Samaritan Nursing and Rehab

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a safe and sanitary manner. This practice had the potential to affect 70 of 71 residents residing in the facility. The facility did not ensure monitoring and documenting of cooling temperatures. The facility did not properly monitor dishwashing temperatures or conduct dishwashing in a manner that ensured dishes were washed and properly sanitized. The facility did not wash and sanitize dishes in the three-compartment sink per manufacturer's guidelines or the facility's policy. The facility did not consistently label food stored for resident consumption with received or open dates. The facility did not obtain food temperatures in a manner to prevent cross-contamination.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not establish and maintain an infection control program designed to help prevent the development and transmission of communicable disease and infection. This practice had the potential to affect all 71 residents (R) residing in the facility. The facility's infection surveillance line lists did not contain all pertinent information for identification, tracking, reporting, investigating, and mitigating infections. R59 was diagnosed with urinary tract infections (UTIs) in April and May 2026. R59 was not included in the facility's surveillance data for April. [...]

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure drugs and biologicals were stored in accordance with the facility's policy. Two medication carts contained expired medication and syringes. One medication storage room contained expired medication and syringes. This practice had the potential to affect more than 4 of the 71 residents residing in the facility. The medication cart on 4 North contained 1 opened box of expired Mucinex DM, 1 opened bulk bottle of expired calcium with vitamin D, 9 expired Bisacodyl suppositories, and 8 expired syringes. The medication cart on 3A contained 1 opened bulk bottle of expired calcium with vitamin D and 12 expired syringes. The fourth floor medication storage room contained 1 expired bottle of Advil and 2 expired boxes of syringes.

Inspectors wroteBased on staff interview and record review, the facility did not implement written policies and procedures that prohibit and prevent abuse for 1 staff (Registered Nurse (RN)-I) of 8 staff reviewed for caregiver background checks. The facility did not ensure a Certificate of Release or Discharge from Active Duty (DD214) was received from RN-I prior to RN-I's employment on 8/5/24.

Inspectors wroteBased on staff, resident, and resident representative interview and record review, the facility did not ensure the comprehensive plan of care was reviewed and revised for 1 resident (R) (R59) of 22 sampled residents. R59's care plan was not revised to reflect the level of assistance R59 required to complete activities of daily living (ADLs). In addition, the care plan did not contain updated interventions to assist R59 with completing ADLs.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure the resident environment remained as free of accident hazards as possible for 3 residents (R) (R10, R51, and R42) of 4 sampled residents. R10 was known to smoke. A smoking assessment, dated 11/25/25, indicated R10 required assistance with smoking. The facility did not reassess R10 for smoking. R51 was known to smoke. A smoking assessment, dated 9/10/25, indicated R51 did not smoke. The facility did not reassess R51 for smoking. R42 was known to smoke. The facility did not complete a smoking assessment for R42.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not provide appropriate cather care and services for 1 resident (R) (R40) of 2 sampled residents. R40 had an indwelling catheter and was prone to urinary tract infections (UTIs). R40's catheter bag was in contact with the floor on multiple occasions.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure adequate nursing oversight for the administration of as needed (PRN) narcotic medication for 1 resident (R) (R5) of 1 sampled resident. Medication Technician (MT)-M administered PRN hydromorphone HCL (a narcotic pain medication) to R5 and completed pre-and post-pain assessments without a licensed nurse.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure the accurate and safe administration of medication for 2 residents (R) (R3 and R35) of 16 sampled residents. R3 had medication in R3's room. R3 did not have an order to self-administer medication or a self-administration of medication assessment that indicated R3 could safely and accurately self-administer medication. In addition, R3 did not have a care plan for self-administration of medication or to store medication at the bedside. R35 had medication in R35's room. R35 did not have an order to self-administer medication or a self-administration of medication assessment that indicated R35 could safely and accurately self-administer medication. In addition, R35 did not have a care plan for self-administration of medication or to store medication at the bedside.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure it served food at a safe and palatable temperature for 2 residents (R) (R72 and R37) of 2 sampled residents. On 5/12/26, R72 and R37 were served hot food that was below the recommended temperature of 135 degrees Fahrenheit (F) and cold food that was above the recommended temperature of 41 degrees F.

Inspectors wroteBased on staff interview and record review, the facility did not implement their antibiotic stewardship program to ensure the accurate use of antibiotics for 2 residents (R) (R59 and R6) of 8 sampled residents. R59's medical record indicated R59 had urinary tract infections (UTIs) in April and May 2026 and was treated with antibiotic therapy. R59's UTIs were not included on the facility's infection surveillance line list, including criteria for antibiotic therapy. R6's medical record indicated R6 was started on antibiotic therapy for a UTI in May 2026 without completed criteria that indicated R6 had a UTI.

Inspectors wroteBased on staff interview and record review, the facility did not ensure influenza and pneumococcal vaccines were administered for 1 resident (R) (R10) of 5 sampled residents. R10 signed consent for influenza and pneumococcal vaccines on 2/24/26. R10 did not receive the vaccines.

Inspectors wroteBased on staff interview and record review, the facility did not screen, educate, or offer the COVID-19 vaccination to 3 residents (R) (R10, R59, and R7) of 5 sampled residents. R10's COVID-19 vaccination form signed on 6/13/25 was incomplete. The form did not indicate whether R10 consented to or declined the vaccination. R10's medical record did not indicate whether or not a COVID-19 vaccine was provided. R59's medical record did not indicate R59 was offered or declined a COVID-19 vaccination since admission on [DATE]. R7's medical record did not indicate R7 was offered or declined a COVID-19 vaccination since admission on [DATE].

Inspectors wroteBased on observation and staff interview, the facility did not ensure nurse staffing was posted daily. This practice had the potential to affect all 71 residents residing in the facility. The facility did not post nurse staffing on 5/12/26 or 5/14/26.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure the resident environment was free of abuse for 2 residents (R) (R1 and R10) of 10 sampled residents. On 2/15/26, Certified Nursing Assistant (CNA)-J observed R1 crying and R6's hand in R1's shirt touching R1's breast. The facility did not implement preventative safety measures to ensure the safety of R1. In addition, the facility did not complete thorough behavior monitoring and behavior tracking for R6. On 2/11/26, CNA-N observed R10 in R9's room touching R9's private area inside R9's upper thigh. The facility did not complete thorough behavior monitoring and behavior tracking for R10 and did not develop a care plan to address the fact that R10 appeared to target and fixate on R9. [...]

Inspectors wroteBased on staff interview and record review, the facility did not have a qualified Social Worker. This practice has the potential to affect all 75 residents residing in the facility. Social Services Designee (SSD)-G did not meet the necessaray requirements for a qualified Social Worker in a facility licensed for 131 beds.

Inspectors wroteBased on staff interview and record review, the facility did not ensure allegations of abuse were reported to the State Agency (SA) for 6 residents (R) (R6, R1, R10, R9, R7, and R8) of 9 sampled residents. On 2/15/26, Certified Nursing Assistant (CNA)-J observed R6 touching R1's breast. The facility did not report the allegation of abuse to the SA. On 2/11/26, CNA-N observed R10 touching R9's pubic area and thigh. The facility did not report the allegation of abuse to the SA. On 9/14/25, staff observed R1 and R7 in a verbal dispute. R1 stated R1 hit R7 and showed staff R1's reddened left palm. The facility did not report the allegation of abuse to the SA.On 12/23/25, staff observed R8 punch R1 in the arm after R1 grabbed R8's walker. The facility did not report the allegation of abuse to the SA. On 3/6/26, R1 struck and threw a glass of orange juice at R9. [...]

Inspectors wroteBased on staff interview and and record review, the facility did not ensure allegations of abuse were thoroughly and accurately investigated for 6 residents (R) (R6, R1, R9, R10, R7, and R8) of 9 sampled residents. On 2/15/26, Certified Nursing Assistant (CNA)-J observed R6 touching R1's breast. The facility did not ensure the allegation of abuse was thoroughly and accurately investigated. In addition, the facility did not ensure ongoing behavior monitoring was thoroughly completed. On 2/11/26, CNA-N observed R10 touching R9's pubic area and thigh. The facility did not ensure the allegation of abuse was thoroughly and accurately investigated. In addition, the facility did not ensure ongoing behavior monitoring was thoroughly completed. On 9/14/25, staff observed R1 and R7 in a verbal dispute. R1 told staff R1 hit R7 and showed staff R1's reddened palm. [...]

Inspectors wroteBased on staff interview and record review, the facility did not implement policies and procedures for 1 of 8 sampled staff to prevent abuse, neglect, misappropriation, and exploitation of residents. The facility did not ensure a thorough background check was completed for Licensed Practical Nurse (LPN)-H.

Inspectors wroteBased on staff and resident interview and record review, the facility did not ensure bathing/showering assistance was provided for 2 residents (R) (R5 and R2) of 5 sampled residents. R5 and R2 did not receive weekly baths/showers as scheduled.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure physician orders were followed and treatment was not provided without an order for 1 resident (R) (R4) of 3 sampled residents. R4 had an order for bilateral Tubigrips (elasticized tubular bandages designed to provide firm, sustatined support for general edema). The order was not consistently followed. In addition, R4 had a Kerlix (woven gauze) wrap dressing around R4's lower left leg. R4 did not have an order for the dressing.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure adequate supervision and assistance to prevent accidents was provided for 1 resident (R) (R6) of 2 sampled residents. R6 had a history of inappropriately touching residents and staff. The facility did not implement an appropriate intervention to prevent recurrence. On 4/13/26, staff placed R6 within reach of R13. R6 touched and grabbed R13.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure it was free of a medication error rate of 5% or greater. During medication administration observations, 2 errors occurred during 29 opportunities which resulted in a 6.8% medication error rate that affected 2 residents (R) (R11 and R12) of 4 residents observed during medication pass. R11 and R12 did not receive medications as ordered because the medications were not reordered or available.

Inspectors wroteBased on staff interview and record review, the facility did not ensure it was free from a significant medication error for 1 resident (R) (R3) of 6 sampled residents. R3 was admitted to the facility on [DATE] and had an order for vancomycin HCl intravenous (IV) 1250 milligrams (mg) twice daily for a right knee infection. R3 did not receive the antibiotic as ordered on 2/13/26, 2/20/26, 2/23/26, and 3/9/26.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure a prescribed diet was provided for 1 resident (R) (R4) of 2 sampled residents. R4 had an order for a consistent carbohydrate (CCHO) diet. R4 was not provided with the designated CCHO diet dessert.

Inspectors wroteBased on staff interview and record review, the facility did not ensure in-service training of at least 12 hours for 2 of 5 sampled Certified Nursing Assistants (CNAs). CNA-Z was hired on 6/14/21. CNA-Z did not receive at least 12 hours of in-service training during CNA-Z's most recent anniversary hire year. CNA-AA was hired on 10/23/23. CNA-AA did not receive at least 12 hours of in-service training during CNA-AA's most recent anniversary hire year.

Inspectors wroteBased on observation, staff and resident interview, and policy review, the facility failed to ensure 2 residents (R) (R10 and R14) of 15 sampled and supplemental sampled residents received meals at a palatable temperature. R10 and R14 reported receiving cold food. A test tray on 3/10/26 revealed food items were served below the required temperatures for food service and palatability.

Inspectors wroteBased on observation, staff, resident, and resident representative interview, and record review, the facility did not provide the necessary care and services to promote healing and/or prevent wounds from worsening for 3 residents (R) (R1, R2, and R4) of 3 sampled residents reviewed for non-pressure related wounds. R1 had a left total knee arthroplasty (a surgical procedure that replaces the damaged surfaces of the knee joint with artificial parts made of metal and plastic) in 2016. On 10/31/24, R1 reported pain, redness, and swelling in the left knee and lower leg. On 10/31/24, Wound Care Physician (WCP)-F recommended a magnetic resonance image (MRI) scan and an orthopedic consult. An MRI was ordered on 11/7/24 and scheduled for 12/5/24. The MRI was canceled due to insurance concerns. The MRI was rescheduled for 12/28/24 and canceled again due to insurance concerns. [...]

Inspectors wroteBased on staff interview and record review, the facility did not ensure care and treatment was provided to prevent the development of pressure injuries and/or promote healing for 2 residents (R) (R2 and R1) of 3 sampled residents. R2 had a stage 3 pressure injury on the right lateral chest. The facility did not ensure R2's wound care order was consistently followed. R1 had a deep tissue injury (DTI) on the left hip. The facility did not ensure R1's wound care order was consistently followed.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure adequate assistive devices were in place to prevent falls for 1 resident (R) (R5) of 3 sampled residents. R5 had falls on 7/2/25, 7/7/25, 7/23/25, and 10/20/25. R5's care plan was not updated with appropriate interventions.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 1 resident (R) (R2) of 3 sampled residents was free of a significant medication error. R2 was prescribed an intravenous (IV) antibiotic for 28 days for a diagnosis of cellulitis of lower extremity with sepsis. The facility did not ensure R2's antibiotic and corresponding flushes were administered as ordered on multiple occasions.

Inspectors wroteBased on staff interview, resident representative interview, and record review, the facility did not ensure adequate assistance and supervision to prevent falls was provided for 1 Resident (R) (R4) of 7 sampled residents. R4 had left-sided hemiparesis (paralysis on one side of the body) because of a cerebrovascular accident (CVA) and required assistance for bed mobility. On 8/26/25 at approximately 8:00 AM, R4 rolled out of bed while Registered Nurse (RN)-C was providing care and sustained an orbital floor blowout fracture with herniated extraconal fat (a trauma-induced break in the thin bone separating the eye socket from the sinuses, allowing fat from around the eye to bulge into the sinus cavity). The facility's fall investigation indicated the fall occurred because R4 was not positioned appropriately in bed and rolled out of bed when RN-C turned away to get a brief. [...]

Inspectors wroteBased on staff interview and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for 2 Residents (R) (R1 and R17) of 4 sampled residents. A grievance filed on 9/2/25 by R1's Power of Attorney for Healthcare (POAHC) indicated R1's iPad was missing. The allegation of misappropriation was not reported to law enforcement or the State Agency (SA). A grievance filed on 9/24/25 by R17's POAHC indicated R17's watch was missing. The allegation of misappropriation was not reported to law enforcement or the SA.

Inspectors wroteBased on staff interview and record review, the facility did not ensure allegations of misappropriation were thoroughly investigated for 2 Residents (R) (R1 and R17) of 4 sampled residents. R1 and R1's Power of Attorney for Healthcare (POAHC) notified the facility that R1's iPad was missing. The facility did not thoroughly investigate the allegation of misappropriation. R17's POAHC notified the facility that R17's watch was missing. The facility did not thoroughly investigate the allegation of misappropriation.

Inspectors wroteBased on observation, staff, resident, and resident representative interview, and record review, the facility did not ensure 3 Residents (R) (R2, R8, and R11) of 17 sampled residents received care and treatment in accordance with physician orders. R2's edema assessments and weights were not completed as ordered to monitor for fluid retention. In addition, R2's thrombo-embolic deterrent (TED) hose and tubular support bandages (Tubigrips) were not applied as ordered. R8 and R11's Tubigrip stockings were not removed at night as ordered.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not provide the necessary respiratory care and services for 1 Resident (R) (R1) of 4 sampled residents. R1 received supplemental oxygen. R1 did not have an order for oxygen or a care plan for oxygen therapy.

Inspectors wroteBased on staff interview and record review, the facility did not provide pharmaceutical services to ensure the accurate administration of medication for 1 Resident (R) (R2) of 4 sampled residents. D-Mannose (a simple sugar related to glucose considered effective for treating carbohydrate-deficient glycoprotein syndrome and can help with digestive issues, low blood sugar and blood clotting disorders), nateglinide (an oral medication used to manage type 2 diabetes), and pregabalin (an anticonvulsant medication) were not administered to R2 in accordance with physician orders.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not provide pharmaceutical services to ensure the accurate administration of medication for 8 residents (R) (R2, R4, R10, R9, R5, R6, R7, and R8) of 10 sampled residents. On 8/12/25, R2 was administered sevelamer. R2 did not have an order for the medication. On 7/31/25 and 8/1/25, multiple medications for R2 were administered late or not in accordance with physician orders. On 8/4/25, 8/20/25, 8/21/25, and 8/22/25, multiple medications for R4 were not administered in accordance with physician orders. In addition, R4's AM medications were not administered timely on 8/25/25. On 8/25/25, R10's ropinirole was not administered in accordance with the physician order. On 8/25/25, R9's Protonix and potassium chloride were not administered in accordance with physician orders. [...]

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure drugs and biologicals were stored in accordance with the facility's policy. This practice had the potential to affect more than 4 of the 67 residents residing in the facility. On 8/26/25. the 400 North medication cart was left unlocked and unattended.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure food was served at a palatable, safe, and appetizing temperature for 4 residents (R) (R1, R3, R2 and R4) of 6 sampled residents. This practice had the potential to affect more than 4 of the 67 residents residing in the facility. R1 and Anonymous Person (AP)-E (on behalf of R3) indicated hot and cold foods were not always served at palatable temperatures. R2 and R4 indicated the food was not palatable. During the lunch meal on 8/25/25, the facility served food that appeared to be burned. During the lunch meal on 8/26/25, food was not held at a palatable temperature.

Inspectors wroteBased on staff interview and record review, the facility did not provide the necessary care and services to prevent pressure injuries from developing and/or promote healing for 4 residents (R) (R2, R7, R14, and R15) of 4 sampled residents. R2 had a pressure injury on the sacrum and deep tissue damage to the right heel. R2's June 2025 Treatment Administration Record (TAR) contained orders for staff to monitor R2's bilateral feet wounds, offer changes of position during the day, apply zinc cream to the sacrum, encourage R2 to wear soft boots at all times, ensure sheep skin is in place at the foot of R2's bed, and good change of position with toileting schedules. The orders were not consistently completed. R7 had a pressure injury on the sacrum. [...]

Inspectors wroteBased on observation, staff interview, and record review, the facility did not maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection for 2 residents (R) (R5 and R7) of 11 residents observed during the provision of care. Staff did not ensure enhanced barrier precautions (EBP) were followed during transfers and cares for R5. Staff did not ensure EBP was followed during catheter care for R7. In addition, staff did not ensure a catheter collection bag was stored properly and a collection bag exchange was completed appropriately. Staff did not ensure medical equipment was sanitized after use and before being placed in storage.

Inspectors wroteBased on staff interview and record review, the facility did not ensure effective pain management was provided for 1 resident (R) (R2) of 1 sampled resident. R2 was not assessed or provided pain medication during the night (NOC) shift of 3/11/25 into 3/12/25.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not provide pharmaceutical services to ensure the accurate administration of medication for 3 residents (R) (R9, R1 and R3) of 9 sampled residents. R9 had an order for Tresiba (long-acting insulin) and self-administered the medication. R9 did not have a physician order to self-administer Tresiba or a self-administration of medication assessment that indicated R9 could self-administer Tresiba. In addition, 444 units of R9's Tresiba were unaccounted for and allegedly borrowed from other residents' supplies for administration. R1's medical record indicated R1 did not receive multiple doses of medication, including controlled substances and pain medication. In addition, R1 did not receive Rosuvastatin on 4/23/25 and had to request the medication from Registered Nurse (RN)-G. [...]

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure food preferences were honored for 2 residents (R) (R1 and R3) of 2 sampled residents. R1 was not provided R1's preferred breakfast item of fried eggs and was told by kitchen staff that eggs were not available. R3's meal ticket indicated R3's food preference for breakfast was 3 fried eggs if available. R3 did not receive fried eggs and was told by kitchen staff that eggs were not available.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This practice had the potential to affect all 69 residents residing in the facility. Staff did not monitor and document cooling temperatures. Staff did not consistently monitor and document food cooked temperatures Staff did not wash and sanitize dishes in the three-compartment sink per manufacturer's guidelines or the facility's policy.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure nutritional needs were met or diet orders were followed for 5 residents (R) (R7, R26, R16, R24, and R48) of 5 sampled residents. This practice had the potential to affect multiple other residents in the facility. Residents on pureed diets did not receive the correct serving size for lunch on 1/27/25 and 1/28/25 and breakfast on 1/28/25. Residents on carb controlled (CCHO) and low concentrated sweets (LCS) diets did not receive their diets as ordered for lunch on 1/27/25 and 1/28/25 and breakfast on 1/28/25. R26's meal ticked indicated R26 should receive double portions, diet Jell-O and sugar-free cereal. R26's meal ticket was not followed during lunch on 1/27/25 and breakfast on 1/28/25. R48 had an order for ground meat when served roasts. R48 did not receive ground pork roast for lunch on 1/28/25. [...]

Inspectors wroteBased on staff interview and record review, the facility did not ensure court-ordered protective placement was obtained for 1 resident (R) (R48) of 2 sampled residents. R48 had a legal Guardian. The facility did not obtain court-ordered protective placement to ensure R48 resided in the least restrictive environment at the facility.

Inspectors wroteBased on staff and resident representative interview and record review, the facility did not ensure 3 residents (R) (R13, R15, and R168) of 3 sampled residents received a copy of the Skilled Nursing Facility Advanced Beneficiary Notice (ABN) form or were provided a Notice of Medicare Non-Coverage (NOMNC) form in a timely manner. The facility did not provide R13 and R15 with an ABN form or a timely NOMNC form when R13 and R15's Medicare services ended and R13 and R15 remained in the facility. The facility did not provide R168 with a timely NOMNC form when R168's Medicare services ended on 11/18/24.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not provide privacy during showers for 1 resident (R) (R7) of 1 sampled resident. R7 indicated staff interrupted R7 and entered the shower room during R7's showers. R7 filed a grievance with the facility on 1/23/25. Staff created a sign for R7 to use while R7 showered, however, staff were not educated about the sign and interrupted R7 again on 1/27/25.

Inspectors wroteBased on staff and resident interview and record review, the facility did not ensure the provision of safe and comfortable water temperatures for 2 residents (R) (R7 and R16) of 23 sampled residents. R7 reported to staff that R7 did not have warm water while showering on multiple occasions. R16 reported that staff gave R16 a bath with cool water.

Inspectors wroteBased on staff and family interview and record review, the facility did not make a prompt effort to resolve a grievance for 1 resident (R) (R25) of 2 sampled residents. R25 had a lab culture obtained on 1/2/25. On 1/3/25, 1/4/25, 1/5/25, and 1/6/25, R25's Family Member ((FM)-N) called the facility for the culture results but staff were unable to provide the results. FM-N filed a grievance with the facility on 1/6/25. At a care conference for R25, FM-N was notified the grievance was resolved, however, the facility did not provide an explanation of what happened or the resolution.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure treatment and services were provided to prevent the development of pressure injuries and/or promote healing for 1 resident (R) (R44) of 4 sampled residents. R44 had impaired skin integrity and multiple wounds, including a chronic ulcer of the buttocks. R44's pressure-relieving air mattress was not correctly set to R44's body weight. In addition, R44's care plan did not contain an individualized setting for the mattress.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure 2 residents (R) (R15 and R368) of 3 sampled residents received the appropriate care and services to prevent urinary tract infections (UTI). R15's uncovered catheter bag was observed on the floor underneath R15's wheelchair on multiple occasions. R368 was on enhanced barrier precautions (EBP). R368's uncovered catheter bag was observed on the floor underneath R368's bed.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not provide pharmaceutical services to ensure accurate administration of drugs and biologicals for 3 residents (R) (R7, R114, and R15) of 8 sampled residents. R7 did not receive eight doses of scheduled medication because the medication was not available. R114 did not receive a scheduled medication because the medication was not available. Licensed Practical Nurse (LPN)-U dispensed an expired medication for R15 and did not dispose of the medication according to the facility's policy.

Inspectors wroteBased on staff interview and record review, the facility did not ensure prompt laboratory services for 1 resident (R) (R25) of 1 sampled resident. R25 had an order for a wound culture on 1/2/25. R25's wound culture was obtained on 1/2/25 and again on 1/5/25. Due to a delay in submitting the culture sample timely, R25 did not start antibiotic therapy until 1/8/25.

Inspectors wroteBased on resident and staff interview and record review, the facility did not provide pharmaceutical services to meet the needs of 1 resident (R) (R1) of 6 sampled residents. R1 was admitted to the facility on [DATE] and had an order for Vyvanse. The facility did not provide R1 with prescribed medication from 11/9/24 through 11/11/24.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure nutritional needs were met for 1 resident (R) (R3) of 1 resident who had an order for double entree portions at all meals. R3's diet order included double entrees at all meals for wound healing. R3 did not receive a double entree during the lunch meal on 12/5/24.

Inspectors wroteBased on staff interview and record review, the facility did not ensure the resident environment remained free of abuse for 1 resident (R) (R1) of 6 sampled residents. During the night (NOC) shift on 9/24/24-9/25/24, Licensed Practical Nurse (LPN)-D observed R2 touch R6's leg and try to kiss R6. LPN-D immediately separated R2 and R6 and documented the incident in R2's medical record. Following the incident, no interventions were put in place to ensure the safety of R6 or other residents. On 9/25/24 at approximately 11:00 AM, Registered Nurse (RN)-C observed R1 and R2 in the lounge. R2 had one arm around R1's shoulders and the other hand inside R1's brief. R2 moved R2's hand back and forth while R1 attempted to push R2's hand away. RN-C separated the residents, placed R2 on 1:1 supervision, and notified supervisory staff. [...]

Inspectors wroteBased on observation and interview the facility did not ensure that food was stored, prepared and served under sanitary conditions. Staff were observed touching ready to eat food after touching non-sanitized food surfaces with no barrier or handwashing. This deficient practice had the potential to affect 42 of 43 residents served food from these kitchenettes. On 10/31/23, Dietary Aide-S was observed touching ready to eat food (cupcakes) with a bare hand after touching non-sanitized food surfaces (counter and steam table lid covers) and place the food item onto trays for residents to eat.

Inspectors wroteBased on interview and record review the facility did not establish and maintain a comprehensive Water Management Plan (WMP), to reduce the growth and spread of Legionella, which has the potential to affect 43 of the 43 residents residing in the facility at the time of the survey. The facility's Water Management Plan (WMP) did not address components of a complete water management plan to include; [...]

Inspectors wroteBased on staff interview and record review the facility did not ensure incidents of potential abuse were investigated thoroughly for 1 (R10) of 2 residents reviewed for potential abuse. *R10 was discovered with a large bruise. The facility completed an investigation and reported the incident to the state agency; however, the facility's investigation did not include resident interviews or like resident assessments to identify the scope of the allegation.

Inspectors wroteBased on interviews and record review the facility did not ensure that residents received care and treatment in accordance with professional standards of practice for 1 (R342) of 12 residents reviewed for Quality of Care. R342's admission orders, which included insulin and blood sugar monitoring, were not correctly transcribed onto the Medication Administration Record (MAR). R342 sustained a fall related to a hypoglycemic (low blood sugar) episode.

Inspectors wroteBased on observation, interview and record review the facility did not ensure residents with pressure injuries received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 (R38) of 3 residents reviewed for pressure injuries. R38 was admitted to the facility with an identified pressure injury to the sacrum. The wound was not comprehensively assessed and was staged incorrectly. In addition, treatment for the pressure injury was not implemented upon admission.

Inspectors wroteBased on observation, interview and record review the facility did not ensure residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise for 1 (R1) of 2 residents reviewed for weight loss. R1 had daily weights ordered which were not consistently completed. R1 sustained weight loss over 9 days of 8.6 pounds (6.06%). Neither the Physician or Dietician were notified of R1's weight loss.