Silver City Care Center

Inspectors wroteBased on record review and interview, the facility failed to meet professional standards of practice for 1 (R #1) of 3 (R #1, R #2 and R #3) residents reviewed for insulin (injectable medication used to help lower blood glucose levels) administration, when staff failed to administer insulin as ordered by the provider. This deficient practice could likely lead to uncontrolled blood glucose levels (BGL) or worsening of medical conditions.

Inspectors wroteBased on record review, and interview, the facility failed to notify the provider when insulin was not administered as ordered for 1 (R #1) of 3 (R #1, R #2, and R #3) residents reviewed for insulin (injectable medication used to help lower blood glucose levels) administration. This deficient practice could likely lead to uncontrolled blood glucose levels (BGL), result in residents not receiving necessary care, or worsening of medical conditions.

Inspectors wroteBased on observation and interview, the facility failed to store food under sanitary conditions for all 64 residents who eat food from the kitchen (residents were identified by the resident matrix provided by the administrator on (01/05/26) when staff failed to label and date all items in the kitchen refrigerator. Failure to store food under safe and sanitary conditions could likely lead to foodborne illnesses in residents.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure care plan revisions occurred for 4 (R #7, R #11, R #47, and R #71) of 4 (R #7, R #11, R #47, and R #71) residents when the staff failed to revise the care plan with the most current resident information. This deficient practice could likely result in the care plan not being updated with the most current resident conditions and appropriate interventions, staff being unaware of changes in care provided, and residents not receiving the care related to changes in their health status or healthcare decisions.

Inspectors wroteBased on interview and record review, the facility failed to complete performance reviews at least every 12 months for 2 (CNA #16 and CNA #17) of 2 (CNA #16 and CNA #17) CNAs sampled for 12 hours of annual training. This deficient practice could likely result in staff being undertrained and providing inadequate care.

Inspectors wroteBased on record review and interview, the facility failed to ensure the consultant pharmacist's recommendations were reviewed and implemented by the physician and/or the physician provided documentation of a rationale (a set of reasons or a logical basis for a course of action or a particular belief) for not following the consultant pharmacist's recommendation in the residents' medical record for 4 (R #8, R #10, R #32 and R #63) of 5 (R #7, R #8, R #10, R #32 and R #63) residents reviewed for unnecessary medications. This deficient practice could likely result in residents receiving medications that are no longer necessary and may cause unnecessary drug interactions (changes to medication action caused by being combined with other foods, beverages, or drugs) or adverse side effects (unwanted, undesirable effects from medication).

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure medical records were complete and accurate for 4 (R #5, R #10, R #11, and R #16) of 4 (R #5, R #10, R #11, and R #16) residents reviewed accuracy of documentation when staff failed to: 1. Accurately document R #5's dental assessment. 2. Accurately document activity participation for R #10 and R #11. 3. Accurately document R #16's skin assessment. These deficient practices have the potential to negatively impact the care staff provide to meet residents' needs due to inaccurate records.

Inspectors wroteBased on observation, and interview, the facility failed to have reasonable accommodations for 1 (R #61) of 1 (R #61) resident sampled for environment, when they failed to put R #61's call light in a place he could reach it. This deficient practice could likely result in residents not being unable to notify staff when they are in need of assistance.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure the MDS assessment was accurate for 2 (R #5 and R #9) of 8 (R #5, R #6, R #9, R #13, R #33, R #51, R #62 and R #80) residents reviewed for accurate MDS assessments. This deficient practice could likely result in the facility not having an accurate assessment of the resident's current health status and being unable to meet the resident's current needs.

Inspectors wroteBased on record review and interview, the facility failed to meet professional standards of practice for 1 (R #63) of 2 (R #7 and R #63) residents reviewed for physician's orders, when staff did not update an order for R #63's enteral feed. This deficient practice could likely lead to the resident having adverse (unwanted, harmful, or abnormal result) side effects or not receiving the desired therapeutic effect of the medication.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents received quality treatment and care for 1 (R #16) of 4 (R #4, R #5, R #16, and R #80) residents reviewed for wound treatment when staff failed to: 1. Document R #16 had a wound on his right elbow. 2. Notify the provider and obtain orders for wound treatment for R #16 wound on his right elbow. 3. Provide wound care for R #16's wound on his right elbow. These deficient practices could likely lead to residents needs not being met and/or a worsening of their wounds.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide respiratory care in accordance with professional standards for 1 (R #3) of 2 (R #3 and R #47) residents reviewed for respiratory care when staff failed to follow the physician's order for oxygen use. This deficient practice could likely result in residents receiving too much or not enough oxygen and can lead to worsening of their condition.

Inspectors wroteBased on interview and record review the facility failed to ensure residents obtained dental services for 1 (R #7) of 3 (R #5, R #7 and R #63) residents sampled for dental services, when they failed to ensure residents receive routine dental care to include an annual inspection of the mouth for signs of disease, dental cleaning, fillings, or minor partial or full denture adjustments. This deficient practice is likely to cause the resident unnecessary pain, embarrassment over the condition/appearance of teeth, and potential dental or oral complications.

Inspectors wroteBased on record review and interview, the facility failed to ensure CNAs received the required in-service training of 12 hours per year for 2 (CNA #16 and CNA #17) of 2 (CNA #16 and CNA #17) CNAs reviewed for required in-service training. This deficient practice is likely to result in the CNAs not receiving the necessary training to meet the care needs of the residents.

Inspectors wroteBased on record review, observation, and interview, the facility failed to maintain proper infection prevention measures when staff failed to ensure facility staff follow transmission-based precautions (actions to prevent the spread of infectious agents from individuals who are suspected to be infected, such as (gloves, facemasks, and gowns) for residents diagnosed with COVID-19 (an acute respiratory disease in humans characterized mainly by fever and cough and capable of progressing to severe symptoms and in some cases death, especially in older people and those with underlying health conditions) for 1(R #24) of 1(R #24) resident reviewed. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure the griddle, essential equipment (vitally important; absolutely necessary) was in safe operating condition for 69 residents of 72 residents who eat food from the kitchen (residents were identified by the resident matrix provided by the Administrator on 11/05/25) when the facility failed to ensure the kitchen griddle had knobs to control the gas burners. If knobs are not in working order, then it could likely affect temperature range, making it difficult or impossible to adjust the heat.

Inspectors wroteBased on observation and interview, the facility failed to safeguard resident's personal privacy and medical record information for 3 (R #12, R #13 and R #24) of 3 (R #12, R #13 and R #24) residents sampled for privacy and confidentiality of records when the facility failed to do the following: 1. Repair the privacy curtain between R #12 and R #13's room. 2. Keep resident's vital signs and name confidential for R #24. These deficient practices could likely result in the residents feeling that their privacy is not valued and their information could be viewed by unauthorized residents, visitors, and staff.

Inspectors wroteBased on record review and interview, the facility failed to ensure care plan revisions occurred for 2 (R #3 and R #8) of 6 (R #1, R #2, R #3, R #4, R #8, and R #9) residents reviewed for care plan accuracy when the staff failed to revise the care plan with the most current resident information. This deficient practice could likely result in the care plan not being updated with the most current resident conditions and appropriate interventions, staff being unaware of changes in care provided, and residents not receiving the care related to changes in their health status or healthcare decisions.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide foot care for 1 (R #1) of 1 (R #1) resident reviewed for foot care when staff failed to provide nail care for R #1's toenails or make an appointment to a podiatrist for foot care. This deficient practice could likely cause podiatric complications (foot and ankle health issues, often arising from underlying systemic diseases like diabetes or poor circulation, that can lead to problems such as ulcers, infections, nerve damage (neuropathy), and, in severe cases, amputation in residents with diabetes).

Inspectors wroteBased on record review and interview, the facility failed to ensure medical records were complete and accurate for 2 (R #1 and R #8) of 6 (R #1, R #2, R #3, R #4, R #8 and R #9) residents reviewed for documentation accuracy when staff failed to: 1. Document blood pressure and heart rate readings for R #1. 2. Document the correct diagnosis on the medication administration record for R #8. This deficient practice has the potential to have a negative impact on the care staff provide to residents due to missing or inaccurate records and resident information.

Inspectors wroteBased on record review, interview, and observation the facility failed to provide activities of daily living (ADL; activities related to personal care such as bathing, showering, dressing, walking, toileting, and eating) assistance for 1 (R #1) of 1 (R #1) resident reviewed for ADL care when staff failed to cut R #1's fingernails. This deficient practice is likely to negatively affect the dignity and health of the residents.

Inspectors wroteBased on record review and interview, the facility failed to thoroughly investigate an allegation of abuse/mistreatment for 1 (R #16) of 3 (R #1, R #16, and R #17) residents reviewed when they failed to: 1. Identify that staff using a deceased resident to carry out a prank/joke on another staff member was abuse/mistreatment of the resident. 2. Thoroughly investigate all components of the allegation. 2. Prevent further abuse/mistreatment by not removing RN #1 [initiator of the prank] from resident care. 3. Initiate corrective action to ensure staff are not dehumanizing residents and continue to treat residents with respect even after they are deceased . If the facility is not adequately investigating allegations of abuse, then corrective action is not implemented to prevent other residents from similar abuse which puts residents at risk of adverse serious outcomes.

Inspectors wroteBased on record review and interview, the facility failed to have an effective administration that maintained the highest practicable well-being of residents for 1 (R #16) of 3 (R #1, R #16, and R #17) residents reviewed when the administration failed to recognize the mistreatment, dehumanization (the process of depriving a person or group of positive human qualities) and disrespect to R #16 when she was used by staff to prank another staff member after she was deceased . If the administration is unable to adequately identifying the mistreatment of residents, even of deceased residents still under the care of the facility and establish a standard of practice by implementing adequate corrective action when failures are identified, then residents remain at risk of serious adverse outcomes.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents had a right to a dignified existence and were treated with respect and dignity for 1 (R #16) of 3 (R #1, R #16, and R #17) residents when facility staff used R #16 (without consent) to play a prank/joke on another staff member after R #16 was deceased . This deficient practice was disrespectful and dehumanizing to R #16 and her family.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents, their representatives, and the Ombudsman received a written notice of transfer as soon as practicable for 4 (R #8, R #9, R #11 and R #13) of 4 (R #8, R #9, R #11 and R #13) residents reviewed for hospitalization. This deficient practice could likely result in the resident and/or their representative not knowing the reason or location the resident was discharged .

Inspectors wroteBased on record review and interview, the facility failed to ensure residents or their representatives received a written notice of the bed hold policy which indicated the duration the bed would be held for 4 (R #8, R #9, R #11 and R #13) of 4 (R #8, R #9, R #11 and R #13) residents reviewed for hospitalization. This deficient practice could likely result in the resident and/or their representative being unaware of the bed hold policy upon return from the hospital.

Inspectors wroteBased on record review and interview, the facility failed to ensure care plans were reviewed and revised for 3 (R #1, R #14 and R #17) of 4 (R #1, R #2, R #14, and R #17) residents reviewed for care plans when they failed to revise the care plan with the most current resident information. This deficient practice could likely result in the care plan not being updated with the most current resident conditions and appropriate interventions, staff being unaware of changes in care provided, and residents not receiving the care related to changes in their health status or healthcare decisions.

Inspectors wroteBased on record review, observation, and interview, the facility failed to provide activities of daily living (ADL; activities related to personal care such as bathing, showering, dressing, walking, toileting, and eating) assistance for oral care, baths and showers for 3 (R #1, R #2, and R #17) of 3 (R #1, R #2, and R #17) residents reviewed for ADL care. This deficient practice is likely to affect the dignity and health of the residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure that facility staff followed physician's order for 2 (R #1 and R #13) of 5 (R #1, R #2, R #8, R #11 and R #13) residents reviewed for quality of care. Failure to follow physician orders could likely lead to facility staff and physician being unaware of changes in resident condition and could likely lead to worsening of resident's condition.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure food items were dated when initially opened, failed to ensure staff wore beard covers or hair nets while in the kitchen, and failed to ensure staff performed handwashing between glove use. These failures had the potential to affect 56 residents who consumed food prepared by the facility's kitchen.

Inspectors wroteBased on interview, record review, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure one (R #28) of 33 residents reviewed for Minimum Data Set (MDS) had a quarterly assessment successfully transmitted and accepted within the allotted time frame.

Inspectors wroteBased on interview, record review, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure one (R #28) of 33 sampled residents reviewed for Minimum Data Set (MDS) assessment had a quarterly assessment successfully transmitted and accepted within the allotted time frame.

Inspectors wroteBased on interview and record review, the facility failed to ensure an accurate Level 1 Pre-admission Screening and Resident Review (PASARR) was completed after a new diagnosis for one of one sampled resident (R21) reviewed for PASARR.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to revise the care plan (CP) of one resident out of six residents (R8) reviewed for accidents/falls out of a total sample of 29 residents. This failure to revise the care plan of R8 by implementing interventions to prevent future falls has the potential to lead to serious adverse consequences.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure the oxygen (O2) concentrators had dust free filters on the inlet where the air came into the machine for two of three residents (R29 and R43) of 25 sample residents. This deficient practice had the potential to allow an increased chance of infection and unnecessary respiratory treatment.

Inspectors wroteBased on daily nursing staff report review and interview, the facility failed to indicate the daily census in the space provided on the daily posted form. This failure had the potential for resident family, friends, or other visitors not to know the ratio of nursing staff to residents causing uncertainty of ability and availability of the staff for residents' needs.

Inspectors wroteBased on record review and interview, the facility failed to ensure medical records were complete and accurate for 1 (R #14) of 3 (R #12, R #14, and R #15) residents reviewed for abuse. This deficient practice has the potential to negatively impact the care staff provide to meet residents' needs due to missing or inaccurate records and resident information.

Inspectors wroteBased on observation and interview, the facility failed to store, and serve food under sanitary conditions in accordance with professional standards of food service safety for 77 residents that eat food prepared in the kitchen in the facility (residents were identified on the resident matrix provided by the Administrator on 09/11/23), when they failed to: 1. Wear facial hair coverings and hairnets in the kitchen. 2. Store food in a sanitary manner. If the facility fails to adhere to safe food handling practices, hygiene practices, and safe food storage, residents could likely to be exposed to foodborne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins).

Inspectors wroteBased on record review and interview, the facility failed to report to the State Survey Agency within five (5) days of the incident for 1 (R #21) of 1 (R #21) residents sampled for abuse. If the facility fails to report abuse to the State Agency, then corrective action may not be taken, and residents could likely continue to be abused and/or suffer serious bodily injury.

Inspectors wroteBased on record review and interview, the facility failed to revise the care plan for 2 (R #11 and R #21) of 4 (R #11, R #12, R #13, and R #21) residents reviewed for care plans when they failed to: 1. Revise R #11's care plan to include her regular/liberalized dysphagia advanced diet (moist foods in bite-sized pieces). 2. Have the required Interdisciplinary Team (IDT, team members from different disciplines working collaboratively, with a common purpose to set goals, make decisions, and share resources and responsibilities) members participate in the care plan meeting for R #21. This deficient practice could likely result in staff being unaware of changes in care provided and residents not receiving the care related to changes in their health status or healthcare decisions.

Inspectors wroteBased on record review and interview, the facility failed to provide metal health services for 1 (R #21) of 1 (R #21) residents reviewed for mental health concerns, when the facility failed to provide metal health services for R #21 after the provider placed an order for mental health services. This deficient practice could likely result in worsening of behaviors and worsening of behavioral or mental health conditions causing increased depression and anxiety.

Inspectors wroteBased on interview and record review, the facility failed to provide social services for 1 (R #21) of 1 (R #21) residents reviewed for behavioral/emotional health, when they failed to provide timely referrals for R #21 to other long term nursing facilities after R #21 requested to be transferred. This deficient practice could likely lead to residents to feel that their wishes are not important and not attaining, or maintaining, their highest practicable mental and psychosocial well-being.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents did not receive psychotropic medications unless the medication was necessary to treat a specific psychiatric diagnosis and was documented in the medical record for 1 (R #12) of 3 (R #11, R #12 and R #13) residents reviewed for unnecessary psychotropic medications. This deficient practice could likely result in residents receiving medications without a medical reason and being at a higher risk of adverse side effects (unwanted, harmful, or abnormal result).

Inspectors wroteBased on record review and interview, the facility failed to have a discharge summary that includes a summary of the resident's stay at the facility for 1 (R #22) of 3 (R #21, R #22, and R #23) residents reviewed for discharge. Failure to provide a complete discharge summary that includes a description of the resident's stay at the facility could likely result in the receiving facility or home health or home health agency not having the most current information to provide care to the residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure that staff received the appropriate behavioral health training and have the skills to provide behavioral health services for 1 (R #21) of 1 (R #21) residents reviewed for behavioral health concerns. This deficient practice is likely to result in residents not getting the care and assistance they need.

Inspectors wroteBased on observation, record review, and interview the facility failed to provide a therapeutic diet (a diet ordered by a physician or delegated registered or licensed dietitian as part of treatment for a disease or clinical condition, or to eliminate or decrease specific nutrients in the diet) as ordered by a physician for 1 (R #11) of 3 (R #11, R #12, R #13) residents reviewed for dietary services. If the facility fails to provide a diet as ordered, then residents are likely to experience weight loss due to not receiving their prescribed nutritional caloric intake and may be at risk for choking.

Inspectors wroteBased on observation, and interview the facility failed to keep the residents free from accidents for all 61 residents on the 100 and 200 Units (Residents were identified by the resident Census provided by the Administrator on 05/6/24), when they failed to keep treatment carts (a movable piece of equipment used in healthcare facilities to store, transport, and dispense treatment supplies and tools) locked when not supervised by staff. This deficient practice could likely result in injury to residents obtaining medical equipment which can cause injury/death.

Inspectors wroteBased on record review and interview, the facility failed to notify the provider of a change in condition for 1 (R #1) of 3 (R #1, R #3, and R #4) residents reviewed for change of condition, when they failed to notify the facility provider about R #1's low blood pressure, low temperature, and abdominal pain. This deficient practice could likely result in residents not receiving necessary care or a delay in treatment.

Inspectors wroteBased on record review and interview, the facility failed to meet professional standards of quality for 1 (R #3) of 4 (R #1, R #2, R #3, and R #4) residents reviewed for professional standards of care when the facility staff failed to monitor R #3's blood sugar. If the facility is not monitoring the resident and reporting to the provider, it may lead to a delay in treatment or changes in residents' health status may go untreated.

Inspectors wroteBased on record review and interview, the facility failed to ensure medical records were complete and accurate for 3 (R #1, R #2, and R #3) of 3 (R #1, R #2, and R #3) residents reviewed for accuracy of documentation. This deficient practice has the potential to negatively impact the care staff provide to meet residents' needs due to missing or inaccurate records.

Inspectors wroteBased on record review and interview, the facility failed to ensure the MDS assessment accurately reflected the resident's status at the time of the assessment for 1 (R #3) of 4 (R #1, R #2, R #3, and R #4) residents sampled for MDS accuracy. This deficient practice could likely result in residents not receiving the care and treatment they need.

Inspectors wroteRecite from 08/10/22 Based on observation and interview, the facility failed to ensure essential equipment (vitally important; absolutely necessary) was in safe operating condition when the facility failed to ensure: 1. The transportation vehicle (transportation van used by facility to transport residents to and from appointments as needed) had a working air conditioner, 2. The kitchen stove had knobs used to control the gas burners. If essential equipment is not in working order then residents could likely not be able to achieve the highest practicable well being because they are unable to go to medical appointments or get food prepared on the stove.

Inspectors wroteBased on observation and interview, the facility failed to maintain a safe and clean environment by not maintaining the facility's odor in the 200 Unit between room [ROOM NUMBER] and 208 and between 213 and 217. This has the potential to affect all 40 residents in the facility's 200 Unit (residents were identified by the Census provided by the Administrator on 09/11/23). This deficient practice could likely result in residents not maintaining their highest practicable well being in the facility.

Inspectors wroteBased on record review and interview, the facility failed provide a written notice of the bed hold policy at the time of the transfer to the resident and their representative(s) for 2 (R #68 and R #178) of 2 (R #68 and R #178) residents sampled for hospitalizations. This deficient practice could likely result in the resident and their representative being unaware that the resident is permitted to return and resume residence in the nursing facility upon discharge from the hospital.

Inspectors wroteBased on record review and interview, the facility failed to ensure that a Minimum Data Set (MDS) assessment was completed every three months for 1 (R #37) of 1 (R #37) residents reviewed for MDS assessments. This failed practice is likely to result in resident assessments being outdated and residents not receiving care and treatment that meets their current needs.

Inspectors wroteBased on observation, record review, and interview, the facility failed to meet professional standards of quality for 1 for (R #63) of 4 (R #1, R #58, R #63, and R #181) residents observed during medication administration, when CMA #1 held R #63's blood pressure medication without specific parameters (numerical or another measurable factor) from the medical provider. This deficient practice could likely lead to the resident having adverse (unwanted, harmful, or abnormal result) side effects or not receiving the desired therapeutic effect of the medication due to it not being administered.

Inspectors wroteBased on record review and interview, the facility failed to provide an ongoing activity program for 2 (R #1 and R #55) of 4 (R #1, R #43, R #55 and R #179) resident reviewed for activities. If the facility does not ensure that all residents are receiving an ongoing activity program, documenting resident refusals, and making in-room activity accommodations, then residents are likely to demonstrate an increase in isolation and depression.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents received adequate and timely transportation to each vision appointment for 3 (R #18, R #25, and R #28) of 3 (R #18, R #25, and R #28) residents reviewed for timely transport to vision appointments. If the facility is not assisting residents in accessing treatment to maintain their vision, then residents are likely to lose their ability to see, which will compromise their quality of life.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure that resident's received appropriate treatment and services to prevent further decrease in range of motion for 2 (R #19 and R #59) of 2 (R #19 and R #59) residents reviewed for restorative therapy, when they failed to initiate restorative nursing care (nursing service that often follows skilled rehabilitation services provided by physical or occupation therapists with the goal to maximize function and prevent functional decline in residents dependent on staff for certain actions). This deficient practice could likely result in decreased mobility or a decrease in residents' abilities to participate or perform their own ADL's (activities of daily living).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate treatment and services for Foley Catheter tubing/Collecting bag (soft plastic or rubber tube that is inserted to the bladder to drain the urine and is connected to a collecting bag) care for 1 (R #8) of 1 (R #8) residents sampled for Urinary Catheter, when they failed to keep R #8's Foley catheter and tubing off the floor. This deficient practice could likely result in residents getting infections.

Inspectors wroteBased on interview and record review, the facility failed to provide social services for 1 (R #3) of 1 (R #3) residents reviewed for behavioral/emotional health, when they failed to refer R #3 to veterans facility after he requested to be transferred. This deficient practice could likely result in a resident experiencing anxiety and depression because their concerns with the facility have not been addressed or resolved.

Inspectors wroteBased on record review and interview, the facility failed to ensure pharmaceutical services (the direct, responsible provision of medication-related care) were met for 1 (R #178) of 1 (R #178) residents reviewed for medications when they failed to provide routine medications to residents. This deficient practice could likely lead to unresolved infections, worsening of infection or uncontrolled pain.

Inspectors wroteBased on record review and interview, the facility failed to ensure that pharmacy recommendations were followed after the Physician accepted them for 3 (R #19, R #28 and R #68) of 5 (R #19, R #28, R #48, R #55 and R #68) residents reviewed for unnecessary medications. This deficient practice could likely result in residents being at a higher risk of adverse side effects.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents did not receive antipsychotic medications unless the medication was necessary to treat a specific psychiatric condition or diagnosis and was documented in the medical record for 1 (R #19) of 5 (R #19, R #28, R #48, R #55, and R #68) residents reviewed for unnecessary medications. This deficient practice could likely result in residents receiving medications without a clinical indication (medical reason) and being at a higher risk of adverse side effects (unwanted, harmful, or abnormal result).

Inspectors wroteBased on observation and interview, the facility failed to properly store medications, when they failed to: 1. Dispose of loose tablets stored in the medication carts for the 100, 200, and Memory Care Units. 2. Ensure medication was not expired in the medication refrigerator. 3. Document temperatures for the 100 Unit medication refrigerator. This could affect all 81 residents in the facility (Residents were identified by the resident matrix provided by the Administrator on 09/11/23). These deficient practices could likely result in residents obtaining medications that are no longer effective or that are not prescribed to them resulting in adverse side effects.

Inspectors wroteBased on observation and interview, the facility failed to store and serve food under sanitary conditions in accordance with professional standards of food service safety for 80 residents that eat food prepared in the kitchen in the facility (residents were identified on the resident matrix provided by the Administrator on 09/11/23), when they failed to: 1. Keep the deep freezer and kitchen floors clean, 2. Wear facial hairnets in the kitchen, 3. Failed to keep the stoves and surrounding areas clean from grease, 4. Ensure that spices in the kitchen are labeled and dated, 5. Ensure that food and spices are sealed properly after opening. If the facility fails to adhere to safe food handling practices, hygiene practices, and safe food storage, residents could likely to be exposed to foodborne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins).

Inspectors wroteBased on record review and interview, the facility failed to ensure documents were complete and accurate for 1 (R #43) of 1 (R #43) residents who were reviewed for documentation, when they failed to accurately document R #43's participation in activities. This deficient practice could likely result in staff not having the information they need to provide competent, comprehensive care and services if vital information is missing from the documents.

Inspectors wroteBased on record review and interview, the facility failed to ensure a discharge summary that included a recapitulation (a summary describing the resident's course of treatment while residing in the facility) was completed for 1 (R #75) of 1 (R #75) residents sampled for discharge from the facility. This deficient practice could likely lead to the receiving facility or hospital not knowing what the current care needs and significant medical history are for the resident.

Inspectors wroteBased on record review and interview, the facility failed to require that physician visits were made by the physician personally for 1 (R #59) of 1 (R #59) residents reviewed for pressure ulcer/injury when R #59 was seen by the attending physician via telemedicine (the remote diagnosis and treatment of patients by means of telecommunications technology) and not face to face. This deficient practice could likely result in residents not receiving the required medical assessment and review resulting in resident receiving less than optimal care.

Inspectors wroteBased on record review and interview the facility failed to schedule an appointment for dental services for 1 (R #42) of 3 (R #32, R #42 and R #68) residents sampled for dental services. This deficient practice could likely result in residents' continued dental pain.