident at risk for fluid overload (a condition where the body has too much fluid) or dehydration (condition that occurs when the loss of body fluids, mostly water, exceeds the amount that is taken in).

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 one (1) of four (4) sampled employees in accordance with the facility assessment when Licensed Vocational Nurse 3 (LVN3) did not have a medication administration competency completed upon hire. This deficient practice has the potential to cause improper medication administration causing medication errors which could result in resident harm.

Inspectors wroteBased on observation, interview and record review, the facility failed to promptly provide dental services for one (1) of 1 sampled resident (Resident 3) reviewed for dental care as indicated in the facility's policy and procedure. This deficient practice had the potential to result in Resident 3's inability to effectively chew food, weight loss, discomfort, and develop infection in the oral cavity.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain accurate medical records for one of 18 sampled residents (Resident 2) in accordance with the facility's Policy and Procedure (P&P). This deficient practice had the potential to result in miscommunication, improper delivery of wound management and inaccurate information of the care provided, which could result in skin breakdown to Resident 2.

Inspectors wroteBased on interview and record review, the facility failed to implement their protocol for Antibiotic Stewardship (the ongoing effort by a provider and clinical caregivers to optimize and minimize the use of antimicrobial medicines) for one (1) of two sampled residents (Resident 72), after being prescribed an antibiotic (drug used to prevent and treat bacterial infections) without meeting the criteria for cellulitis (bacterial skin infection that may appear as a red, swollen area, feeling hot and tender to the touch), soft tissue or wound infection. This deficient practice had the potential for Resident 72 to develop antibiotic resistance (when bacteria change so antibiotic medicines cannot kill them or stop their growth) from unnecessary or inappropriate antibiotic use.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 10 of 36 rooms (17, 42, 42, 44, 51, 52, 53, 54, 62, and 63) met the requirement of 80 square feet (sq. ft.) for each resident in multiple resident rooms. This deficient practice had the potential to affect the residents' personal space, decrease freedom of mobility and could compromise the provision of care.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the facility exit doors and hallways were free from obstruction and clutter. This deficient practice had the potential to place residents and facility staff at risk for accidents, such as tripping and falling, and impede or hinder immediate evacuation from the facility in cases of emergency.

Inspectors wroteBased on interview and record review, the facility failed to report to the State Agency (SA) within 24 hours after an unusual occurrence (events or situations that do not happen daily or that may have had an impact on the residents) for one of two sampled residents (Resident 1) when the facility was made aware on 2/3/2025 of Resident 1's sustained a fracture (complete or partial break in the bone) from a fall in accordance with the facility's policy and procedure titled Unusual Occurrence Reporting. This deficient practice had a potential for ongoing/ another unusual occurrence for Resident 1 or other residents in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement a care plan for one of two sampled residents (Resident 1) by not ensuring a floor mat (a cushioned floor pad designed to help prevent injury should a person fall) was placed at Resident 1's bedside after an unwitnessed fall on 1/26/2025 wherein the resident sustained a fracture (the cracking or breaking of the bone). This deficient practice has the potential for Resident 1 to have further falls with injury.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the facility staff performs hand hygiene (an action of hand cleansing such as with soap and water or applying alcohol based handrub to the surface of the hands) according to the facility's policy for one (1) of 4 sampled residents. This deficient practice had the potential to spread infection to staff and residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure one (1) of two (2) sampled residents (Resident 1) who was assessed as a high risk for falls and with diagnoses of dementia (a progressive state of decline in mental abilities), cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), lack of coordination and repeated falls was free from falls and injury. On 1/18/2025, the Director of Activities (DOA) wheeled Resident 1 outside of the activity room to take care of other residents and left Resident 1 unattended while sitting in a wheelchair (WC) at the hallway (outside the activity room). This deficient practice resulted in Resident 1 fell in the hallway outside the activity room on 1/18/2025 around 11:13 AM. Resident 1 sustained redness on the right side of resident's forehead. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement the comprehensive care plan related to alleged rough handling by staff for one of one sampled resident (Resident 1) in accordance with the facility policy. This deficient practice had the potential to result in delay or lack of delivery of care and services to Resident 1 which could affect resident's overall wellbeing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its infection control policy for one (1) of two (2) sampled residents (Resident 1) by failing to ensure staff were using a gown while rendering diaper change and administering medication via gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for residents with swallowing problems) tube to Resident 1 who was on enhanced barrier precaution (EBP, an infection control practice that involves wearing gowns and gloves during high-contact activities with residents in nursing homes). This deficient practice had the potential to result in Resident 1 developing an infection and spread of infection among staff and residents.

Inspectors wroteBased on interview and record review the facility failed to provide care consistent with the professional standards of practice (the set of guidelines, principles, and expectations that govern the conduct and performance of nursing professionals) to prevent worsening of the pressure ulcer (PU, a localized area of skin damage caused by prolonged pressure on the skin) for one of two sampled residents (Residents 1) by failing to: 1. Assess and document detailed observations in SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents) of Resident 1's change with skin condition and/ or wound condition on the resident's sacral area (lower back region specifically triangular- shaped bone called the sacrum) and/ or left buttocks on 10/17/2024, 10/24/2024, 11/14/2024 and 11/30/2024. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure licensed nurses document accurate information of Resident 1's skin condition and wound care treatment in the resident's Skilled Nursing Assessment form on 9/11/2024 and 10/25/2024 and in the Weekly Summary form on 9/18/2024, 10/11/2024, and 10/18/2024, This deficient practice had the potential to result in miscommunication, improper delivery of care and delayed communication of the progression of Resident 1's pressure ulcer.

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat resident with respect and dignity, and maintain privacy for five (5) of 23 sampled residents (Residents 47, 59, 73, 75, and 25) in accordance with the facility policy by failing to ensure: 1. Resident 47 was fed at eye level. 2. Resident 59's curtain or door was closed when staff changed the resident. 3. Resident 73's curtain or door was closed when staff changed the resident. 4. Failing to address Resident 25 by her name. 5. Resident 75 was fed at eye level. These deficient practices had the potential to negatively affect Residents 47, 59, 73, 75, and 25's self-worth, self-esteem, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were provided a comfortable and homelike environment (one that de-emphasizes the institutional character of the setting and is as close to that of the environment of a private home as possible) for five of seven sampled residents (Resident 8, 22, 43, 44, and 72) who were in attendance during the Resident Council (a group of residents who meet regularly to discuss concerns, suggest improvements, and plan activities related to their living situation within the facility) meeting by the facility failing to provide communal dining to their residents. This deficient practice had the potential to result in decreased social interactions, decreased psychosocial wellbeing, and weight loss in residents.

Inspectors wroteBased on observation and interview, the facility failed to provide a communication board (a device that displays photos, symbols, or illustrations to help people with limited language skills express themselves) for three (3) of four (4) sampled residents (Residents 41, 42 and 63) readily accessible with the language the residents were able to understand in accordance with the facility's policy. This failure had the potential for the residents to experience a delay in receiving appropriate care and treatment and feeling lonely and isolated due to the staff not being able to properly communicate with the residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure two of two sampled residents (Residents 78 and 22) were provided activities, based on comprehensive assessment and resident's preferences and interests in accordance with the facility policy. This deficient practice had the potential to negatively affect Residents 78 and 22's physical, mental, and psychosocial well-being.

Inspectors wroteBased on interview and record review the facility failed ensure resident's drug regimen was free from unnecessary medication use for four (4) of five (5) sampled residents (Residents 47, 62, 33, and 45) in accordance with the facility policy by failing to ensure: 1.a. Resident 47 was free from taking two anxiety (a feeling of nervousness, panic, and fear) medications, Clonazepam (drug used to treat anxiety) and Lorazepam (drug used to relieve anxiety [fear characterized by behavioral disturbances] and treat insomnia caused by anxiety or temporary situational stress) 1.b. A specific indication for use/behavior was monitored for Resident 47's use of Clonazepam and Lorazepam. 1.c. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure its medication error rate was less than five (5) percent (%). Four (4) medications 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 25 opportunities (observed administered medications) for error and yielded a facility medication rate of 16% for two (2) of 5 sampled residents (Resident 31 and Resident 284) observed during medication administration (med pass). 1. Licensed Vocational Nurse 5 (LVN 5) failed to ensure Resident 31 received the full dose of Humulin R insulin (a hormone that removes excess sugar from the blood) by not waiting approximately 5 seconds before removing the needle after injection. [...]

Inspectors wroteBased on observation, interview, and review, the facility failed to label and store drugs in locked compartments when the facility failed to: 1. Ensure safe drug storage by leaving two medications unattended on top of the medication cart. This deficient practice had the potential to result in other residents having access to medications causing adverse consequences or possible hospitalization if ingested. 2. Ensure the unopened insulin (a hormone that works by lowering levels of sugar in the blood) pens of Residents 75 and 48 were stored inside the refrigerator instead of inside the medication cart per manufacturer's guidelines. This deficient practice had the potential for loss of efficacy of the insulin injection. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper food handling practices in accordance with their policy and procedure by failing to: 1. Discard expired food and label food in the dry storage room, refrigerators, and freezers in the kitchen with item name, date opened and expiration date, and failed to 2. Ensure kitchen equipment and food carts were clean and free of food debris (leftover food particles). 3. Ensure electric fans were free form dust and were not stored in the kitchen dry storage room. 4. Ensure dietary staff (Cook 1 and Chef 1) perform hand hygiene (is the act of cleaning the hands with soap or handwash and water to remove viruses/bacteria/microorganisms, dirt, grease, or other harmful and unwanted substances stuck to the hands) and change gloves during cooking and tray line assembly. [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to observe infection control measures in accordance with the facility policy by failing to : 1. Handle soiled linens in a safe and sanitary method while changing Resident 16's soiled bedding. 2. Clean and disinfect the glucometer (an instrument for measuring the concentration of glucose [sugar] in the blood) after use with Resident 31 and before returning it in the medication cart drawer. 3. Post an enhanced barrier precautions (set of infection control measures that use personal protective equipment [PPE] to reduce the spread of multi drug resistant organisms [MDRO, microorganisms that are resistant to multiple classes of antibiotics and antifungals, which could be difficult to treat and spread quickly]) signage by Resident 63's room who was on isolation precautions. 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe environment for one of 23 sampled residents (Resident 43) by: 1. Failing to ensure the designated exit door was not blocked by a wheelchair. This deficient practice had the potential for residents to be placed at risk for injury by not allowing a rapid evacuation in case of an emergency. 2. Failing to ensure the hallway for Resident 43 to pass through back and forth from the resident's room to the activity room was not cluttered with multiple parked wheelchairs and equipment (such as Hoyer lift [mechanical device that helps transfer people with limited mobility from one place to another. It allows a person to be lifted and transferred with a minimum of physical effort], walker and clean linen cart). This deficient practice placed Resident 43 at risk for accident, tripping, or fall.

Inspectors wroteBased on observation, interview, and record review, the facility failed to fully inform the resident in advance, of the risks and benefits of proposed care for two of 23 sampled residents (Resident 185 and 62) in accordance with the facility policy when: 1. Resident 185's admission Consent Forms (consent for treatment, disclose medical record, and photograph) were not completed and signed upon admission on [DATE]. 2. An informed consent was not obtained prior to Resident 62's use of psychoactive medication (drug that changes brain function and results in altercations in perception, mood, consciousness or behavior) Seroquel (an antipsychotic drug to treat certain mental conditions). This deficient practice had the potential for Residents 185 and 62 not to be able to exercise their right to choose their treatment plan.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policy on Self-administration of Medications for one (1) of 23 sampled residents (Resident 20) by failing to obtain a physician order and conducting an assessment to determine if the resident was capable to self-administer medications. This deficient practice had the potential to result in unsafe medication administration, omission, and/or duplication of medications, which can result to complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light (device used by residents to call staff) was in reach for one (1) of 23 sampled residents (Resident 185) in accordance with the facility policy and procedure for Residents'Call System. This failure had the potential for Resident 185 to not be able to call for assistance, which could result in untimely delivery of care and services.

Inspectors wroteBased on interview and record review, the facility failed to inform and provide a written information for one (1) of four (4) sampled residents (Resident 21) on the option to formulate an advance directive (a written instruction, such as a living will or durable power of attorney for health care, recognized under State law relating to the provision of health care when the resident is incapacitated [clinical state in which a resident is unable to participate in a meaningful way in medical decisions]) as indicated on the facility's policy. This deficient practice violated the resident's and/or the representative's right to be fully informed of the option to formulate their advance directives and had the potential to unwanted treatment with the resident's wishes regarding health care.

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to provide privacy and confidentiality (safeguarding the content of information including video, audio, or other computer stored information from unauthorized disclosure without the consent of the resident and/or the individual's surrogate or representative) of the resident's medical records for one of 23 sampled residents (Resident 71). This deficient practice had the potential to expose Resident 71's records to others and violated the resident's right for privacy and confidentiality.

Inspectors wroteBased on interview and record review, the facility failed to ensure the preadmission screening and annual resident review assessment (PASARR, preventing individuals with mental illness, developmental disability, intellectual disability, or related conditions from being inappropriately placed in nursing homes for long term care) form was accurately completed for a resident who had a mental illness for one of four sampled residents (Resident 62). This deficient practice led Resident 62 to not receive the necessary and appropriate psychiatric (of or relating to the study of mental illness) level of treatment and evaluation in the facility.

Inspectors wroteBased on interview and record review, the facility failed to develop a resident-centered comprehensive care plan (a care plan developed and implemented to meet the resident's preferences and goals, and addresses the resident's medical, physical, mental, and psychosocial needs) with individualized interventions for one (1) of 23 sampled residents (Resident 8) who was hard of hearing and refused to wear his hearing aid. This deficient practice had the potential to negatively affect and delay the delivery of care and services for Resident 8.

Inspectors wroteBased on interview, and record review, the facility staff failed to ensure one (1) of 23 sampled residents (Resident 8) received treatment and care in accordance with professional standards (the guidelines, policies, and procedure that define the expected behaviors and performance level for specific profession) of practice by failing to perform appropriate laboratory tests and monitor Resident 8's blood sugar (concentration of glucose in the blood). This deficient practice had the potential to result in a lack of or delay in assessing for possible complications of hypoglycemia (when the blood sugar is lower than normal) and hyperglycemia (high blood sugar) for Resident 8 which can lead to hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled resident (Resident 70), who was assessed at moderate to high risk for falls, had a floor matt placed in Resident 70's room as ordered by facility physician. This deficient practice had the potential to result in injury to Resident 70.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide and accurately monitor fluid intake for one of one sampled resident (Resident 75) with fluid restrictions. This deficient practice had the potential to cause fluid overload (too much fluid in the body) or increase Resident 75's risk for dehydration (condition that occurs when the loss of body fluids, mostly water, exceeds the amount that is taken in).

Inspectors wroteBased on interview and record review, the facility failed to implement the order for gastrostomy tube (GT, a tube inserted through the belly that brings nutrition directly to the stomach) feeding for one of two sampled residents (Resident 78) in accordance with the facility's policy. This deficient practice resulted in Resident 78 to not receive the volume of tube feeding formula ordered which could lead to weight loss and worsening malnutrition (serious condition that occurs when a resident's diet does not contain the right amount of nutrients).

Inspectors wroteBased on interview and record review, the facility failed to provide treatment and care to manage pain of one of two sampled residents (Resident 64) by failing to: a. Administer Resident 64's methadone (medication used to treat moderate to severe pain. It can also treat narcotic drug addiction) on 11/18/2024 at 9 AM as ordered by the physician. b. Reassess Resident 64's pain level after administering pain medication (methadone and Percocet [medication to treat moderate to severe pain]) on 11/21/2024 at 10 AM, to ensure pain medication was effective. These deficient practices resulted in Resident 64 experiencing severe pain reporting a pain score of nine out of ten (9/10) on 11/18/2024 from 10 AM to 12:01 PM (2 hours and 1 minute). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures to ensure the accurate acquiring, administering of all drugs and biologicals to meet the needs of two (2) of five sampled residents (Resident 31 and Resident 284) in accordance with the facility's policy and procedure (P&P) by failing to: 1. Ensure Resident 31 received the full dose of Humulin R insulin (a hormone that removes excess sugar from the blood) by not waiting approximately five (5) seconds before removing the needle after injection as indicated in the facility's policy and procedure (P&P). This deficient practice placed Resident 31 at risk of inadequate blood sugar management which can cause hyperglycemia (elevated blood sugar level) or hypoglycemia (low blood sugar level) 2.a. [...]

Inspectors wroteBased on interview and record review, the facility failed to relay to the doctor the recommendations form the pharmacist indicated in the Medication Regimen Review (MRR, a monthly thorough evaluation by the consulting pharmacist of a resident's medication regimen, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) for the month of September 2024 for two of five sampled residents (Resident 45 and 55). The MRR indicated to consider a gradual dose reduction (GDR - a periodic attempt to manage a resident's behavioral issues with a lower dose of medication) related to the use of Seroquel (an antipsychotic medication used to treat a severe mental condition in which thought, and emotions are so affected that contact is lost with external reality also called psychosis) for Resident 55 and 45. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two (2) of five sampled residents (Resident 31 and Resident 284) were free from significant medication errors by failing to: 1. Administer Resident 31's of Humulin R insulin (a hormone that removes excess sugar from the blood) 4 units as indicated in the facility's policy and procedure (P&P) and manufacturer's guidelines. This deficient practice placed the resident at risk of inadequate blood sugar management, which can cause hyperglycemia (high blood sugar) and untreated can lead to complications, such as eye, kidney, or heart disease or nerve damage. 2.a. Ensure Resident 284's Mometasone spray (medication used to treat and prevent the symptoms of seasonal and year-round allergy symptoms) 50 micrograms (mcg- unit of measurement) was not expired when administered on [DATE] to [DATE]. 2.b. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide appropriate food preferences for one of 23 sampled residents (Resident 284). This deficient practice had the potential to result in decreased meal intake and can lead to weight loss and malnutrition (the condition that develops when the body is deprived of vitamin, minerals, and other nutrients it needs to maintain healthy tissue and organ function).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 23 sampled residents (Resident 286) was provided mechanically altered (texture of a diet is altered) diet as indicated on the physician's order. This deficient practice had the potential to cause Resident 286 to choke (severe difficulty in breathing because of a constricted/obstructed throat) which could lead to death.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of 23 sampled residents (Residents 21 and 185) medical record is complete by failing to ensure Residents 21 and 185's Resident's Clothing and Possessions Form we're signed by the resident/ resident representative. This deficient practice placed Resident 21 and 185 at risk for loss or theft of belongings.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light (a device used by a resident to signal his or her need for assistance) was functioning to alert the staff that assistance was needed as for one (1) of 23 sampled residents (Resident 25). This deficient practice had the potential to result in delay in meeting Resident 25's needs for hydration, toileting, and activities of daily living (ADL) which can lead to falls and/ or accidents.

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, staff, and visitors.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 10 of 36 rooms (17, 42, 43, 44, 51, 52, 53, 54, 62 and 63) met the square footage requirement of 80 square feet (sq. ft.) per resident in multiple resident rooms. This deficient practice had the potential of not providing the required space for resident's personal care, or the ability to permit the use of residents' care devices, room for visitors, and the use of personal furniture.

Inspectors wroteBased on interview and record review, the facility failed to provide a copy of the medical records for one of one sampled resident (Resident 1) within 48 hours (excluding weekends and holidays) from when the written request was received from the resident's representative on 10/3/2024. This deficient practice has resulted in the delay of access to Resident 1's medical records in a timely manner.

Inspectors wroteBased on observation, interview and record review, the facility failed to create a resident- centered care plan for one (1) of three (3) sampled residents (Resident 1) with interventions to prevent future fall (to drop suddenly or collapse) after the resident's fall incidents on 5/22/2024, 7/26/2024 and 9/27/2024. This failure resulted in Resident 1 had another fall on 7/26/2024 and 9/27/2024 and place resident at risk for another incident of fall.

Inspectors wroteBased on interview and record review the facility failed to provide treatment and care in accordance with the professional standards of practice for ne (1) of two (2) sampled residents (Resident 1) by: 1. Failing to record Resident 1's bowel movement (BM) pattern each day on 7/9/24-7/11/24, 7/15/24-7/16/24 and 7/19/24-7/22/24 as indicated in the resident's care plan for constipation (a condition where it's difficult or infrequent to have a BM usually resulting in hard, dry stools). 2. Failing to monitor/document/report to physician (MD) as needed for complications related to constipation when the resident did not have documented evidence of BM from 7/5/2024 to 7/23/2024 (19 days). This failure resulted to Resident 1 being transferred to the General Acute Care Hospital (GACH) on 8/2/2024 due to persistence of abdominal bulge in the resident's right lower quadrant (area) of abdomen. [...]

Inspectors wroteBased on observation and interview, the facility failed to safeguard one of two sampled residents (Resident 1) personal privacy and confidentiality of the medical records. This failure had the potential to result in Resident 1's personal information and medical records disclosed without Resident 1's permission, this will compromise the security or privacy of Resident 1's protected health information.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe provision of pharmaceutical services by failing to store unused insulin (used to help manage blood sugar levels on adults with diabetes [high blood sugar level]) injectable medications in the refrigerator and dispose of expired medications from two (2) of 2 sampled medication carts (Medication Cart one [1] and 3). These deficient practices had the potential for adverse reactions if these improperly stored medications were administered to the residents.

Inspectors wroteBased an interview and record review, the facility failed to ensure the resident's environment was free from accident hazards for one (1) of two (2) sampled resident (Resident 1) by failing to ensure the resident head did not get injured while using the Hoyer lift (a patient lift used by caregivers to safely transfer patients) during transfer. This deficient practice resulted to a 1.5 cm laceration (deep cut or skin tear in the skin) and a small bump to Resident 1's left front part of his head. Resident 1 was also sent to General Acute Care Hospital 1 (GACH 1) on 8/27/24 and was found to have a scalp cephalohematoma (accumulation of blood under the scalp)

Inspectors wroteBased on observations, interview and record review, the facility failed to report the resident- to- resident altercation to the State Survey Agency (SSA), the state ombudsman (advocates for residents of nursing homes, board and care homes and assisted living facilities), and local law enforcement (Local PD) within two (2) hours after the allegation of physical abuse (intentional bodily injury to a person, for example slapping, pinching, choking, kicking, shoving) for one of three sample residents (Resident 1) in accordance with the facility's policy and procedure. This deficient practice had the potential to place Resident 1 for further abuse and placed other residents at risk for elder abuse.

Inspectors wroteBased on observation, interview and record review, the facility failed to supervise and ensure the safety of three of three sampled residents (Residents 1, 2 and 3) in accordance with the facility's policy and procedure by: 1. Facility failed to provide sitter (one staff- to- one resident to provide monitoring) for Resident 1 who is at risk for elopement (leaving the facility without the staff's knowledge and/ or supervision). 2. Facility failed to supervise Resident 2 and ensure the resident signed out and followed the facility's out on pass (OOP; a non-medical visit outside of the facility mostly used for visits with family or friends) procedure when the resident left the faciity on 1/30/2024. 3. Facility failed to supervise Resident 3 who left the facility without signing OOP on 2/2/2024. [...]

Inspectors wroteBased on interview and record review, the facility failed to revise the care plan and interventions for wandering (moving from place to place without a fixed plan)/elopement (leaving the facility without the staff's knowledge and/or supervision) for one of two sampled residents (Resident 2). This failure resulted in Resident 2 eloped on 1/30/2024 and placed resident at risk for illness or serious injury. As of 2/2/2024, facility staff have no knowledge of the resident's where about.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the facility's Falling Star Fall Prevention Program policy was implemented for one (1) of three (3) sampled Residents (Resident 1). This deficient practice had the potential to result in repeated falls, which could cause harm and injury to Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Payroll Based Journal (PBJ, a system for healthcare facilities to submit staffing information. This system allows staffing information to be collected on a regular and more frequent basis than previously collected) report was completed. This deficient practice had the potential for the facility to not be adequately staffed and/or have the necessary staff to provide care to meet the needs of all the residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure the advance directive (a written instruction, such as a living will or durable power of attorney for health care, recognized under State law [whether statutory or as recognized by the courts of the State], relating to the provision of health care when the resident is incapacitated ) or advance directive acknowledgement form (information about advance health care directives and the residents rights to make decisions about their medical treatment) was placed in the residents chart for seven (7) of 12 sampled residents (Resident 38, 40, 49, 57, 66, 70, and 73) as indicated in the facility policy. This deficient practice had the potential not to carry out Residents 38, 40, 49, 57, 66, 70, and 73's wishes regarding health care decisions during an emergency.

Inspectors wroteBased on interview and record review, the facility failed to complete the annual minimum data set (MDS, standardized assessment and care screening tool) timely for two (2) of four (4) sampled residents (Resident 70 and 78) as indicated in the facility policy. This deficient practice resulted to an incomplete MDS which had the potential for Residents 70 and 78 not to have an individualized care plan in accordance with the MDS, which could affect the resident's overall well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two (2) of 2 sampled residents (Resident 40 and Resident 49) were provided communication boards with the language that they were able to understand as indicated on the facility policy. This failure had the potential to result in Residents 40 and 49 experiencing a delay in receiving appropriate care and treatment due to the staff not being able to properly communicate with them.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two (2) of four (4) sampled residents (Residents 1 and 70) had their low air loss (LAL, operates using a blower based pump that is designed to circulate a constant flow of air through the mattress, commonly used to heal pressure ulcers [areas of damaged skin caused by staying in one position for too long]) mattresses set according to the residents' weight in accordance with the facility's policy and procedure (P&P). 1. Resident 1, who weighed 93 pounds (lbs., unit of measurement), was observed with the LAL mattress set at 250 lbs. 2. Resident 70, who weighed 155 lbs. was observed with LAL set between 175 to 210 pounds This deficient practice placed Residents 1 and 70 at risk for development of new pressure ulcer and progression of existing pressure ulcer.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the facility was free of medication error rate of five percent (%) or greater as evidenced by the identification of nine (9) medication errors (any preventable event that may cause or lead to inappropriate medication use or resident harm while the medication is in the control of the health care professional) out of 32 opportunities (observed administered medications) for error, which yielded a cumulative medication error rate of 28 % for four sampled residents (Residents 39, 46, 51, and 54) observed during medication administration (med pass). This deficient practice had the potential to result in harm to Residents 39, 46, 51, and 54 by not administering medications as prescribed by the physician in order to meet their individual medication needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the storage, preparation and distribution of food was done under sanitary conditions by not ensuring: 1. Blender for mechanical soft diet was clean. 2. Opened food items were labeled and stored in resealable bags or tightly closed containers. 3. Window above the three (3) compartment sink was closed properly and was not broken. 4. Five (5) of 5 refrigerators were free from food build up from food residue. 5. Storage bin for clean water pitcher had a plastic lining and was free from dirt, scratches, calcification build up, and was properly closed. 6. Floor in the dishwashing area was not dirty and dishwasher did not have a calcium build up. 7. Ice machine was free from dirt and calcification. The Weekly Cleaning (Ice Machine) log was not signed from June 2023 to December 2023. 8. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the facility's policies and procedures on infection control by: 1. Failed to ensure all staff wear an N95 mask (National Institute for Occupational Safety and Health (NIOSH) N95 classification of air filtration, meaning that it filters at least 95% of airborne particles. A product that covers the wearer's nose and mouth that protects the wearer from inhaling particles that may be infectious) while in the facility. 2. Failed to ensure Resident 66's oxygen tubing (a long tube, used to deliver supplemental oxygen to a person in need of respiratory help) is not touching the floor. 3. Failed to change Resident 14's oxygen tubing every Wednesday as ordered. 4. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to have safe, clean, comfortable, sanitary, and home like environment in accordance with the facility policy by: by failing to ensure: 1. 10 of 36 rooms (Room H, I, J, K, L, M, N, O, P and Q) nightstands (bedside drawer) and dressers' paint and/ or vinyl panels were not peeled off. Facility also failed to ensure two (2) chairs in the resident's room were in good condition and leather seat cushions were not peeling off in Room P and Q. 2. Bed control (used by residents or facility staff to adjust position of the bed) wiring for Resident 85 was exposed. 3. Resident 54 ceiling was free from insects. 4. The glass window of Resident 60 was cracked (damaged and showing lines on the surface from having split without coming apart). 5. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light (device used by residents to call staff) was in reach for one of 22 sampled residents (Resident 27) in accordance with the facility policy. This failure had the potential for Resident 27 to not be able to call for assistance, which could result in untimely delivery of care and services and fall resulting to serious injury or death.

Inspectors wroteBased observation, interview, and record review, the facility failed to accurately assess the hearing status of one (1) of four (4) sampled residents (Resident 83) on the Minimum Data Set (MDS- an assessment and care screening tool) as indicated on the facility policy. This deficient practice had the potential to not develop and implement an individualized care plan for Resident 83, which could negatively affect the resident's overall wellbeing.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident specific care plan was developed for four (2) of 22 sampled residents (Resident 70 and 83) as indicated on the facility's care plan policy. 1. Resident 70's comprehensive care plan for bowel and bladder incontinence was not developed. 2. Resident 83's comprehensive care plan for hearing impairment was not developed. These deficient practices have the potential for Residents 70 and 83 not to receive interventions specific to their needs which could affect resident's overall wellbeing.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure inventory of all clothing and valuables were documented in the Resident's Clothing and Possessions (RCP, records the quantity of each item, description, and other identifying factors) and signed by the responsible personnel who completed the inventory list for two of five sampled residents (Resident 10 and 141). This deficient practice had the potential to cause misappropriation of property related to the lack of safekeeping of the residents' personal belongings.

Inspectors wroteBased on interview and record review the facility failed to ensure one (1) of four (4) sampled residents (Resident 10) under hospice care (provides medical services, emotional support, and spiritual resources for people who are in the last stages of a terminal illness) services had coordinated care between the facility and the hospice agency. Resident 10 did not receive all services as indicated on Hospice's Initial Order and Plan of Care (IOPC). This deficient practice had the potential for the Resident 10 to not receive the appropriate care and/or services from the facility and the hospice agency.

Inspectors wroteBased on observation, interview, and record review, the facility failed ensure a functioning communication system for seven (7) of 22 sampled residents (Residents 34, 38, 192, 19, 22,71, and 26) as indicated on the facility policy: 1. Resident 34's bedside call light was found on top of the resident's bedside table. Resident 34's bathroom call light did not have a pull string. 2. Resident 38's bedside call light was found on top of the resident's bedside table and was not functional/defective. 3. Resident 192's call light was found under the bed frame. 4. Resident 19's call light was functioning and within the resident's reach (arm's length) 5. Resident 22's call light was functioning and within the resident's reach 6. Resident 71's call light was functioning and within the resident's reach 7. Resident 26's call light was on the floor as observed. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 10 of 36 rooms (17, 42, 43, 44, 51, 52, 53, 54, 62 and 63) met the square footage requirement of 80 square feet (sq. ft.) per resident in multiple resident rooms. This deficient practice has the potential to cause the residents in these rooms not to have enough room for activities of daily living and hinder staff from providing care to the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe and comfortable environment for seven (7) of nine (9) sampled occupied rooms. Rooms A, B, C, D, E, F and G's temperature were below 71 degrees Fahrenheit (unit of measurement). This deficient practice has the potential risk of hypothermia (dangerously low body temperature, below 95 degrees Fahrenheit caused by prolonged exposures to very cold temperatures) to the residents in Rooms A, B, C, D, E, F and G and could potentially affect other residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to implement written policies and procedures that prohibit loss and misappropriation of property for one of three sampled residents (Resident 1) by not documenting in the inventory list (Resident Belonging List) of the resident's blanket brought in by Family 1 on 10/10/23. This deficient practice had the potential to result in a loss of Resident 1's and other residents' personal belongings.