Seacrest Post-Acute Care Center

Inspectors wroteBased on interview and record review, the facility failed to ensure a Care Plan was created for one of three sampled residents (Resident 1) after Resident 1 fell on 4/18/2026. This failure placed Resident 1 at risk for repeated falls, injury and further decline.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of eight sampled residents (Resident's 1, 2, and 3) were provided privacy when using the telephone. These failures resulted in Resident's 1, 2, and 3 being unable to make personal phone calls without staff's presence and monitoring, violating their rights to private communication. These deficient practices had the potential to cause psychosocial harm, including fear of being overheard when discussing personal information, and feelings of distress and isolation due to lack of communication with family.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide enough time for one of one sampled resident (Resident 30) to enjoy their meals. This failure resulted in Resident 30 feeling sad and frustrated.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident's (Resident 30) light cord was within reach. This failure resulted in Resident 30 feeling frustrated and the potential to increase the risk of the resident falling.

Inspectors wroteBased on interview and record review, the facility failed to ensure the quarterly Minimum Data Set (MDS-a comprehensive assessment and care screening tool) assessment dated [DATE] was transmitted to Centers for Medicare and Medicaid Services (CMS) within the 120-day time frame for one of six sampled residents (Resident 11). This failure had the potential for the delay in identifying resident care concerns needing an individualized care plan, providing residents interventions necessary to provide quality care and a delay in the reimbursement process.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the assessment entries on the Minimum Data Set (MDS), a standardized assessment and care screening tool) was accurate for two of six sampled residents (Resident 12 and 75) by failing to:1. Ensure Resident 12's hearing status was accurately coded to reflect Resident12 wore a hearing aid.2. Ensure Resident 75's dental status was accurately coded to reflect Resident 75's missing bottom teeth. These deficient practices had the potential to negatively affect Resident 12 and 75's plan of care and delivery of necessary care and services.

Inspectors wroteBased on observation, interview and record review, the facility failed to revise the communication plan of care for one of six sampled residents, (Resident 12) who was hard of hearing to reflect Resident 12's current care plan. This failure had the potential to negatively affect the care and services for Resident 12.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident who is unable to carry out activities of daily living receives services to maintain good grooming for one of three residents sampled residents (Resident 60) by failing to change Resident 60's soiled incontinent pad ( absorbent pad worn by residents) for long period of time. This deficient practice resulted in Resident 60 feeling frustrated and embarrassed, due to lack of or delay in receiving sufficient services to maintain good grooming, and incontinent care and had the potential to lead to skin breakdown.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Certified Nursing Assistant 4 (CNA 4) report changes in resident skin condition for one of four sampled residents (Resident 60). The facility failed to:1. Ensure CNA 4 completed required daily shift body check and skin assessment for Resident 60 on 3/24/2026. These failures placed Resident 60 at increased risk for delayed identification and treatment of skin breakdown.

Inspectors wroteBased on observation, interview and record review, the facility failed to assess one of four sampled residents (Resident 56) who had indwelling urinary catheter (a flexible plastic tube inserted into the bladder that remains there to provide continuous urinary drainage) upon admission to determine the indication for the catheter and whether it should be removed. This failure placed Resident 56 at risk for unnecessary indwelling urinary catheter use, potential infection, lose ability to regain control of bladder function and other complications related to improper catheter management.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure one of three sampled residents ( Resident 27) maintained adequate nutritional status. The facility failed to:1. Provide one-on-one feeding assistance ( a staff member supports a single resident with eating for the entire meal) as ordered.2. Ensure Boost (nutritional supplement) was administered to Resident 27 as ordered.3. Monitor and respond to Resident 27's declining meal intake.4. Ensure effective communication and follow-through of Registered Dietician nutritional interventions. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure medications were not left open and unattended for one of four sampled residents (Resident 63)'s bedside. This deficient practice placed Resident 63 at risk for medication errors, including missed, duplicated, or inappropriate administration.

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure a monthly Medication Regimen Review ([MRR]- a thorough evaluation of a patient's complete medication list to ensure the medication therapy is safe, necessary, and effective) was conducted and maintained by a licensed pharmacist for one of three residents Resident (27). This failure resulted in a lack of professional oversight to identify potential medication irregularities and placed the residents at risk for adverse drug events, excessive sedation, and the continued use of potentially unnecessary medications.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure one of six sampled residents (Resident 75) was seen by a dentist for her broken, loose missing teeth. This failure had the potential to result in the inability to effectively chew foods, weight loss, lack of energy and loss of muscle mass for Resident 75.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure the accuracy of the medical record for one of three residents (Resident 63). As evidence by documentation indicating medications were administered on 3/24/2026 at 8:08 a.m., while observation revealed medications were left opened/unattended at the bedside and not confirmed as administered. This deficient practice resulted in inaccurate documentation of medication administration and had the potential to affect Resident 63's treatment and care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control measures were observed for three of six sampled residents (Residents 6, 12 and 79). The facility failed to:1. Ensure signage for Enhanced Barrier Precautions (EBP- infection control intervention using gown and gloves during high contact resident care activities designed to reduce the transmission of multi-drug-resistant organisms {microorganisms, predominantly bacteria, that are resistant to one or more classes of antimicrobial agents}) was in place for Resident 6.2. Ensure the laundry staff cleaned and documented the dryer lint trap screens every two hours.3. Ensure the kitchen staff monitored and documented the refrigerator temperatures.4. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement their protocol for Antibiotic Stewardship (refers to a set commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use) for two of three sampled residents (Resident 54 and Resident 66). This deficient practice had the potential for Resident 54 and Resident 66 to develop antibiotic resistance (not effective to treat infection) from unnecessary or inappropriate antibiotic use.

Inspectors wroteBased on observation, interview, and record review, the facility failed to:1. Ensure adequate room size and space to support the comfort and well being for one of six sampled residents (Resident 59).2. Ensure 6 of 26 residents' rooms (Rooms 21, 22, 23, 25, 26 and 27) met the requirements of 80 square feet for each resident. This failure had the potential to negatively impact Resident 59's quality of life by limiting his ability to move freely and safely within his living space and had the potential to result in inadequate provision of safe nursing care and a lack of privacy for residents.

Inspectors wroteBased on interview and record review, the facility failed to notify the physician when Resident 2 presented a new wandering behavior for one of three sampled residents. This failure resulted in Resident 2's wandering behaviors not being addressed and a physical altercation between Resident 1 and Resident 2.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Resident 1 and Resident 2 were free from abuse when Resident 1 and Resident 2 got into a physical altercation on 8/25/2025. The facility failed to ensure: A. Resident 1 received Trazadone (medication for depression [persistent sadness and a lack of interest or pleasure in previously rewarding or enjoyable activities] and insomnia) for three days (8/23/2025, 8/24/2025, and 8/25/2025). B. Resident 2's episodes of wandering (walking around without a specific goal or purpose) and behaviors of taking items from snack carts were communicated to the provider or addressed in a care plan.3. Implement the facility's policy and procedure titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised April 2021 which indicated residents have the right to be free from abuse. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a psychotropic (any medication capable of affecting the mind, emotions, and behavior) medication was not used unnecessarily for one of three sampled residents (Resident 1) by: 1. Failing to monitor manifested behaviors for which Trazadone (medication used to treat depression or insomnia) was prescribed for three consecutive days2. Failing to monitor adverse effects of Trazadone 3. Failing to obtain an active psychotropic informed consent (a process to ensure a resident or the resident's representative receives and understands information about a treatment or medication including its risks, benefits) for Trazadone administration for one of three sampled residents. [...]

Inspectors wroteBased on interview and record review, the facility failed to update a care plan for a new wandering behavior for one of three sampled residents, when Resident 2 was found with new wandering behaviors. This failure resulted in Resident 2's wandering behaviors not being addressed and a physical altercation between Resident 1 and Resident 2.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled employees, Licensed Vocational Nurse (LVN) 1, was competent in medication administration upon hire. This failure resulted in Resident 1 not receiving trazadone for three days on 8/23/2025, 8/24/2025 and 8/25/2025.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure, a resident who was a Full Code (a medical term indicating a person's consent to receive all possible life-saving measures), received basic life support ([BLS], care healthcare professionals provide to anyone whose heart stops beating suddenly), including cardiopulmonary resuscitation ([CPR] an emergency life-saving procedure to restart a person's heart [chest compressions)]) per the resident's Physician Order for Life Sustaining Treatment ([POLST] a form that contains written medical orders for healthcare professionals regarding the residents wishes for specific medical treatments that can or cannot be done during life threatening emergencies where the resident is incapacitated) and facility's policy and procedure, for one of one sampled resident (Resident 1).2. [...]

Inspectors wroteBased on interview and record review, facility failed to provide medical records upon request for one of three sampled residents (Resident 1) when Resident 1's responsible party (RP1) requested Resident 1's records on 10/11/2024. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease ([COPD] a chronic lung disease causing difficulty in breathing), chronic diastolic heart failure ( heart disorder that causes the heart to not pump blood effectively) and ischemic heart disease (condition where the blood vessels that supply the heart muscle become narrowed or blocked). During a review of Resident 1's History and Physical (H&P) dated 4/13/2024, the H&P indicated Resident 1 had the capacity to understand and make decisions. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a physician visited one of four sampled residents (Resident 1) at least once every 60 days. This deficient practice had the potential to result in an undetected decline in medical, health or psychosocial condition and can lead to a delay in necessary care, treatment and services.

Inspectors wroteBased on interview, and record review, the facility failed to protect one of three sampled residents (Resident 2) who is legally blind verbally abuse repeatedly by Resident 1. This deficient practice resulted in Resident 2 feel unsafe and uncomfortable.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe and sanitary food storage and preparation practices when: 1. There was no trash receptacle (trash can) next to the handwashing sink area in the kitchen. 2. One Dietary Aide (DA1) working in the dish machine area did not wash hands and change gloves when removing the clean and sanitized dishes from the dish machine. 3. Several food items were stored in the refrigerator with dates exceeding storage periods for the ready to eat food. There were 25 previously prepared vanilla flavored pudding and 25 previously prepare chocolate flavored pudding stored in small single serve plastic cups with date of 2/21/2025 exceeding storage period for pudding were stored in the reach in refrigerator. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure Resident 54's Humalog [NAME] KwikPen ([generic name - insulin lispro] a medication used to treat high blood sugar) in medication cart was labeled with an 'open date' to ensure medication was not expired prior to medication administration, affecting one of ten reviewed residents. 2. Ensure medications requiring refrigeration were stored in accordance with manufacturer specifications and per facility's policy and procedure (P&P) titled, Storage of Medications, dated 08/2019 at temperature range of 36 degrees Fahrenheit [(°F) is a unit of temperature] to 46°F or 2° Celsius [(°C) is a unit of temperature] to 8°C, affecting two of two facility's medication room refrigerators (Station 1 Medication Room Refrigerator and Station 2 Medication Room Refrigerator). [...]

Inspectors wroteBased on observation interview and record review the facility failed to ensure one of 16 reviewed residents (Resident 29) personal items were returned to Resident 29 after being laundered. This failure resulted in Resident 29's blankets being lost, missing, and received a blanket that did not belong to him.

Inspectors wroteBased on observation, interview and record review, facility failed to ensure call light was within reach for one of five reviewed residents (Resident 139). This failure had the potential to put Resident 319's safety at risk and not meet his personal needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and/or implement an individualized person-centered plan of care with measurable objectives, timeframe, and interventions to meet the resident's needs for one of four reviewed residents (Resident 38). This failure had the potential to negatively affect the delivery of necessary care and services to Resident 38.

Inspectors wroteBased on interview and record review, the facility failed to provide care in accordance with professional standards of practice for one of five reviewed residents (Resident 22) investigated for use of unnecessary psychotropic (any medication capable of affecting the mind, emotions, and behavior) drug, by failing to ensure a medical diagnosis or indication was documented to support administration of Seroquel (generic name - quetiapine, a medication used to treat schizophrenia [a mental illness that is characterized by disturbances in thought]. This failure had the potential to place Resident 22 at risk for significant adverse consequences (unwanted, uncomfortable, or dangerous effects that a drug may have) from the use of unnecessary psychotropic drug, which could result to impairment or decline in the resident's mental, physical condition, functional, and psychosocial status.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure denture care was done for one of 16 reviewed residents (Resident 29). This failure resulted in Resident 29's dentures not being cleaned and stored properly in a denture container.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure two of two reviewed residents (Residents 20 and 319) intravenous catheter (IV - a flexible tube that is inserted into vein to deliver fluids or medications) was maintained in accordance with professional standard of practice. The facility failed to: a. Ensure Resident 20's IV catheter was removed in a timely manner after Resident 20's IV therapy was completed. b. Ensure Resident 318/'s IV site was changed Rotated when Resident 318's IV site was not changed for 14 days. This failure had the potential to cause an infection at the insertion site.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Licensed Vocational Nurse (LVN) 4 was trained and had knowledge of conducting a blood pressure (BP) check for one of ten reviewed residents (Resident 368) prior to determining whether hydralazine (a medication used to treat hypertension [high blood pressure]) should be administered per parameters ordered by physician. This failure had the potential for medication errors, hypertension, hypotension (low blood pressure) and hospitalization for Resident 368.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer medications in accordance with physician order and manufacturer specifications for two of ten reviewed residents (Residents 37 and 367) by failing to: a. Ensure Resident 37's Aspirin (a medication used to prevent heart attack [flow of blood and oxygen is blocked] and stroke [loss of blood flow to a part of the brain]) chewable tablet was administered as chewable during medication administration. b. Clarify order with physician and administer Resident 367's Vitamin D3 (also referred as cholecalciferol - a vitamin used to treat low level of vitamin D) within 60 minutes of its prescribed time as per facility's policy and procedure (P&P) titled, Medication Administration - General Guidelines, dated 11/2021. [...]

Inspectors wroteBased on interview and record review, the facility and consultant pharmacist (a professional responsible for reviewing each resident's medication profile monthly to identify and report changes) failed to identify irregularities during medication regimen review ( MRR a comprehensive evaluation of a patient's current medication list to identify potential drug interactions, adverse effects, and other medication-related issues) related to administration of Seroquel (generic name - quetiapine, a medication used to treat schizophrenia [a mental illness that is characterized by disturbances in thought] without a medical diagnosis or indication, affecting one of five reviewed residents for unnecessary medications (Resident 22). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five reviewed residents (Resident 22), for unnecessary medication care area, was free from the use of unnecessary psychotropic drug (any medication capable of affecting the mind, emotions, and behavior) by failing to ensure there was a medical diagnosis and/or indication to support the administration of Seroquel (generic name - quetiapine, a medication used to treat schizophrenia [a mental illness that is characterized by disturbances in thought]. This failure had the potential to place Resident 22 at risk for significant adverse consequences (unwanted, uncomfortable, or dangerous effects that a drug may have) from the use of unnecessary psychotropic drug, which could result to impairment or decline in the resident's mental, physical condition, functional, and psychosocial status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a medication error rate of less than 5 percent (%) during medication pass for three of ten reviewed residents (Residents 54, 37 and 367) by failing to: a. Ensure Resident 54's Humalog [NAME] KwikPen ([generic name - insulin lispro] a medication used to treat high blood sugar) in medication cart was labeled with an 'open date' to ensure medication was not expired prior to medication administration. b. Ensure Resident 37's Aspirin (a medication used to prevent heart attack [flow of blood and oxygen is blocked] and stroke [loss of blood flow to a part of the brain]) chewable tablet was administered as a chewable during medication administration. c. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure kitchen staff were routinely trained and evaluated for competency related to their duties when: 1. Dietary Aide (DA 1) did not know the proper sanitizer test strip to use for the dish machine sanitizer and the concentration strength of the chlorine sanitizer used in the dish machine (chlorine sanitizer a product that is used to reduce or eliminate pathogenic agents on surfaces). This failure had the potential to result in unsafe and unsanitary food production that could place 60 out of 62 residents in the facility who received food at risk for food borne illness (illness cause by food contaminated with bacteria, viruses, parasites, or toxins )

Inspectors wroteBased on observation, interview and record review, the facility failed to observe infection control measures by not ensuring staff perform hand hygiene for one of one reviewed resident (Resident 33). This failure had the potential to result in cross contamination (the physical movement or transfer of harmful bacteria from one person, object, or place to another) and place the residents at risk for the spread of infection.

Inspectors wroteBased on interview and record review the facility failed to ensure a Surveillance Data Collection form was completed for one of 16 reviewed residents (Resident 39) who received Keflex (antibiotic used to treat infections caused by bacteria) 500 milligrams (mg-unit of measurement) by mouth twice a day from 1/23/2025 to 1/30/2025 to treat a urinary tract infection (UTI- an infection in the bladder/urinary tract). This failure had the potential to put Resident 39 at risk for antibiotic resistance (when bacteria change to resist antibiotics used to effectively treat them) and inappropriate use of antibiotic.

Inspectors wroteBased interview and record review, the facility failed to ensure that staff were being in serviced (staff education) for dementia (a progressive state of decline in mental abilities) care. This failure had the potential to jeopardize the safety of residents when staff are not adequately trained.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staffing information posted was accurate. This failure resulted in the inability of residents and visitors to have knowledge of the facility's staffing information to ensure safe staffing ratios are implemented.

Inspectors wroteBased on observation, interview, and record review. The facility failed to ensure bedrooms room [ROOM NUMBER] and 34 accomodate no morethan four residents.

Inspectors wroteBased on observation, interview, and record review. The facility failed to ensure 8 of 17 residents rooms met the 80 square feet (sq. ft.-unit of measurement) per residents in multiple resident rooms. Rooms 20, 21, 22, 23, 25, 26,27 and 32. This failure had the potential to result in an inadequate provision of safe nursing care, and privacy for the residents.

Inspectors wroteBased on interview and record review the facility failed to notify the physician that one of one resident (Resident 1) has been noncompliant with taking Risperidone (medication is used to treat certain mental/mood disorders) 0.25 milligrams every 8 hours as ordered. This deficient practice had the potential to result in the delay of care for Resident 1 who may need alternative treatment measures prescribed by the physician due to noncompliance of taking the Risperidone.

Inspectors wroteBased on interview and record review the facility failed to develop care plan for one of one resident ' s (Resident 1) noncompliance with care. This deficient practice had the potential to result in the delay of care for Resident 1 who may need alternative interventions and measures.

Inspectors wroteBased on interview and record review the facility failed to provide quality care in accordance with professional standards of practice when the facility failed to ensure one of one resident ' s (Resident 5) lower extremities edema (fluid retention in the body) was assessed after it was identified on 6/21/2024. This deficient practice had the potential to result in unidentified complications with worsening edema and result in poor resident health outcomes.

Inspectors wroteBased on interview and record review the facility failed to ensure one of one resident ' s (Resident 5) echocardiogram (imaging test that checks the structure and function of the heart) was completed as ordered on 6/22/2024. This deficient practice resulted in a delay of care that had the potential to result in a continued undiagnosed heart problem for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure the hand sink in a resident's bathroom was inspected during daily rounds by the maintenance staff and/or the facility's administrative staff, to ensure it was mounted securely to the bathroom wall and did not detach and fall off the wall causing a resident to fall and sustain injuries for one of three sampled residents (Resident 1). This deficient practice resulted in the hand sink in Resident 1's bathroom detaching from the wall and falling to the floor when Resident 1 placed her hands on it while washing her face. Resident 1 fell to the floor and sustained a left hip fracture, a bump with discoloration to her left eye and a bump with discoloration to the left side of the back of her head. This deficient practice had the potential for Resident 1 to sustain more critical injuries including death.

Inspectors wroteBased on interview and record review, the facility failed to ensure documentation was completed and correct when the hand sink in the bathroom for one of three sampled residents (Resident 1) fell off the wall causing Resident 1 to fall to the floor, breaking her hip and causing her to sustain a bump to her left eye and the left side of the back of her head. This deficient practice resulted in confusion regarding the timeline of events related to Resident 1's fall, and the inability to determine what Resident 1's actual assessment was after her fall including the subsequent discovery of Resident 1's injuries. This deficient practice had the potential for a delay in evaluation and treatment and non-continuity of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident, who was walking 85 feet with moderate assistance (about 25-50 percent [%] physical assistance) with a platform walker ([PFW] a type of assistive device with forearm supports to provide extra support during walking), did not decline in walking and subsequently stopped walking, and failed to ensure the resident, who had limited ROM to both lower extremities received restorative nursing treatment to prevent potential decline in ROM for two of 15 sampled residents (Resident 3 and Resident 47). The facility failed to: 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain timely and accurate resident medical records for five of 15 sampled residents (Resident 47, 3,15,19 and 38) when: a. Resident 47's January and February 2024 Restorative Nursing Aide (RNA, nursing aide program that help residents to maintain their function and joint mobility) Documentation Survey Report (record of nursing assistant tasks) was not accurately documented indicating Resident 47 received RNA for ambulation (walking) and ambulated when Resident 47 did not receive RNA treatment for ambulation and/or did not walk. b. Resident 47's quarterly (every three months) Joint Mobility Assessment ([JMA] assessment of joints to monitor joint range of motion {ROM, full movement potential of a joint}) dated 1/10/24 was completed on 2/14/24 (about one month later). c. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure two of 15 sampled residents (Resident 41and Resident 256) baseline care plans were developed and implemented. a. The facility failed to address Speech Therapy in the Care Plan for Resident 41 who was receiving Speech Therapy daily three times a week for four weeks due to dysphagia (difficulty swallowing). b. The facility failed to address mood and behavior concerns in the Care Plan for Resident 256 who was diagnosed with anxiety (intense, excessive, and persistent worry and fear about everyday situations) and depression (mental state of low mood and aversion (a strong dislike) to activity) and taking medications for anxiety. These failures had the potential to result in a delay of Resident 41 and Resident 256 not receiving the necessary care and services.

Inspectors wroteBased on interview and record review the facility failed to ensure two of 15 sampled residents (Resident 41 and Resident 256) Comprehensive Care Plan was developed to address speech therapy, mood, and behavior concerns. a. the facility failed to address speech therapy in the Care Plan for Resident 41 who was receiving Speech Therapy daily three times a week for four weeks due to dysphagia (difficulty swallowing). b. the facility failed to address mood and behavior concerns in the Care Plan for Resident 256 who was diagnosed with anxiety and depression and taking medications for anxiety. These failures had the potential to result in a delay of Resident 41 and Resident 256 not receiving the necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to implement their protocol for Antibiotic Stewardship for two of two sampled residents (Resident 46 and 47) by failing to: a. Resident 46 was prescribed antibiotic drug without meeting the criteria, before being screen for urinary tract infection ([UTI]an infection in any part of the urinary system). b. Resident 47 was prescribed antibiotic drug without meeting the criteria, before being screen for upper respiratory tract infection. These failures had the potential for resident to develop antibiotic resistance (not effective to treat infection) from unnecessary or inappropriate antibiotic use.

Inspectors wroteBased on observation, interview, and record review, the facility failed to notify the resident's physician (MD 1) for one of 15 sampled residents (Resident 47) for a change in condition (COC) for significant decline in physical functioning and inability to ambulate (walk) with Restorative Nursing Aide (RNA, nursing aide program that help residents to maintain their function and joint mobility) over a 4-week period by failing to: a. Assess, address and report to MD Resident 47's inability to ambulate during RNA treatment and decline in physical function from walking 85 feet with moderate assistance (about 25-50 percent [%] physical assistance) with a platform walker (PFW, a type of walking assistive device with forearm supports to provide extra support during walking) to ambulating zero feet from week of 1/18/24 to 2/12/24. b. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure one of 15 sampled residents (Resident 41) Minimum Data Set (MDS - a comprehensive assessment and screening tool) was documented accurately to reflect Resident 41's current health condition of dysphagia (difficulty swallowing) and Speech Therapy (assesses and treats speech and language problems including swallowing disorders) daily three times a week for four weeks due to dysphagia. This failure had the potential to result in a delay of Resident 41 not receiving the necessary care and services.

Inspectors wroteBased on interview and record review the facility failed to ensure one of 15 sampled residents (Resident 45) assessment entries on the Minimum Data Set (MDS- an assessment and care screening tool) related to the section in the MDS called Active Diagnoses was accurately documented to reflect Resident 45's diagnosis of schizophrenia (a mental disorder characterized by recurring episodes of psychosis that are corelated to a misconception of reality). This failure had the potential to result in a negative effect of Resident 45's plan of care and delivery of necessary care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to reviewed and revised care plans to reflect the changes in the Restorative Nursing Aide program (RNA, nursing aide program that help residents to maintain their function and joint mobility) services for one of 15 sampled residents (Resident 15). This deficient practice had the potential to inaccurate provision of services for Resident 15.

Inspectors wroteBased on observation, interview and record review, the facility failed to place the nasal cannula (a device that gives you additional oxygen (supplemental oxygen or oxygen therapy) through the nose to deliver oxygen for one of one sampled resident (Resident 10). This failure had the potential for Resident 10 to not receive necessary respiratory care and services needed.

Inspectors wroteBased on interview and record review, the facility failed to ensure a documented justification for the continuation of an as needed (PRN) psychotropic medication (Ativan - an anti-anxiety medication) and clonazepam (anti-anxiety medication) beyond 14 days for one 1 out of the 15 sampled residents (Resident 45). This failure had the potential to result in Resident 45 receiving unnecessary medications and can lead to adverse side effects.

Inspectors wroteBased on observation, interview and record review, the facility failed to: a. Label canned foods, vegetables spring rolls, ice creams, eggs, juices, meat products, and vegetables with no dates received. b. Ensure Freeze 1 was in good working condition. c. Ensure Dietary Aid 1 (DA1) change gloves and wash his hands in between touching dirty surfaces in the kitchen and Dietary Supervisor (DS) wears a glove while carrying an open lid ice cream. These failures had the potential to not identify when food was received, and when it would expire, which could affect resident's health when serve to the residents in the facility and had the potential to cause food-borne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure laundry aide (LA) perform hand hygiene (hand washing using soap and water, and cleaning hands with waterless or alcohol-based hand sanitizers) after removing dirty gloves and proceeded to handling clean linens. This failure had the potential to cause contamination of clean linens and place residents of the facility at risk for infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 8 of 17 residents rooms met the 80 square feet (sq. ft.) per residents in multiple resident rooms. Rooms 20, 21, 22, 23, 25, 26, 27, and 32 housed four residents per room and room [ROOM NUMBER] and 34 housed five residents per room.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) who had a history of multiple falls, was supervised, monitored, and provided with a Mat alarm (an alarm used on top of a mattress or in a wheelchair to help monitor residents when they rise from the bed or wheelchair to reduce falls and unnecessary injury) in his wheelchair as recommended the Interdisciplinary Team ([IDT] a group of health care professionals with various areas of expertise who work together toward the goals of a resident) to prevent Resident 1 from falling and sustaining an injury. The facility failed to: 1. Ensure Resident 1's care plan was revised to include IDT's recommendations made after Resident 1's fall on 11/13/2023 that included continued use of the Mat alarm, frequent visual checks, and placing Resident 1 in front of or close to the nursing station. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure a resident, who was a high risk for falls, was transferred from a wheelchair to the bed by two persons for one of two sampled residents (Resident 1). The facility failed to: 1. Ensure a certified nursing assistant (CNA 1) and CNA 4 did not transfer Resident 1 from a wheelchair to bed without another staff assistance as indicated in the resident ' s untitled care plan. 2. Ensure CNA 1, CNA 4, and CNA 5 followed the facility ' s policy and procedure (P/P) titled Falls and Fall Risk, Managing by trying to prevent Resident 1 from falling during transfer from a wheelchair to bed by implementing the care plan intervention to have two person physical assistance for the resident ' s transfer. [...]

Inspectors wroteBased on interview and record review, the facility failed to manage pain for one of two sampled residents (Resident 1). The facility failed to: 1. Ensure the licensed vocational nurse (LVN 1) did not let Resident 1 experience excruciating pain without receiving pain medication for 17 and half hours after a fall. 2. Ensure LVN 1 notified Resident 1's physician of Resident 1 experiencing excruciating pain in the right leg after the resident fell; and obtain orders for pain medication. 3. Ensure LVN 1 assessed Resident 1 for pain location and pain severity when Resident 1 complained of pain after a fall. 4. Ensure Resident 1's physician was notified of the resident's fall for the physician to provide orders for timely treatment and transfer to a general acute care hospital (GACH). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two of three sampled residents were assisted with their ADLS ([activities of daily living] activities related to personal care) when a. Resident 2 ' s urinal (a receptable used by men to urinate) was not emptied and it was left at the resident's bedside; and b. Resident 3 call light was not answered in a timely manner. These deficient practices resulted in Resident 2 feeling uncomfortable and undignified as he had to endure the smell of an old urine in his room; and it placed Resident 3 at higher risk for moisture associated skin dermatitis (skin damage that occurs when the skin is repeatedly exposed to various bodily wastes and fluids, also known as MASD).

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 3) were provided incontinence (loss of control of bladder and bowel control)care to prevent the development of skin breakdown. These deficient practices placed Resident 3 at high risk for moisture associated skin dermatitis (skin damage that occurs when the skin is repeatedly exposed to various bodily wastes and fluids, also known as MASD).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of four sampled residents (Resident 3) was assisted to ambulate (walk) during the Restorative Nursing Assistant (RNA) Therapy Program five times a week, as ordered by the physician. This deficient practice has resulted to Resident 3 to feel worried about her health progress and recovery and had the potential to negatively affect her joint function and integrity.