Sherman Village HCC

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to ensure that the call light (a vital safety system in nursing homes that allows residents to signal staff members when they need help) request for assistance was answered promptly for one of the three sampled residents (Resident 1). This deficient practice had the potential not to meet Resident 1s' needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan (is a form that summarizes a person's health conditions and current treatments for their care) for one of three sample residents (Resident 3) for Resident 3's risk for falls. This failure had the potential to place Resident 3 at risk for an avoidable fall.

Inspectors wroteBased on interview and record review, the facility failed to maintain medical records in accordance with acceptable professional standards and practices for one of three sampled residents (Resident 1) when Resident 3 had a fall on 6/21/2026 and the Fall Risk Evaluation (a simple check-up by a healthcare provider to see how likely an older adult is to fall) was inaccurate. This failure resulted in inaccurate documentation of Resident 3's records.

Inspectors wroteBased on interview and record review, the facility failed to respect one of the three sampled residents (Resident 1) rights by failing to ensure Resident 1's Physician Orders for Life Sustaining Treatment (POLST- document that acts as a set of binding medical orders for people with serious illnesses or advanced frailty which is intended for immediate use by emergency responders to honor a patient's wishes for care during a medical crisis) was followed. This failure violated Resident 1's and Resident 1's Representative (RR 1) rights.

Inspectors wroteBased on interview and record review, the facility failed to update a resident's care plan for one of three sampled residents (Resident 1) to reflect Resident 1's current wound treatment orders for sacrococcyx (the large triangular bone at the base of the spine and the tailbone) pressure ulcer (damage to the skin and underlying soft tissue caused by prolonged pressure). This deficient practice had the potential for Resident 1's need not being met.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) received proper care in accordance with professional standards of practice, by: 1. Failing to accurately complete comprehensive assessment for Resident 1 after readmission from the General Acute Care Hospital (GACH) on 10/15/2025.2. Failing to implement treatment consistent with physician orders by not holding hydralazine (a medication to treat high blood pressure) oral tablet when systolic blood pressure was less than 110 millimeters of mercury (mmHg - standard unit of measurement for pressure) on 9/6/2025 and 9/7/2025 during morning shift. These deficient practices had the potential to result in harm to Resident 1 and increased Resident 1's risk for adverse outcome related to blood pressure management. Cross reference F755.

Inspectors wroteBased on interview and record review, the facility failed to hold the hydralazine (a medication to treat high blood pressure) oral tablet when systolic blood pressure was less than 110 millimeters of mercury (mmHg - standard unit of measurement for pressure) on 9/6/2025 and 9/7/2025 during morning shift in accordance with the physician order for one of three sampled residents (Resident 1). This deficiency practice had the potential to result in increased risk for adverse outcome related to blood pressure management to Resident 1. Cross reference F684.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free of any significant medication errors (means the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order, manufacturer's specifications, and accepted professional standards) for one of three sampled residents (Residents 1) by failing to hold Eliquis (a blood thinner-medication used to prevent and treat blood clots [gel-like clumps of blood that forms inside the body when blood vessels [a tube through which the blood circulates in the body] are injured or damaged] by slowing down the body's clotting process and increase the risk for bleeding) as ordered by the physician. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: 1. A licensed Administrator (ADM) was appointed to serve in the capacity of a Nursing Home Administrator (NHA). 2. A licensed Administrator (ADM) was present at the facility for sufficient hours to provide adequate oversight and management of operations. These deficient practices resulted in the facility operating without consistent administrative oversight and had the potential to adversely affect the facility's overall operations, regulatory compliance, and quality of care provided to residents.

Inspectors wroteBased on interview and record review, the facility failed to implement a person-centered care plan (a tool that ensures residents receive personalized, comprehensive, and goal-oriented care in a nursing home setting) for one of three sampled residents (Resident 1) by failing to implement interventions to address Resident 1's preference of not attending group activities. This deficient practice had potential for a delay in the delivery of necessary care and services to Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to provide an ongoing activity program that is resident-centered for one of three sampled residents (Resident 1). This deficient practice had the potential to affect Resident 1's sense of self-worth (the internal sense of being good enough and worthy of love and belonging from others) and psychosocial (the interaction between an individual's mental and emotional state [psychological] and their social environment) well-being.

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) for one of three sampled residents (Resident 2) by failing to follow Resident 2's physician order to hold (temporarily stopping certain medications as instructed by a healthcare provider) amlodipine (medication used to treat high blood pressure) for systolic blood pressure (sbp- the top number in a blood pressure reading, indicating the pressure in your arteries when your heart beats) below 110 millimeters of mercury (mmHg-a standard unit of pressure). This deficient practice had the potential to result in medication error and could cause hypotension (low blood pressure) to Resident 2.

Inspectors wroteBased on interview and record review, the facility failed to maintain accurate and complete medical record for one of three sampled residents (Resident 2) by failing to document medications that were held (temporarily stopping certain medications as instructed by a healthcare provider) following a physician order. This deficient practice had the potential to result in medication errors, cause confusion in care and the medical records containing inaccurate documentation for Resident 2.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its infection control measures for one of three sampled residents (Resident 2) who was on enhanced barrier precaution (EBP- wearing a protective gown and gloves whenever you are doing close-contact care with a patient who might be carrying these germs) by failing to ensure Licensed Vocational Nurse 1 (LVN 1) wore protective gown while providing gastrostomy (G tube-a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) tube care. This deficient practice had the potential for cross contamination (unintentional transfer of bacteria or germs or other contaminants from one surface to another) of infection among staff and residents.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the medical records of one of three sampled residents (Resident 1) were maintained in accordance with accepted professional standards and practice, complete, and accurately documented by failing to ensure Resident 1's Change of Condition (COC -major decline or improvement in a resident's status that will not resolve without intervention) form contained documentation of Resident 1's oxygen administration and vital signs (measurements that indicate a resident's basic psychological functions such as temperature, heart rate, blood pressure, respiratory rate, and oxygen saturation) monitoring. This deficient practice had the potential to result in inaccurate medical interventions for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Provide supervision (refers to the ongoing monitoring and guidance provided by staff to ensure the safety and well-being of a resident) to one of one sampled resident (Resident 97), who was cognitively impaired (refers to difficulties with thinking, learning, remembering, and using judgment, among other mental abilities), unable to verbalize needs due to aphasia (a disorder that makes it difficult to speak), had history of falls and elopement (the act of leaving a facility unsupervised and without prior authorization), and identified as at risk for elopement, by: A. Failing to monitor Resident 97's whereabouts on 7/25/2025 at 12:14 p.m. (date and time of Resident 97's elopement). The facility staff were not aware Resident 97 had left the facility until around 5 p.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide reasonable accommodation of resident needs and preferences by failing to ensure: 1. The call light (CL, an alerting device for nurses or other nursing personnel to assist a resident when in need) was within reach for two (2) of five (5) residents (Resident 1 and 10) reviewed under the Environment task. 2. The pad call light (a specialty alerting device that have ultra-sensitive touch surface for patients with limited mobility for nurses or other nursing personnel to assist a patient when in need) was within reach for two (2) of four (4) sampled residents (Residents 8 and 71) reviewed under the Environment task. These deficient practices had the potential to result in a delay of care and services and possible injury to residents when they are unable to summon health care workers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignity including the right to be free from physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the resident's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) for one of seven sampled residents (Resident 10, 44, ) reviewed during the Physical Restraints care area by failing to: 1. Ensure side rails (SR, adjustable rigid bars attached to the bed that may be positioned in various locations; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from unnecessary psychotropic medication (medications that affect the mind, emotions, and behavior) and the use of chemical restraints (any drug that is used for discipline or staff convenience and not required to treat medical symptoms) for one of seven sampled resident (Residents 13) reviewed during the Accidents care area by failing to: 1. Provide ongoing re-evaluation of the need for psychotropic medication by ensuring as needed (PRN) lorazepam (a medication used to relieve symptoms of anxiety [a mental health condition that may result in restlessness, irritability, feelings of nervousness, panic, and fear]) was ordered with an end date (time at which a medication will no longer be dispensed and will be required to be re-prescribed) for Resident 13. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive care plan (CP, a plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs) for six of seven sampled residents (Resident 13, 102, 112, 70, 97, 82, and 2) by failing to: 1). Develop and implement a CP that included side effects and behavior monitoring for Resident 13's as needed (PRN) lorazepam (a medication used to relieve symptoms of anxiety [a mental health condition that may result in restlessness, irritability, feelings of nervousness, panic, and fear]) administration. 2). Ensure a care plan was developed in a timely manner for the use of lower side rails (SR - often metal rails that normally hang on the side of the resident's bed) for Resident 102. 3). [...]

Inspectors wroteBased on interview and record review, the facility's licensed nursing staff failed to provide care in accordance with professional standards for: 1. Three of three sampled residents (Residents 21, 103, and 8) reviewed for insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) use by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (sq, beneath the skin) insulin administration sites. The deficient practice had the potential for adverse effect (unwanted, unintended result) of the same site subcutaneous administration of insulin such as excessive bruising, lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin). 2. [...]

Inspectors wroteBased on interview, and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical well-being for one of four sampled residents (Resident 97) by failing to: 1. Develop a comprehensive person-centered care plan (a plan of care that summarizes a resident's health conditions, specific care and services facility staff need to provide a resident to promote healing and prevent a worsening of a condition, and current treatments) for Resident 97's risk for elopement (the act of leaving a facility unsupervised and without prior authorization). This deficient practice resulted in Resident 97 eloping on 7/25/2025 at 12:14 p.m. 2. Provide supervision for Resident 97 during all meals as ordered. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received care consistent with professional standards of practice to prevent pressure injury (also called pressure ulcer, localized damage to the skin and/or underlying tissue usually over a bony prominence) for four (4) of four (4) sampled residents (Residents 112, 70, and 102) investigated under pressure injury by: 1. Failing to ensure Resident 112's and 92's low air loss mattress (LALM - a mattress that helps prevent and treat pressure injuries by circulating air and relieving pressure on the body) was set according to residents` weight or comfort. 2. Failing to ensure Resident 70's and 102's LALM was replaced timely when the LALM was beeping indicating low pressure and the resident's appeared sunk in the bed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were incontinent of urine received appropriate treatment and services to prevent urinary tract infections (UTI, an infection in the bladder/urinary tract) for four of four randomly sampled residents (Resident 36, 1, 5, and 55) by failing to: 1. Ensure the urinal bottle (a container used to collect urine and is made for either male or female anatomy) was labeled with a resident identifier for Residents 36, 1, and 55. 2. Anchor the urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) tubing in the stat lock (a strap-free device which secures a Foley catheter [a hollow tube inserted into the bladder to drain or collect urine] in place, stabilizes the catheter and reduces the likelihood of a sudden pull) of Resident 5. [...]

Inspectors wroteBased on observation, interview, and record review the facility: 1. Failed to ensure residents receiving enteral feeding (EF - also known as tube feeding, a method of supplying nutrients directly into the stomach) received appropriate care and services to prevent complications of EF for three (3) of six (6) sampled resident (Residents 71, 89, and 81) reviewed for tube feeding when: 1.1. Resident 71's and 89's water flush bag label did not indicate the residents' name, room number, and administration rate. 1.2. Resident 81's EF bottle was not labeled accurately with the administration rate and matches with the administration rate on the gastrostomy (GT - a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) feeding pump and the water flush bag indicated the resident's name and running rate. [...]

Inspectors wroteBased on observation, interview, and record review the facility: 1. Failed to ensure the resident was reassessed for the use of bed rails (SR - also known as side rails, adjustable rigid plastic or metal bars attached to the bed that may be positioned in various locations on the bed; upper or lower, either or both sides), which includes a review of risks including entrapment (when a resident is trapped in the spaces in between or around the bed rails, mattress, or bed frame) for one of four sampled residents (Resident 102) reviewed under bedrails by failing: 1.1 To ensure an entrapment risk assessment was completed on 2/2025 for the use of bilateral half upper SR. 1.2 To ensure an entrapment risk assessment was completed on 11/26/2024, 2/2025, 5/27/2025, and 7/26/2025 for the use of lower SR up for preference or family request. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure Registered Nurse (RN) 1, RN 2, Licensed Vocational Nurse (LVN) 1, Certified Nursing Assistant (CNA) 1, CNA 2, and CNA 3 had the skills and knowledge to identify and prevent one of one sampled resident (Resident 97) who was an identified as an elopement (the act of leaving a facility unsupervised and without prior authorization) risk, from eloping. This deficient practice resulted in Resident 97 eloping from the facility on 7/25/2025 at 12:14 p.m.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free of any significant medication errors (the observed or identified preparation or administration of medications or biologicals which are not in accordance with the prescriber's order, manufacturer's specifications, and accepted professional standards) by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (sq, beneath the skin) insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) administration sites for three of three sampled residents (Residents 21, 103, and 8) reviewed for insulin use. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Remove one expired admelog insulin (a medication used to control blood sugar) pen from the medication cart affecting Resident 13 in one of three inspected medication carts (Station 2 Cart.) 2. Remove one expired bottle of latanoprost eye drops (a medication used to treat eye problems) from the cart affecting Resident 85 in one of three inspected medication carts (Station 1 Cart). 3. Label an open salmeterol/fluticasone inhaler (a medication used to treat breathing problems) with an open date affecting Resident 82 in one of three inspected medication carts (Station 1 Cart). 4. Store an unopened glargine insulin (a medication used to control blood sugar) pen in the refrigerator per the manufacturer's requirements affecting Resident 81 in one of three medication carts (Sub-Acute Cart 2). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: 1. Food items in the refrigerator were stored without use by date for: -Applesauce -Pineapples -Grape jelly -Vanilla pudding -Cranberry sauce -Fruit cocktail 2. Resident 46's cut raw cactus in a Ziploc bag with no name, received date, use by date stored in a grocery bag with a date of 2/12/2025, was observed in the kitchen refrigerator on 7/29/2025. 3. Biscuit mix and pasta penne in dry storage with no use by date. 4. The following food items were not discarded: -Cinnamon Streusel Topping Mix with use by date of 6/12/2025. -Nilla Wafers with use by date of 7/25/2025. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain accurate clinical records in accordance with accepted professional standards and practices by failing to: 1. Ensure Registered Nurse (RN) 7 accurately documented in the change of condition/ situation, background, assessment, recommendation form (COC/SBAR - a communication tool used by healthcare workers when there is a change of condition among the residents) for one of one sampled resident (Resident 2) the physician's reply when Resident 2 had a fall incident on 6/30/2025. 2. Ensure there were no missing documentation in Resident 8's respiratory therapy electronic Medication Administration Record (eMAR) on 6/19/2025 at 9 p.m. and 7/28/2025 at 9 p.m. 3. Ensure Certified Nursing Assistant (CNA) 1 accurately documented how much Resident 97 ate on 7/25/2025 during lunch. 4. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the binding arbitration agreement (a resident waives the right to sue the nursing home in court, and instead agrees to have any future disputes handled by a private arbitrator) indicated the resident or anyone else (e.g., resident's representative) were allowed to communicate with federal, state, or local officials such as federal and state surveyors, other federal or state health department employees and representative of the Office of the State Long Term Care Ombudsman for three of three sampled residents (Residents 23, 33, and 51) reviewed for Arbitration Facility Task. This deficient practice had the potential for residents to be unaware of their rights pertaining to Arbitration Agreement.

Inspectors wroteBased on interview and record review, the facility failed to ensure the binding arbitration agreement (a resident waives the right to sue the nursing home in court, and instead agrees to have any future disputes handled by a private arbitrator) indicated the selection of a neutral arbitrator agreed upon by both parties; and the selection of a venue that is convenient to both parties for three of three sampled residents (Residents 23, 33, and 51) reviewed for Arbitration Facility Task. This deficient practice had the potential for residents to be unaware of their rights pertaining to Arbitration Agreement.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement appropriate infection control practices by failing to: 1. Ensure cleanliness of one of two shower rooms (Station 1) was maintained. 2. Ensure the door seal gaskets of two of three dryer tumblers (dryer 1 and dryer 2) were not torn and not covered with tape. 3. Ensure Licensed Vocational Nurse (LVN) 2 implemented Contact Precautions (an infection control measure aimed to prevent spread of infection by direct or indirect contact by the use of personal protective equipment [PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments]) for one of seven sampled residents (Resident 26) reviewed under the Infection Control task area. 4. [...]

Inspectors wroteBased on interview and record review, the facility failed to honor the resident's right to be informed in advance by the physician or other practitioner or professional, of the risks and benefits of proposed care, treatment and treatment alternative or options for two of five sampled residents (Residents 100 and 112) reviewed for unnecessary medications by failing to ensure: 1. Resident 1's Depakote (it helps manage manic or mixed episodes [periods of high energy, irritability, or both] in adults with bipolar disorder) indicated the correct preparation/form on the consent form. This deficient practice violated the residents' right to make an informed decision regarding the use of psychoactive medications (substances that, when taken in or administered into one's system, affect mental processes, e.g. perception, consciousness, cognition or mood and emotions). 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the residents were informed of their right to file a complaint with the State Survey Agency and certification agency (a health and safety inspector for places that provide healthcare, like hospitals and nursing homes) and that the State Survey Agency name, address and telephone number was visible and readable for four of five sampled residents (Resident 21, 23, 51, and 90) reviewed under the Resident Council task. This deficient practice had the potential to deprive the residents of assistance from resident advocacy groups should unresolved issues arise in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe and sanitary homelike environment for two of seven sampled residents (Resident 1 and 36) reviewed under the Environment task area by failing to ensure the trashcan lid in the bathroom was clean and did not have brown stains and a yellow substance on the lid. This deficient practice had the potential to negatively affect the residents' physical and psychosocial wellbeing and make the residents feel uncomfortable in their living space.

Inspectors wroteBased on interview and record review, the facility failed to report incidents of elopements (the act of leaving a facility unsupervised and without prior authorization) in a timely manner per the facility's policy and procedure (P&P) for one of one sampled resident (Resident 97) when: 1. Resident 97 eloped on 1/29/2025 at 9 p.m. 2. Resident 97 eloped on 7/25/2025 at 5 p.m. This deficient practice resulted in a delay in an investigation by the State Agency (SA) and had the potential to negatively affect the safety of residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the comprehensive care plan is reviewed and revised by an interdisciplinary team for two of three sampled residents (Residents 5 and 103) reviewed for physical restraint (the use of a manual hold to restrict freedom of movement of all or part of a person's body, or to restrict normal access to the person's body, and that is used as a behavioral restraint) use by failing to update the care plan on the use of tab alarm (is a device designed to alert caregivers when a patient or resident is attempting to get out of bed or a chair, potentially preventing falls). The deficient practice had the potential for delay of necessary care and services to residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the necessary care and services to maintain or improve a resident's ability to carry out the activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily) was provided for one of ten sampled residents (Resident 59) observed during dining observation task by failing to provide feeding assistance to the resident during lunch time on 7/29/2025. The deficient practice had the potential for the resident's inadequate intake and possible weight loss and contributed to feeling of helplessness of the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents maintained acceptable parameters of hydration status (amount of water intake needed for the body to function) for one of one sampled resident (Resident 25) reviewed during the Hydration care area by failing to ensure the resident was offered sufficient fluid intake per the prescribed physician's orders to provide an adult handicap non-spill cup (adaptive drinking cup designed to assist adults with various physical limitations in drinking independently and safely) within reach of the resident. This deficient practice had the potential to result in dehydration (a condition that occurs when the body uses or loses more fluid than it takes in) placing residents at risk for electrolyte imbalances, organ failure and death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respiratory care provided to residents was consistent with professional standards of practice for one of one sampled resident (Resident 50) reviewed for respiratory care by failing to ensure Resident 50's oxygen via nasal cannula (NC - a simple, two-pronged device that delivers extra oxygen to the nose) was not touching the floor. The deficient practice had the potential for residents to develop complications such as shortness of breath and desaturation (low levels of oxygen in the blood) and respiratory infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for: 1. One of three inspected medications carts (Sub-Acute Cart 2) by failing to accurately account for one dose of oxycodone (a controlled medication used to treat pain) 10 milligrams (mg - a unit of measure for mass) affecting Resident 27. This deficient practice increased the risk of diversion (any use other than that intended by the prescriber) of controlled mediations (medications with a high risk for diversion) and the risk that Resident 27 could have received too much or too little medication due to lack of documentation possibly resulting in serious health complications requiring hospitalization. 2. [...]

Inspectors wroteBased on interview, and record review, the facility failed to complete the Quarterly Minimum Data Set (MDS-a resident assessment tool) Assessment timely for one of two sampled residents (Resident 76) reviewed under the Resident Assessment task. This deficient practice had the potential to negatively affect the provision of necessary care and services needed Resident 76.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the Minimum Data Set (MDS - a resident assessment tool) was transmitted timely to the Centers for Medicare and Medicaid Services (CMS-a federal agency that administers major healthcare programs) system for one of two sampled residents (Resident 48) reviewed under Resident Assessments facility task. This deficient practice had the potential to negatively affect the provision of necessary care and services needed by Resident 48.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) received quality of care in accordance with professional standards of practice to meet Resident 1's physical, mental, and/or psychosocial needs (consists of the emotional and social requirements that individuals have to feel safe, supported, and function effectively in their environment), when Registered Nurse (RN 1) stated Licensed Vocational Nurse (LVN 1) did not timely report Resident 1's fever which was a change in condition. This failure resulted in a delay in providing care and services to Resident 1, which may have led to further physical decline of Resident 1 prior to the arrival of emergency personnel.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents receiving enteral feeding (EF-also known as tube feeding, a method of supplying nutrients directly into the stomach) received appropriate care and services to prevent complications of enteral feeding for one of three sampled residents (Resident 3) by failing to secure and cover the feeding tube tip with a cap when the feeding tube was disconnected from Resident 3. This failure had the potential to result in gastrointestinal (GI-relating to stomach and intestines) infection to Resident 3.

Inspectors wroteBased on interview and record review, the facility failed to implement the infection prevention policy by failing to prevent the presence of mice (small rodents) inside the facility's residential rooms occupied by four of eleven sampled residents (Residents 1, 2, 3, and 4). This deficient practice increased the risks in creating an unsafe and unsanitary living conditions for the residents, staff, and visitors.

Inspectors wroteBased on interview and record review, the facility failed to provide a safe, sanitary, and comfortable homelike environment by failing to prevent the presence of mice (small rodents) inside the facility's residential rooms which were occupied by four of eleven sampled residents (Residents 1, 2, 3, and 4). This deficient practice increased the risks in creating an uncomfortable and unsanitary living conditions for the residents, staff, and visitors.

Inspectors wroteBased on interview and record review, the facility failed to implement an effective pest control program by failing to prevent presence of mice (small rodents) inside the facility's residential rooms occupied by four of eleven sampled residents (Residents 1, 2, 3, and 4). This deficient practice increased the risks in creating an unsafe and unsanitary living conditions for the residents, staff, and visitors. Cross reference F880 and F921 Findings During a review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 11/6/2024 with diagnoses including essential (primary) hypertension (high blood pressure), need for assistance with personal care, and anxiety disorder (a condition that causes excessive fear, worry, and feelings of dread or uneasiness that persist over time and can interfere with daily life). [...]

Inspectors wroteBased on observation, interview, and record review: 1. The facility failed to ensure that the pad call light (a device with sensitive touch surface ideal for patients who may have difficulty using standard call cord to signal need for assistance from a professional staff) was within reach for three out of five sampled residents (Residents 3. 40, and 89) observed during random observations. 2. The facility failed to ensure the call light (an alerting device for nurses or other nursing personnel to assist a resident when in need) was within reach for one of eleven residents (Resident 19) investigated during review of the environment task. This deficient practice had the potential to result in the delay of care and services and possible injury to residents when they are unable to ask assistance from facility staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a homelike environment by failing to: 1. Ensure the residents bathroom flooring under the shower chair was in good repair for one of five sampled residents (Resident 42) investigated during review of accidents care area. 2. Place a flat sheet on the mattress while the resident was lying in bed for one of three sampled residents (Resident 62) investigated during review of pressure ulcer (also called pressure injuries and decubitus ulcers - injuries to skin and underlying tissue resulting from prolonged pressure on the skin) care area and one of one sampled residents (Resident 80) investigated during review of general care area. 3. Maintain the cleanliness of resident desk fans for one of four randomly observed residents (Resident 68). [...]

Inspectors wrote2. During a review of Resident 46's admission Record, the record indicated the facility admitted the resident on 10/3/2020, and readmitted the resident on 4/23/2024, with diagnoses including quadriplegia (a condition where all four limbs experience paralysis), seizures (a sudden, uncontrolled burst of electrical activity in the brain that can cause changes in behavior, movement, and awareness), and traumatic brain injury (a form of acquired brain injury, occurs when a sudden trauma causes damage to the brain). During a review of Resident 46's History and Physical (H&P), dated 4/23/2024, the H&P indicated the resident was incapacitated and had muscle weakness with limited movement, and required visit for safety. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide care in accordance with professional standards for: 1. Four of ten sampled residents (Resident 24, 43, 61 and 85) investigated under insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) care area by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous ([SQ] -beneath the skin) insulin administration sites. 2. For one of one sampled resident (Resident 60) investigated during review of anticoagulant use by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous ([SQ] -beneath the skin) anticoagulant injection sites. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the resident's environment was free of accident hazards for seven (7) out of seven (7) sampled residents (Residents 89, 25, 446, 60, 11, 19, and 42) by failing to ensure: 1. Resident 89's sensor pad alarm (a device that triggers an audible alarm when a patient attempts to rise off the pad) in bed was properly functioning. 2. Residents 25, 446, and 60's beds were placed on the lowest position when not providing activities of daily living (ADL - basic tasks that must be accomplished every day for an individual to thrive) care. These deficient practices placed the residents at risk for falls resulting in injuries, and even death. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the staff providing care and services to the resident who has a feeding tube (are soft plastic tubes through which liquid nutrition travels through the gastrointestinal tract [the series of organs that food and liquids pass through as they are digested, absorbed, and leave the body as feces]) are aware of, competent in, and utilize facility protocols regarding feeding tube nutrition and care for three of six sampled residents (Residents 84, 28, 33, 35 and 60) investigated during review of tube feeding by failing to: 1. Label Residents 84 and 60's water flush bag (a bag for holding water) with the resident's name, the infusion rate of water flush, and the start and date time. 2. Label Resident 28's EF bottle with the start date and time 3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to administer parenteral fluids (the intravenous administration of medication) consistent with professional standards of practice: 1. For one (1) out of two (2) sampled residents (Resident 445) during random observation of residents with intravenous (IV) catheter (a thin, flexible tube that is inserted into a vein to draw blood and give treatments including IV fluids, drugs, or blood transfusions) by: a. Failing to ensure the IV fluid infusing on the left upper arm (LUA) midline (ML - a long, thin, flexible tube that is inserted into a large vein in the upper arm) was free from signs and symptoms of infiltration (a condition that occurs when the IV fluid or medication accidentally leaks into the surrounding tissues outside the intended vein). b. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess the medical need, evaluate the risks of entrapment (a state in which a person is trapped by the bed rail [also known as side rails, a type of safety device that can be attached to a bed frame to help prevent falls and provide support for getting in and out of bed] in a position that they cannot move from), obtain an informed consent, and/or follow the physician's order for the use of bed rails and/or placement of pillows underneath the mattress for one of three sampled residents (Resident 46) investigated during review of bed rails and for two of five sampled residents (Resident 37 and 73) investigated during review of physical restraints (any manual method, physical or mechanical device, equipment, or material that is attached or adjacent to the resident's body, cannot be removed easily by the resident, [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the consultant pharmacist's (CP) recommendation for July 2024 Medication Regimen Review (MRR) (a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) was carried out as per standard of care for one of five sampled residents (Resident 24) reviewed for unnecessary medications. The deficient practice increased the risk of receiving medication that was not optimal for Resident 24's medical condition, that would not maintain the resident's highest level of physical, mental, and psychosocial well-being and/or increase the risk of adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have) from the medication therapy.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents' drug regimen was free from unnecessary drugs (any drug in excess) for one of five sampled residents (Resident 24) reviewed for unnecessary medication. Resident 24's duplicate medication orders for the same indication remained as active drugs on the Medication Administration Record ([MAR]- a record of medications administered to a resident) and were administered since 5/25/2024. This deficient practice had the potential to cause Residents 24 to receive suboptimal (less than the highest standard or quality) care and increase the risk of adverse consequences (unwanted, uncomfortable, or dangerous effects that a drug may have) and health complications.

Inspectors wroteBased on interview and record review, the facility failed to ensure one (1) of five (5) sampled residents (Resident 24) drug regimen was free from the use of unnecessary (any medication in excessive dose, excessive duration, without adequate monitoring) psychotropic (any medication capable of affecting the mind, emotions, and behavior) medications in accordance with the facility policy and procedure by failing to: 1. Indicate a specific duration for the use of Pro Re Nata ([PRN]- as needed) lorazepam (a psychotropic medication used to treat anxiety, also known as anxiolytic) order. 2. Provide a detailed clinical rationale for continuing Escitalopram (generic name for Lexapro [a psychotropic (any medication capable of affecting the mind, emotions, and behavior) medication used to treat depression]) as originally prescribed on 3/10/2023. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than 5 percent (%) due to 2 errors observed out of 31 total opportunities (error rate of 6.45%). The medication errors were as follows: 1. Resident 67 received a dose ascorbic acid (a medication used to improve the immune system) that was not ordered by Resident 67's physician. 2. Resident 74 did not receive multivitamin (a medication used as a dietary supplement to provide essential vitamins, minerals, and other nutritional elements) with iron (a supplement used to treat iron deficiency [having low amounts of iron in the blood] and anemia [a condition with lower-than-normal number of red blood cells]) as ordered by Resident 74's physicians. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were free of any significant medication errors (means the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order, manufacturer's specifications, and accepted professional standards) by failing to: 1. Rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous ([SQ] -beneath the skin) insulin [a medication used to regular blood sugar levels] and enoxaparin (a blood thinner) administration sites for five of ten sampled residents (Resident 24, 43, 60, 61 and 85) investigated under insulin and enoxaparin. 2. Have six licensed vocational nurses (LVNs) not administer expired insulin to one of five sampled residents (Resident 85) investigated for insulin. 3. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to remove and discard from use one expired insulin (medication used to regulate blood sugar levels) Humulin R (short-acting insulin) vial for Resident 85, in accordance with manufacturer's requirements in one of three inspected medication carts (Medication Cart 2.) This practice increased the risk that Residents 85 could have received medication that had become ineffective or toxic due to improper storage or labeling, possibly leading to health complications resulting in hospitalization or death.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow the menu and did not meet nutritional needs of 2 of 3 residents (Resident 29 and Resident 39) on Renal diet (diets that are restricting food high in salt, potassium, and phosphorus due to kidney disease) by not using the correct scoop or utensil to ensure accurate portion sizes. This deficient practice had the potential to cause increased in potassium (an essential mineral the body needs to function properly), sodium (an element found in salt), phosphorus (a mineral that naturally occurs in many foods that play roles in the body) intake and decrease food intake resulting to weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: a. Refrigerators one (1) and refrigerator two's (2) vent and fan had dust build up. b. Walk-in refrigerator and walk-on freezer's shelves were not smooth, cracked and had amber discoloration. c. Staff were wearing watches, gold bracelet and three (3) rings. d. Ice machine room floor was dusty. e. One (1) of four (4) shelves was not six (6) inches ([in.], unit of measurement) or more from the floor. These failures had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (transfer of bacteria from one object to another) in 65 of 100 medically compromised residents who received food and ice from the kitchen.

Inspectors wroteBased on observation, interview, and record review the facility failed to have a policy regarding the use and storage of food brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption when the policy did not include the facility's responsibility for storing food brought in by family and other visitors for more than one meal and there was no designated refrigerator for resident's outside food sources. This deficient practice had the potential to cause a decrease food intake resulting to unintentional (without trying) weight loss, frustrations, and psychosocial harm to 65 of 100 facility residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose garbage and refuse properly by not maintaining the trash area free from trash, soiled gloves and plastic cups on the floor and other dirt debris. This deficient practice had a potential to attract birds, flies, insects, pest and possibly spread infection to 65 of 100 facility residents.

Inspectors wrote4. During a review of Resident 43's admission Record, the record indicated the facility admitted the resident on 7/31/2020, and readmitted the resident on 4/5/2024, with diagnoses including chronic respiratory failure (a long-term condition that prevents the body from exchanging oxygen and carbon dioxide properly), tracheostomy, and gastrostomy (a surgical procedure used to insert a tube, often referred to as a g-tube, through the abdomen and into the stomach). During a review of Resident 43's H&P, dated 4/5/2024, the H&P indicated the resident was bedbound with limited function. During a review of Resident 43's MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others and was totally dependent on personal hygiene. The MDS also indicated the resident was incontinent of urine. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents were treated with respect and dignity in a manner that promotes maintenance or enhancement of his or her quality of life by failing to ensure Restorative Nurse Aide 1 (RNA 1) did not provide feeding assistance simultaneously to two residents for two of ten residents (Resident 6 and 49) observed during the dining task. This deficient practice had the potential to result in a decrease in psychosocial well-being for Residents 6 and 49.

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote the resident rights to examine the results of the state inspection results (a survey to determine compliance with state and federal regulations) of the facility by failing to post survey results in a place that is prominent and accessible (a place where individuals wishing to examine survey results do not have to ask to see them) to residents, family members, and legal representatives of residents. This deficient practice had the potential for residents' and their representative not having access to examine the most recent survey results.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents receive an accurate assessment for one of five sampled residents (Resident 37) investigated under the physical restraints (any manual method, physical or mechanical device, equipment, or material that is attached or adjacent to the resident's body, cannot be removed easily by the resident, and restricts the resident's freedom of movement or normal access to his/her body) care area when Resident 37's Minimum Data Set (MDS, a standardized assessment and care screening tool) did not indicate the use of bed rails (also known as side rails [SR], adjustable metal or rigid plastic bars that attach to the bed and are available in a variety of types, shapes, and sizes ranging from full to one-half, one-quarter, or one-eighth lengths and may be positioned in various locations on the bed; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents who had a Preadmission Screening and Resident Review (PASARR, a federal requirement to help ensure all residents to a nursing facility are evaluated for serious mental disorder [clinically significant disturbance in an individual's cognition, emotional regulation, or behavior] and receive the services they need) Level I pre-screen that was negative and were later identified with a serious mental disorder were referred for a Level II evaluation (provides a determination of an individual's mental health needs) for one of one sampled residents (Residents 52) reviewed under the PASSAR care area and one randomly reviewed resident (Resident 42). [...]

Inspectors wrote2. During a review of Resident 63's admission Record, the admission Record indicated the facility admitted the resident on 9/13/2022 and readmitted in the facility on 9/20/2022 with diagnoses including but not limited to chronic respiratory failure (a long term condition in which the lungs have a hard time loading the blood with oxygen and can leave a patient with low oxygen), tracheostomy (a surgical procedure to create an opening through the neck into the trachea [windpipe] to facilitate breathing), and generalized muscle weakness. During a review of Resident 63's H&P, dated 4/1/2024, the H&P indicated the resident did not have the capacity to understand and make decisions. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene to one of one sampled resident (Resident 60) investigated during review of activities of daily living by failing to provide Resident 60 showers every Wednesdays and Saturdays as scheduled. This deficient practice had the potential to negatively impact Resident 60's quality of life and self-esteem due to lack of personal hygiene.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents with pressure ulcers (also called pressure injuries and decubitus ulcers - injuries to skin and underlying tissue resulting from prolonged pressure on the skin) received treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for one of three sampled residents (Resident 62) investigated under the pressure ulcer care area when Resident 62's low air loss mattress (LALM - mattress designed to distribute the resident's body weight over a broad surface area and help prevent skin breakdown) did not have a flat sheet placed over it. This deficient practice had the potential for the resident to develop additional skin issues. Cross-reference F584.

Inspectors wroteBased on interview and record review the facility failed to offer and educate about the risks and benefits of the 2023/2024 influenza vaccine (medication used to prevent a highly contagious respiratory illness, which spreads easily through the air or when people touch contaminated surfaces) for one of five sampled residents (Resident 16) reviewed during the Infection Control task. This deficient practice had the potential to result in increased risk for residents to develop complications from influenza.

Inspectors wroteBased on interview and record review, the facility failed to provide education about the risks and benefits of, obtain consent or refusal for , and administer the 2023/2024 coronavirus disease 2019 vaccine (medication used to prevent complications from COVID-19 [a highly contagious viral infection that can trigger respiratory tract infection]) for three of five sampled residents (Resident 16, 43, and 46) reviewed during the Infection Control task. This deficient practice had the potential to result in increased risk for residents to develop complications from COVID-19 including acute respiratory failure (a serious condition that occurs suddenly when the lungs cannot get enough oxygen).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were provided a functioning call light system (device used to summon facility staff) for one of 11 sampled residents (Resident 70) when Resident 70's call light did not activate alert light outside Resident 70's doorway after the resident activated the call light. This deficient had the potential for Resident 70 to be unable to summon staff and cause a delay in provision of care.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 4) was provided dignity when Resident 4 ' s gown was down to her waist, exposing the resident's breasts to other residents and staff. This deficient practice had the potential for residents having decreased feelings of self-worth.

Inspectors wroteBased on interview and record review, the facility failed to provide daily shower as per physician ' s order for one of three sampled residents (Resident 4). This deficient practice had the potential to negatively impact Resident 4 ' s quality of life from lack of personal hygiene.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the appropriate treatment and services to prevent complications of enteral (within the digestive system) feeding for one of three sampled residents (Resident 1) by: 1. Failing to keep Resident 1 ' s gastrostomy tube (G-tube, also called as gastric tube, a tube inserted through the abdomen that delivers nutrition directly to the stomach) clean and in good condition. 2. Failing to clean and change resident ' s G-tube stoma (opening in the skin of the abdomen where a feeding tube is inserted into the stomach) dressing as ordered by the physician. These deficient practices had the potential to result in Resident 1 ' s G-tube to harbor bacteria and cause infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 4) who had obstructive sleep apnea (a blockage in your airway keeps air from moving through your windpipe while you're asleep) had a physician ' s order to continue using Resident 4's continuous positive airway pressure (CPAP- a machine that uses mild air pressure to keep breathing airways open while you sleep) machine. This deficient practice can negatively impact the resident's health and well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 4) who had negative skin scraping for scabies (a parasitic infestation caused by tiny mites that burrow into the skin and lay eggs, causing intense itching and a rash) was not given Elimite cream (medication used to treat scabies). This deficient practice had the potential to result in Resident 4 receiving unnecessary medications.

Inspectors wroteBased on interview and record review, the facility failed to maintain accurate and complete medical records for one of three sampled residents (Resident 4) by failing to document the clarification of Elimite Cream order with Physician Assistant (PA) on 8/8/2024. This deficient practice had the potential to cause confusion in Resident 4's care and can result in Resident 4's medical record containing inaccurate and incomplete documentation.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement infection control measures for one of three sampled residents (Resident 4) who was placed on enhanced barrier precaution (EBP-expand the use of personal protective equipment and refers to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of multidrug resistant organisms [MDRO- are germs that are difficult to treat because they are resistant to many antibiotics) by: 1. Failing to ensure Registered Nurse 1 (RN 1) wore a facemask properly while talking to Resident 4. 2. Failing to ensure RN 1 wore a protective gown before changing Resident 4 ' s oxygen tubing and removing Resident 4's hospital gown. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a notice of bed-hold (when a nursing home holds a bed when the residents go to the hospital) policy and return form for one of three sampled residents (Resident 1). This deficient practice had a potential to result in the resident's responsible party being unaware of the bed hold policy.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a safe, functional, and comfortable environment for one of four sampled residents (Resident 1). During an onsite investigation on 7/26/2024, observed hallways with wheelchairs and linen cart pushed up against both walls. This deficient practice had the potential to place residents at a risk for injury from accidents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection control procedures for one of three sampled residents (Resident 1) by failing to change the oxygen equipment weekly as indicated in the facility ' s policy and procedures. Resident 1 was suspected of scabies on 5/3/2024. The oxygen equipment was last changed on 4/12/2024. This deficient practice placed Resident 1 at risk for contracting infections and possible reinfestation of scabies.

Inspectors wroteBased on observation, interview, and record review the facility failed to observe professional standards of quality to one of three sampled residents (Resident 1) by failing to obtain a physician ' s order for a midline catheter (a catheter 3 inches (unit of measurement) to 8 inches in length and it is inserted via the veins) to receive appropriate care and treatment. This deficient practice had the potential to increase Resident 1's risk of having infections and midline catheter site complications.

Inspectors wroteBased on interview and record review, the facility failed to ensure medical records are complete and accurately documented for one of three sampled residents (Resident 1). The facility failed to: a. Ensure every change of condition (COC) of Resident 1 was documented separately. b. Ensure the communication with Resident 1 ' s physician was documented in the resident ' s medical records. c. Ensure Resident 1 ' s physician orders were documented in the resident ' s medical records. This deficient practice had the potential for inaccurate medical documentation and cause a delay in provision of appropriate interventions for Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care in a manner that maintained or enhanced a resident's dignity and respect in full recognition of their individuality for four (Residents 53, 28, 149, and 91) out of four sampled residents investigated for dignity by failing to: 1. Ensure Certified Nursing Assistant 1 (CNA 1) was not standing over Resident 53 while assisting the resident to eat. 2. Ensure Residents 28, 149, and 91 had a dignity bag to cover their urinary catheter drainage bag (drains urine from your bladder into a bag outside the body). These deficient practices had the potential to affect the residents' sense of self-worth and self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents' call lights (a device used by a patient to signal his or her need for assistance from professional staff) were within reach for three (Residents 28, 29, and 81) out of four sampled residents investigated for call lights. These deficient practices had the potential to result in the residents not being able to call for facility staff assistance and increase their risk for injury or fall

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement a comprehensive care plan with measurable objectives and time frames; and person-centered interventions for three (Residents 56, 67, and 97) out of 23 sampled residents by: 1. Failing to ensure Resident 56 has a care plan that addressed the use of oxygen. 2. Failing to ensure a restorative nursing program (a type of care designed to improve or maintain a resident's functional ability) care plan was developed for Resident 67. 3. Failing to ensure a fall care plan was developed for Resident 97 who was assessed as high risk for fall. These deficient practices had the potential to cause a disruption in the continuity of care for the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed: 1. To ensure Resident 29's low air loss (LAL - composed of multiple inflatable air tubes that alternately inflate and deflate, mimicking the movement of a patient shifting in bed or being rotated by a caregiver, never leaving the patient in one position for any extended length of time) mattress was provided timely as prescribed by the physician. This deficient practice had the potential to increase the resident's risk of worsening pressure ulcers. 2. To ensure a resident's LAL was set according to the resident's weight per manufacturer's guidelines, for four (Residents 29, 66, 76, and 40) out of four sampled residents investigated for pressure ulcer/injury (injury to skin and underlying tissue resulting from prolonged pressure on the skin). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and/or administering of all drugs and biologicals) for two of three sampled residents (Resident 20 and 37) by: 1. Failing to ensure Resident 20's intravenous antibiotic (medications that are administered directly into a vein so that they can enter the bloodstream immediately) was infused timely as indicated on the label and according to the facility's policy and procedures on intravenous therapy. This deficient practice had the potential for a delay in the treatment of the resident's infection and receiving the full benefit of the medication. 2. Failing to ensure that eight (8) medications were not crushed together, mixed as one mixture, and administered to Resident 37. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five percent (%). A total of eight (8) medication errors were observed out of 27 total opportunities (observations during medication pass) contributed to the overall medication error rate of 27.5%, affecting one out of three sampled residents (Resident 37). This deficient practice of administering medications contrary to accepted professional standards had the potential to negatively affect the health and well-being of Resident 37.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the ice machine in a clean, safe, and sanitary condition by failing to ensure the ice storage bin is free of dust. This deficient practice had the potential to result in harmful bacteria growth that could lead to foodborne illnesses (illness caused by the ingestion of contaminated food or beverages).

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program by: 1. Failing to ensure Resident 56's oxygen tubing was kept off the floor and by failing to change the oxygen tubing that was touching the floor prior to connecting the tubing to the oxygen concentrator. 2. Failing to ensure Resident 43's oxygen tubing was not touching the floor and by failing to ensure Resident 43's filled suction canister was placed in a plastic bag and disposed in a specific labeled container. 3. Failing to ensure Certified Nursing Assistant 4 (CNA 4) and Certified Nursing Assistant 5 (CNA 5) did not use a different resident's wash basin while providing a bed bath to Resident 82. 4. Failing to ensure Resident 29's urinary catheter drainage bag was not touching the floor. 5. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and homelike environment for residents when the facility's window screens did not fit securely into the frame which may potentially be an entry point for flies and insects for one of three (room [ROOM NUMBER]) resident rooms investigated under the under-environment facility task. This deficient practice had the potential for insect infestation that could pose a health risk to residents residing in room [ROOM NUMBER].

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was at high risk for falls had floor mats (designed to reduce injuries from falls off hospital beds) as ordered by the physician for one (Resident 75) out of four sampled residents investigated for accidents and hazards. This deficient practice had the potential to increase the resident's risk for injury in the event of a fall.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Certified Nursing Assistant 2 (CNA 2) rinsed the soap off the resident's skin when providing perineal care (involves cleaning the private areas of a patient) for one (Resident 148) out of one sampled resident investigated for bowel and bladder incontinence (a problem holding in urine or stool). This deficient practice had the potential to cause irritation to the resident's skin with the potential to cause skin breakdown.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure licensed nurses administer oxygen to a resident continuously as per physician's orders for one (Resident 56) out of two sampled residents reviewed for respiratory care. This deficient practice placed the resident at risk for respiratory distress due to not receiving oxygen therapy as ordered by the physician.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure unopened insulin lispro (medication used to control high blood sugar) pen is stored in the refrigerator until removed for administration for one of one (Resident 90) resident investigated under the facility tasks Label/Store Drugs and Biologicals. This deficient practice of failing to store medications appropriately according to the facility policy and procedure increased the risk of the resident receiving a medication which may have become ineffective or toxic resulting in a negative impact to Resident 90`s health and well-being.