Sea Cliff Healthcare Center

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure four of five final sampled residents (Residents 1, 2, 3, and 4) reviewed for unnecessary medications were free from unnecessary psychotropic medications. * The facility failed to ensure Resident 1's nonpharmacological interventions for quetiapine (antipsychotic medication) and risperidone medications were separately monitored. * Resident 2 was receiving Risperdal (risperidone, antipsychotic medication) 1.5 mg, when the order was for Risperdal 1 mg. In addition, the facility failed to ensure Resident 2's nonpharmacological interventions for Risperdal, citalopram (antidepressant medication), and Remeron (antidepressant medication) medications were separately monitored. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided for five of five final sampled residents (Residents 24, 95, 99, 132, and 161) and one nonsampled resident (Resident 113) reviewed for respiratory care * The facility failed to ensure Resident 24 was provided with continuous oxygen at 2 LPM via nasal cannula as per the physician's order. In addition, the facility failed to ensure only the licensed nurse administered oxygen to Resident 24. Moreover, the facility failed to ensure Resident 24's nebulizer mask was not stored in a set bag when not in use. * The facility failed to ensure Resident 95's nebulizer mask was dated and stored in a set-up bag when not in use. * The facility failed to ensure Resident 99's nasal cannula was labeled with the date. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure four of five final sampled residents (Residents 1, 2, 3, and 6) reviewed for unnecessary medications were free from the unnecessary medications. * The facility failed to monitor Resident 1's SBP prior to administering the midodrine (medication to treat low blood pressure) medication as ordered by the physician. In addition, the facility failed to follow the physician's order to hold the midodrine medication when Resident 1's SBP was greater than 120 mmHg. * The facility failed to follow the physician's order to hold the midodrine medication when Resident 2's SBP was greater than 130 mmHg. * The facility failed to follow the physician's order to hold the clonidine (medication to treat high blood pressure) medication when Resident 3's systolic blood pressure (SBP) was less than 160 mmHg. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure proper medication storage for two of three medication rooms inspected (Medication Room A and Central Supply Room) and two of five medication carts inspected (Medication Carts A and B). * The facility failed to ensure the expired medication was removed from Medication Cart A. * The facility failed to ensure the medications were stored in a proper room temperature in Medication Room A. * The facility failed to ensure the expired supplies were removed from Medication Cart B. * The facility failed to ensure the externally used medications were stored separately from the orally used medications in the central supply room. [...]

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the food safety and sanitary requirements were met in the kitchen. * The facility failed to ensure food preparation utensils and equipment were in good, sanitary, and cleanable working conditions. * The facility failed to ensure food items were discarded by the best by or use by date. * The facility failed to ensure fruits with tough rinds or peels like cantaloupes were washed with a brush. These failures had the potential to cause foodborne illnesses to the medically vulnerable resident population who consumed food prepared in the kitchen.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to maintain the infection control practices to help prevent the development and transmission of diseases and infection. * The facility failed to ensure the infection control practices were implemented in the facility's laundry room when the laundry staff folded the clean linen towards her body touching her uniform. In addition, the facility failed to maintain the laundry area free from grayish dust particles. * LVN 4 failed to disinfect the insulin pen injector prior to the administration of medication for Resident 6. * RN 3 failed to disinfect the vial medication prior to the medication administration for Resident 9. * The facility failed to ensure Resident 42's five small bottles of water were not on the floor. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to fully inform the resident or responsible party and obtain a completed informed consent prior to the use of the psychotropic medications for three of five final sampled residents (Residents 2, 4, and 14) reviewed for unnecessary psychotropic medications. * The facility failed to ensure Resident 2's consent form for the use of risperidone (antipsychotic medication) included information about the medication's exact daily dosage. * The facility failed to ensure the informed consent was obtained from Resident 4's representative prior to Resident 4's use of mirtazapine (antidepressant medication), alprazolam (antianxiety medication) and quetiapine (antipsychotic medication). [...]

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure two of 33 final sampled residents (Residents 23 and 162) were assessed to self-administer medications. * Resident 23's nightstand drawer had a stomach relief bismuth subsalicylate (medication to treat diarrhea, heartburn, nausea, and upset stomach) inside the drawer. There was no physician's order for bismuth subsalicylate and no self-administration assessment for Resident 23. *Resident 162's bedside table had two calcium carbonate (a medication used as antacids for relief from heartburn or acid indigestion) tablets. These failures had the potential to impact Resident 23 and 162's safety and well-being.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure two of 33 final sampled residents (Residents 2 and 30) were treated with dignity. * CNA 6 failed to close Resident 2's privacy curtains, exposing the resident's thighs to other residents, visitors, and staff. * CNA 6 was standing when she fed Resident 2, who was eating in bed. * Resident 30 was observed from the hallway wearing a diaper and their thigh exposed. Additionally, Resident 30's privacy curtain was open. These failures had the potential to impact Resident 2 and 30's psychosocial well-being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to develop a care plan and implement care plan interventions for four of 33 final sampled residents (Residents 42, 95, and 161) and one of three closed record sampled residents (Resident 83). * The facility failed to implement Resident 42 and 95's care plan intervention to monitor the residents' safety for entrapment every shift. * The facility failed to develop a care plan to address Resident 83's intergluteal cleft extending to perianal (describes the natural groove between the buttocks that reaches the anus) MASD (Moisture-Associated Skin Damage, skin inflammation or erosion from prolonged exposure to moisture like urine, feces, sweat, or wound drainage, weakening the skin's barrier and making it vulnerable to irritation, infection, friction, and breakdown). [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the plan of care was revised for one of 33 final sampled residents (Resident 30). * Resident 30's care plan was not revised to address the specific care needs for the resident's weight loss and pressure injury prevention. This failure posed the risk for Resident 30 to not receive the person-centered care and services required to attain or maintain her highest level of physical and mental well-being.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent the development of a new pressure injury (areas of damaged skin caused by staying in one position for a long time which reduces blood flow to the area and causes the skin to die and develop a sore) and promote healing of the existing pressure ulcer for two of four final sampled residents (Residents 2 and 30) reviewed for pressure injury. * RN 4 failed to follow Resident 2's physician's order to cleanse the pressure injury with normal saline during the wound care observation. * The facility failed to ensure Resident 30's heels were elevated on pillow to offload pressure as ordered by the physician. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of three final sampled residents (Resident 30) reviewed for nutrition maintained acceptable parameters of nutritional status. * The facility failed to ensure Resident 30's weight was monitored monthly as indicated in the care plan. This failure had the potential to negatively impact the resident.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to properly maintain and assess the IV accesses for three of three final sampled residents (Residents 9, 161, and 196) reviewed for IV catheters. * The facility failed to ensure Resident 9's arm circumference was measured after the initial assessment related to the resident's PICC line catheter as per the facility's P&P. * The facility failed to ensure Resident 161's midline catheter dressing was changed in seven days as per the physician's order. In addition, there was no measurement of the arm circumference after the initial assessment. Moreover, the physician's orders for the cap changes of the midline catheter were for a PICC line instead of a midline catheter. * The facility failed to ensure Resident 196 had orders for monitoring the midline IV catheter. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to attain or maintain the highest physical well-being for one of one final sampled resident (Resident 95) reviewed for dialysis care. * The facility failed to ensure Resident 95's fluid intake and output related to the dialysis were consistently monitored. This failure posed the risk of possible medical complications for Resident 95.

Inspectors wroteBased on observation, interview, medical record review, and facility document review, the facility failed to ensure the facility staff (LVNs 4 and 8) had specific competencies and standard of practice skill sets needed to provide the safe and efficient nursing care to the residents. * LVN 4 administered expired insulin to Resident 6. * LVN 8 administered medications left at Resident 102's nightstand prepared by another licensed nurse. These failures had the potential to put the residents at risk for care not provided in a safe and competent manner.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the pharmaceutical services to ensure the accurate administration of the medication. The facility's medication error rate was 4.76%. * LVN 4 administered expired insulin to Resident 6. * LVN 8 administered medications left at Resident 102's nightstand prepared by another licensed nurse. These failures had the potential to put the residents at risk for care not provided in a safe and competent manner.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the Pharmacist Consultant identified and reported all irregularities during the monthly medication regimen for one of five final sampled residents (Resident 6) reviewed for pharmaceutical services. * Resident 6 was diagnosed with diabetes and was on long term insulin. Resident 6 did not have a Hemoglobin A1C test completed for over a year. This failure resulted in inadequate management of Resident 6's diabetes, increasing the risk of serious health issues.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure two of five sampled residents (Residents 2 and 3) reviewed for unnecessary medications were free from significant medication errors. * The facility failed to ensure Resident 2 received the appropriate dose of Risperdal (antipsychotic medication) as ordered by the physician. * The facility failed to ensure Resident 3's clonidine HCL (hydrochloride) (medication to lower blood pressure) was held as ordered by the physician. These failures had the potential to negatively impact the residents' health outcomes.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the PASRR (Preadmission Screening and Resident Review) screening was accurately completed for one of five final sampled residents (Resident 12) reviewed for PASRR. * Resident 12's PASRR Level 1 screening was not updated to include the serious mental illness diagnosis. This failure had the potential of not providing the resident to be screened for mental illness or intellectual disabilities with additional resources if needed.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable well-being for one of eight sampled residents (Resident 4). * The facility failed to assess and monitor Resident 4's condition after the resident had difficulty swallowing his morning medications on [DATE]. In addition, the facility failed to administer the warfarin sodium (blood thinner) to Resident 4 daily as ordered by the physician on [DATE]. These failures had the potential to negatively impact the resident's well-being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the pharmaceutical services for one of eight sampled residents (Resident 4) when: * LVN 4 crushed Resident 4's iron (supplement) tablet and administered it to the resident. This failure had the potential to negatively affect the resident's health conditions and posed the risk for possible complications.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the comprehensive plan of care for one of eight sampled residents (Resident 4) was revised to reflect the resident's current care needs and interventions. * The facility failed to ensure Resident 4's plan of care for swallowing problem was reviewed and revised to address Resident 4's difficulty in swallowing the medication and coughing with sips of water. This failure posed the risk of not providing appropriate, consistent, and individualized care to the resident.

Inspectors wroteBased on observation, interview, and the facility P&P review, the facility failed to ensure one of four sampled residents (Resident 3) was assessed to determine if it was safe for the resident to self-administer the medications. * Resident 3 was observed with a medication cup filled with multiple medications at the bedside table. Resident 3 had no assessment, physician's order, and/or care plan problem addressing the self-administration of the medications. This failure had the potential for Resident 3 to administer medications inaccurately.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to maintain the infection control program and practices to help prevent the development and transmission of diseases and infections. * The laundry and clean linen rooms were not maintained to ensure a clean area, free from potential contamination. * Resident 144 (final sampled resident)'s infection was not reported on the facility's monthly infection control log. * Residents 127 and 159's infections (nonsampled residents) were incorrectly listed as meeting McGeer's Criteria on the facility's monthly infection control log. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to notify the resident and/or their representative of the transfer and reasons for the transfer in writing and send a copy of the notice to the LTC Ombudsman when the resident was transferred to the acute care hospital for one of three final sampled residents (Resident 25) reviewed for hospitalization. This failure had the potential for the resident and their representative of not knowing about the appeal process and posed the risk of the LTC Ombudsman not being aware of the circumstances of the resident's transfer/discharge should the resident and their representative believe the transfer or discharge was inappropriate or involuntary.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the resident and/or their representative were provided with the written information regarding the facility's bed-hold policy when the resident was transferred to the acute care hospital for one of three final sampled residents (Resident 25) reviewed for hospitalization. This failure had the potential for Resident 25 and/or their representative to be unaware of their rights to request a bed hold and return to the first available bed should the resident's hospital stay exceed the seven-day bed-hold period.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services related to the GT per the facility's P&P for three of three final sampled residents (Residents 87, 111, and 152) reviewed for enteral feeding. * Two of two licensed nurses administered the medications to Residents 111 and 152 by pushing the medications through the GT instead of gravity. * One of two licensed nurses (LVN 4) did not check the tube placement and residual volume before the GT medication administration for Resident 111. * Resident 87's GT placement and residual checks were not performed prior to starting the resident's enteral feeding. [...]

Inspectors wroteBased on observation, interview, medical record review, and the facility P&P review, the facility failed to ensure the oxygen was administered as ordered by the physician for one of two final sampled residents (Resident 152) reviewed for oxygen use. This failure had the potential to affect the respiratory health and well-being of Resident 152.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the provision of pharmacy services met the needs of the residents in accordance with the facility's P&P when: * The licensed nurse left Resident 152's medications unattended on the resident's bedside table during the medication administration. This failure had the potential for misuse of the medications by the residents, facility staff and/or visitors. * An opened container of the CII E-kit was not replaced timely within 72 hours after being opened. This failure had the potential for the emergency medications to be unavailable when needed. * One tablet of Percocet (narcotic pain medication) was removed from CII E-kit and wasted due to the resident's refusal was not disposed of as per the facility's policy; [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure two of five sampled residents (Residents 47 and 57) reviewed for unnecessary psychotropic (drug that affects brain activities associated with mental processes and behaviors) medications were free from unnecessary psychotropic medications when: * For Resident 57, the physician did not document the rationale and specified duration for the extended use of the as needed hydroxyzine (a psychotropic medication for anxiety and tension caused by nervous and emotional conditions. also used to relieve symptoms of allergic conditions) beyond 14 days. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medication error rate during the medication administration observation was less than 5%. * The facility had a cumulative medication error rate of 20%. Six medication errors occurred out of 30 opportunities during the medication administration for two out of four residents (final sample residents, Residents 111 and 152). This failure resulted in medications not given in accordance with the physician's orders and the facility's P&P, which had the potential for residents not receiving the full therapeutic effects of the medications and worsening of the residents' medical conditions.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to store and label the medications in accordance with the manufacturer's instructions and the facility's P&P when: * An amber bottle of megestrol acetate (appetite stimulant) oral suspension was not properly labeled with the specific instruction on preparation in Medication Cart 2. * A bottle of Katerzia (amlodipine, use for treatment of hypertension, to lower blood pressure) oral suspension requiring refrigerated storage condition was stored at a room temperature in Medication Cart 2. * An opened Levemir insulin vial was stored without an open date in Medication Cart 1. [...]

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the food safety and sanitation guidelines were followed as evidenced by: 1. The frozen meat was not thawed in a safe manner. 2. The food preparation equipment was not clean or in good working condition. 3. The dry bulk food was not stored properly. 4. The meal preparation equipment was not air dried. 5. Two floor drains did not have a backflow prevention. 6. The cleaning equipment was not stored in a sanitary manner. These failures posed the risk for food borne illnesses in highly susceptible resident population of 157 facility residents who received food prepared in the kitchen.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the RD completed or reviewed the MDS Nutritional Status assessment and the quarterly nutritional assessment for accuracy for one of 33 final sampled residents (Resident 87). This failure posed the risk for the residents' nutritional needs to not be met in the facility.

Inspectors wroteBased on interview, medical record review and the facility P&P review, the facility failed to ensure the medical records were complete and accurately maintained for 12 of 33 final sampled residents (Residents 16, 25, 32, 37, 46, 47, 56, 57, 65, 87, 146, and 158). * Resident 47's POLST incorrectly showed the resident had the advanced directive and health care agent (person listed in the advanced directive who can legally make health-care decisions for the resident). * Resident 87's POLST failed to show the names of facility staff who reviewed and confirmed the form with the resident's responsible party. * Resident 57's post fall eInteract Change in Condition Evaluation V4.2 showed the incorrect time for the physician and resident notification. * Resident 158's POLST failed to show the physician's signature. * Resident 146's POLST failed to show the physician's signature. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services for two of four final sampled residents (Residents 16 and 93) reviewed for hospice services * The facility failed to ensure Residents 16 and 93 received HA visits two times a week per the hospice provider's calendar. This failure posed the risk for delays in the communication between the hospice provider and facility, which may affect the residents' care.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review the facility failed to implement an antibiotic stewardship program to reduce the risk of unnecessary or inappropriate antibiotic use when two nonsampled residents (Residents 127 and 159) were being treated for conditions which did not meet the McGeer's criteria. This failure had the potential of not accurately identifying true infections and exposing the residents to unnecessary antibiotic use.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to maintain the essential equipment in the safe operating conditions. * The facility's ice machine was not cleaned and sanitized as per the manufacturer's instructions. This failure had the potential for the essential equipment not functioning in the way it was intended and in turn cause contamination of the food, leading to illnesses for the residents.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the MDS was coded accurately for two of three final sampled residents (Residents 25 and 87) reviewed for nutrition. * The facility failed to ensure the MDS was coded accurately when Resident 25 had a weight loss of more than 5% in a month. * Resident 87's MDS was inaccurately coded to reflect the resident's weight gain. These failures had the potential for the residents to not receive individualized plans of care to address their individual care needs and inaccurate data for quality measures.

Inspectors wroteBased on interview, medical record review and facility P&P review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable well-being for one of four final sampled residents (Resident 47) reviewed for accidents. * Resident 47's post fall neurological evaluation was missing the hourly neurological assessments after the resident had an unwitnessed fall on 1/18/25. This failure had the potential for a delay in providing care to the resident.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to protect the residents' rights to be free from the physical abuse for two of six sampled residents (Residents 1 and 2). * Resident 2 allegedly called Resident 1 a bad word and scratched Resident 1's face. In response, Resident 1 bit Resident 2's hand and was found by staff with Resident 2's hand in her mouth. Resident 1 had a scratch mark on her face and Resident 2 had a bite mark on her right hand. This failure had the potential for Residents 1 and 2 to be seriously injured or have psychosocial harm.

Inspectors wroteBased on interview, medical record review and facility P&P review, the facility failed to develop a plan of care to reflect the individual care needs for one of six sampled residents (Resident 3). * The facility failed to develop a care plan problem to address Resident 3's refusal of taking medications. This posed the risk of not providing appropriate, consistent, and individualized care to the resident.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to comply with the State law when two staff (CNAs 2 and 6) were not wearing their name badges while on duty. This failure had the potential to place the residents at risk to be cared for by unidentified persons.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services for two of seven sampled residents (Residents 2 and 5). * Resident 2 did not receive Marinol (medication to stimulate appetite) as ordered from 2/2 - 2/7/24, and the physician was not notified. Additionally, there was no follow up with the pharmacy about the medication not being delivered timely. * Resident 5 complained of numbness and feeling like having a stroke; however, the physician was not notified until six hours and 11 minutes later. These failures had the potential to negatively affect the residents'health conditions and well-being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to one of two sampled residents (Resident 1) as ordered by the physician. * The facility failed to order and administerResident 1's aspirin (a medication used to thin the blood) and atorvastatin (a medication to treat high cholesterol) according to the discharge medication orders from the hospital. This failure had the potential to negatively affect the residents' health condition and well-being.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to promote dignity and respect for eightof 14 sampled residents (Residents 2, 3, 7, 8, 9, A, B, and C) * The facility failed to ensure the resident's call lights were answered in a timely manner for Residents 3, 7, 8, 9, A, B, and C. * The facility failed to ensure the call light was within the reach of Resident 2. These failures posed the risk to negatively affect the residents' physical and emotional well-being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to develop the comprehensive plan of care to reflect the individual activity needs for one of 14 sampled residents (Resident 2). This failure posed the risk of not providing individualized activities to the residents.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to one of 14 sampled residents (Resident 9). * The facility failed to ensure Resident 9 received the protein supplement as ordered by the physician two times a day. This had potential for not providing necessary care and services to meet the care needs for this resident and medical complication.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the RNA services to seven of 14 sampled residents (Residents 2, 9, 10, 11, 12, 13,and 14) as ordered by the physician. This failure had the potential for the resident's decline in ROM functions and deterioration in their ability to perform ADL care. Findings. Review of the facility's P&P titled ROM (range of motion) and Contracture Prevention revised 5/2019 showed the facility is to ensure that resident receive services, care, and equipment to assure that every resident maintains, and/or improves to his/her highest level of range of motion and mobility, unless reduction is clinically unavoidable. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one sampled resident (Resident 1) wasassessed to determine if it was safe to self-administer their medications prior to self-administration of the medications as per the facility's P&P. * LVN 3 left Resident 1's oral medications at the Resident 1's bedside unattended for Resident 1 to self-administer medications without LVN 3's supervision. However, Resident 1 was not assessed to safely self-administer the medications. This failure put Resident 1 at risk for unsafe self-administration of the medications.

Inspectors wroteBased on observation and interview, the facility failed to maintain a safe, clean, comfortable, and homelike environment for one of three sampled residents (Resident 3). * The baseboards and walls by the baseboards in Resident 3's bathroom (in Room A) were observed in a state of disrepair: the walls and baseboards were unclean, stained, had exposed plaster, holes in some areas, and had peeling paint. The toilet seat was also observed with yellow stains. This failure had the potential to negatively impact the resident's safety, right to a dignified existence, and quality of life.

Inspectors wroteBased on interview and medical record review, the facility failed to obtain radiology services for one of three sampled residents (Resident 1). * The facility failed to obtain a chest x-ray for Resident 1 as ordered. This had the potential to result in delayed diagnosis and treatment for Resident 1.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the medical record for one of three sampled residents (Resident 1) was accurate. The facility failed to ensure Resident 1's Fall Risk Evaluation was completed accurately. This had the potential for the resident's care needs not being met as their medical information was inaccurate.

Inspectors wroteBased on observation, interview, facility P&P review, facility document review, the facility failed to follow the menu for 19 residents who were on a pureed diet. The facility failed to ensure the kitchen staff used the correct scoop size when serving pureed broccoli. This failure had the potential of not following the menu and not meeting the residents' nutritional needs which could lead to nutritional-related health complications.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure the food safety and sanitation requirements were met. * The facility failed to air dry equipment. * The facility failed to ensure the upper plate domes and bottom plates were free from chip and cracks. * The facility failed to ensure the chlorine strips and pH sanitizer strips were not expired. * The facility failed to ensure Resident 53's food items were not served to Resident 42. These failures had the potential to cause foodborne illnesses in a medically vulnerable resident population who consumed food prepared in the kitchen.

Inspectors wroteBased on interview, facility document review, and facility P&P review, the facility failed to implement their infection control program in accordance with the facility's P&P. * The facility failed to implement their infection control surveillance program for the months of January 2022 through September 2022. The facility conducted surveillance of the resident infections based on whether the residents were prescribed the antimicrobial medications. The facility failed to determine whether the residents who were not prescribed antimicrobial medications met the facility's criteria for infection (utilizing McGeer's Criteria) and thus, failed to include these residents in the facility's infection control surveillance program. [...]

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure care was provided in a manner which promoted respect and dignity for two of 33 final sampled resident (Residents 39 and 526). * Resident 39 had to wait 40 minutes to an hour to have her soiled diaper changed by the facility staff. This had the potential of not maintaining or enhancing the resident's self-esteem and self-worth. * The facility failed to ensure privacy during the delivery of personal care and services by pulling the privacy curtains closed and providing clothing or a cover to prevent exposure of body parts for Resident 526. This failure posed the potential to negatively impact the resident's psychosocial well-being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to obtain an informed consent (process in which a health care provider educates a patient about the risks, benefits, and alternatives of a given procedure or intervention to obtain agreement or permission for care, treatment, or services) for the psychotropic medications for one of 33 sampled residents (Resident 99). This failure had the potential to compromise the right of the residents or responsible parties (persons designated to make decisions on behalf of the residents) to be fully informed regarding care and treatment to make health care decisions.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the facility's P&P addressing self administration of the medications was implemented for one nonsampled resident (Resident 5). * LVN 11 left Resident 5's oral medications at the resident's bedside unattended and Resident 5 took the oral medications without LVN 11's supervision. However, Resident 5 was not a candidate to safely self-administer the medications. This failure put Resident 5 at risk for unsafe self-administration of the medications.

Inspectors wroteBased on interview and medical record review, the facility failed to provide information on how to formulate an advance directive for four of 33 final sampled residents (Residents 82, 95, 121, and 471). This had the potential for the residents' decision regarding their healthcare and treatment options not being honored.

Inspectors wroteBased on interview and medical record review, the facility failed to protect Resident 526's right to be free from physical abuse by Resident 60. This had the potential for physical abuse to continue for Resident 526.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure accurate assessment and coding of MDS for two of 33 sampled residents (Residents 99 and 144) as evidenced by: * The facility failed to accurately assess Resident 99 when the quarterly assessment dated [DATE], showed Resident 99 did not receive any antipsychotic medication the last seven days. The MAR showed Resident 99 received antipsychotic medication from 6/15/22 through 6/21/22. * The facility failed to accurately code Resident 144's weight loss in the MDS. These failures resulted in inaccurate assessment which could delay appropriate therapy leading to poor resident outcomes.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to develop the plans of care to reflect the individual care needs for six of 33 final sampled residents (Resident 98, 99, 123, 138, 140, and 144). * The facility failed to develop a comprehensive person-centered care plan to address Resident 123's indwelling urinary catheter. * The facility failed to develop a comprehensive person-centered care plan to address Resident 140's Trazodone use. * The facility failed to develop a comprehensive person-centered care plan to address Resident 144's refusal of meals and weight loss. * The facility failed to implement bilateral floor mats for Resident 138. * The facility failed to implement bilateral floor mats for Resident 98 to prevent injury if fall occurred, and failed to develop a care plan to address Resident 98's left first toe wound. [...]

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the comprehensive plan of care for one of 33 final sampled residents (Resident 95) was revised to reflect the resident's current care needs and interventions. This posed the risk of not providing Resident 95 with individualized and person-centered care.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services provided to meet care needs related to wound assessments and soft neck collar (cervical collar or neck brace, a medical device worn around the neck to help provide stability and support) application for two of 33 final sampled residents (Residents 95 and 98). * Resident 98 was observed with a wound on the tip of his left first toe; however, Resident 98's medical record failed to show documentation the facility conducted an assessment of the wound. This posed the risk for a delay in the identification of a wound and the implementation of treatments and interventions necessary to promote wound healing. * The facility failed to ensure the soft neck collar was applied to Resident 95 as per the physician's order. [...]

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to provide floor mats for three of 33 final sampled residents (Residents 95, 98, and 138) as per the physician's orderd and the plans of care. This failure posed the risk for additional falls and injury to the residents.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to provide the necessary services and care for the use of an indwelling urinary catheter for one of 33 final sampled residents (Resident 123) when there was no documented evidence showing an indication for the indwelling urinary catheter use for Resident 123. This posed the risk for infection related to unnecessary catheter use.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure one of 33 final sampled residents (Resident 523) received the appropriate and necessary services for the care of a colostomy bag. * The staff failed to ensure proper care for Resident 523's colostomy bag by pricking a hole in the colostomy bag due to the initial improper application of the colostomy bag to the resident's lumbar region. This failure had the potential to result in leakage of gas and fecal matter and made the resident feel embarrassed and frustrated.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of 33 final sampled residents (Resident 144) received the appropriate services to meet their nutritional needs and maintain desirable weight. * The facility failed to notify the physician regarding Resident 144's weight loss and develop a plan to address the resident's weight loss. These failures had the potential for further weight loss and not meeting the nutrition needs for Resident 144.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure necessary care and services related to GT were provided for two of 33 final sampled residents (Residents 50 and 138). * The licensed nurse failed to check the GT (a flexible tube surgically inserted into the abdomen to the stomach for feeding and medication administration) placement correctly before medication administration for Resident 138. * The facility failed to ensure Resident 35's head of bed was elevated at 30-45 degrees during GT feeding administration as ordered. These failures had the potential for complication related to GT including aspiration.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure one of 33 final sampled residents (Resident 50) received appropriate care for peripheral IV (intravenous, infusion of substances such as an antibiotic directly into a vein). * Resident 50's IV site was on the left wrist, and Resident 50's left hand was observed swollen while IV fluid was infusing. In addition, the IV site dressing was undated. Furthermore, the IV administration was not documented and the IV monitoring was incomplete. These failures posed the risk for Resident 50 to develop complications related to the use of the peripheral IV catheter.

Inspectors wroteBased on observation, interview, medical record review and facility's P&P, the facility failed to provide the necessary treatment to five of 33 final sampled residents (Residents 15, 27, 88, 95, and 521) receiving oxygen therapy and receiving medication through a nebulizer (a device which delivers medicated mist to a person via a mouth piece or a face mask). * The facility failed to change the nebulizer mask and tubing for Residents 15, 27, and 95 as per the facility's P&P. In addition, the facility failed to ensure Resident 95's humidifier bottle was dated. * The facility failed to ensure Residents 15, 95, and 521's oxygen tubing were dated. * The facility failed to change the emptied and expired oxygen humidifier bottle for Resident 88. These failures had the potential to negatively impact the residents' medical conditions.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure accurate reconciliation of controlled medications for one sampled resident (Resident 421) and one nonsampled resident (Resident 621). The facility failed to ensure administration of controlled medications for Residents 421 and 621 were accurately documented to ensure accurate reconciliation and to prevent medication administration errors. This posed the risk for diversion of controlled medications and medication administration errors.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 33 sampled residents (Resident 99) was free from unnecessary medication when the facility failed to ensure Resident 99's behavior manifested for pseudobulbar affect was being monitored for effectiveness of Nuedexta (medication used to treat pseudobulbar affect) and non-pharmacological approach to care was not implemented for this behavior. This failure had the potential for increased risks associated with medication use that include but are not limited to diarrhea, peripheral edema, and dizziness and may result in poor resident outcome.

Inspectors wroteBased on interview, record review, and facility's P&P review, the facility failed to ensure two of 33 final sampled residents (Residents 99 and 140) were free from unnecessary psychotropic medications when: * The facility failed to ensure Resident 99's Seroquel was used to treat a specific diagnosed and documented condition. * The facility failed to document the behaviors and implement non-pharmacological approach for yelling out behavior prior to Resident 99's Seroquel being ordered. * The facility failed to monitor the behaviors specific to Resident 99's Seroquel and mirtazapine use. * The facility failed to monitor adverse consequences for Resident 99's psychotropic medications. * The facility failed to monitor the behaviors specific to the use of trazadone and side effects of trazadone for Resident 140. [...]

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 14.29%. Three of four licensed nurses (LVNs 10, 12, and 14) had performed the medication errors during the medication administration observation. * LVN 12 failed to properly administer the medication via the GT (a flexible tube surgically inserted into the abdomen to the stomach for feeding and medication administration) to Resident 138. * LVN 14 failed to properly administer the eye drops to Resident 67. * LVN 10 failed to properly administer insulin to Resident 65. These failures had the potential to negatively affect the residents' health.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to store the drugs and biologicals in a safe manner. * Two expired bottles of Aspirin tablets (medication used to reduce fever and to relieve mild to moderate pain) were observed in Medication room [ROOM NUMBER]. * One open bottle of Antacid tablets extra strength (medicine that counteracts (neutralize the acid in stomach to relieve indigestion and heartburn) with no open date was found in Medication Cart 2 at Nursing Station 4. * One open tube of Medi-Honey (An ointment used to treat wounds) with no open date was observed in the Main Treatment Cart. * Multiple open medication containers with no open date were found in Nursing Station 3's medication cart. These failures had the potential for unsafe administration of medications.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the medical record was accurate for two of 33 final sampled residents (Residents 57 and 99). * Resident 99's Weekly Nursing Summaries showed no antipsychotic medications were used; however, Resident 99 received Seroquel (antipsychotic medication) in September and October 2022. * The facility failed to ensure the wound care's MD progress notes were included in Resident 57's medical record. These failures had the potential for the residents' care needs not being met as the medical information was inaccurate, incomplete, and not readily available.

Inspectors wroteBased on observation and interview, the facility failed to ensure the freezer compartment inside the resident's refrigerator was free of ice buildup. This had the potential for the refrigerator not being maintained in safe operating condition.