Skyline Healthcare Center - La

Inspectors wroteBased on interview, and record review, the facility failed to develop and implement a person-centered care plan (a tool that ensures residents receive personalized, comprehensive, and goal-oriented care in a nursing home setting) for four of four sampled residents (Residents 1, 4, 5, and 6) by failing to: 1. Develop a care plan for Resident 1's use of cane (walking stick). 2. Develop a care plan for Residents 1, 4, 5, and 6's out on pass (a resident is temporarily allowed to leave a hospital, long-term care facility, or rehabilitation center without being officially discharged ). These failures had potential for Residents 1, 4, 5, and 6's delays in the delivery of necessary care and services and could place the residents at risk of accidents.

Inspectors wroteBased on interview and record review, the facility failed to maintain accurate and complete medical record for four of four sampled residents (Residents 1, 4, 5, and 6) by failing to: 1. Ensure Licensed Vocational Nurse (LVN) 2 documented that Resident 1 went out on pass (a resident is temporarily allowed to leave a hospital, long-term care facility, or rehabilitation center without being officially discharged ) on 5/11/2026, using a cane (walking stick) and leaving behind his (Resident 1) wheelchair (a mobilized seating device with wheels, used by individuals who have difficulty or are unable to walk due to injury, illness, disability, or age-related conditions). 2. Ensure LVN 1 and LVN 5 documented the date and time Residents 4, 5, and 6 returned to the facility after an out on pass. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure one of three sampled residents (Resident 1) was safely assessed for the use of a cane before allowing to leave the facility on an Out on Pass (a resident is temporarily allowed to leave a hospital, long-term care facility, or rehabilitation center without being officially discharged ) order on 5/11/2026. This failure had the potential for Resident 1 to fall outside of the facility that could potentially cause injury.

Inspectors wroteBased on interview and record review, the facility failed to ensure interventions to prevent falls were in place for one of three sampled residents (Resident 2) by failing to update Resident 2's Fall Risk Evaluation (a process used by healthcare providers to determine a person's likelihood of falling) when Resident 1 had a fall on 12/10/2025. This deficient practice had the potential for an inaccurate assessment of Resident 2, placing Resident 2 at a risk for a fall.

Inspectors wroteBased on interviews and record review, the facility failed to ensure one of three sampled residents (Resident 2) who complained of pain received medication according to the physician orders. This failure resulted in Resident 2's pain management to be ineffective resulting in Resident 2 being in pain.

Inspectors wroteBased on interview and record review. the facility failed to ensure one of three sampled residents (Resident 2) was free of any significant medication error when Licensed Vocational Nurse (LVN) 1, failed to administer medications as ordered. This deficient practice had the potential to negatively affect Resident 2.

Inspectors wroteBased on interview and record review, the facility failed to inform the attending physician (MD) of one of three sampled residents (Resident 2) behavioral Change of Condition (COC) on 8/24/2025. This deficient practice had the potential to result in a delay in care.

Inspectors wroteBased on interview and record review, the facility failed to implement its policy and procedure (P&P) titled, Abuse, Reporting and Investigations, for one of three sampled residents (Resident 2) when on 8/24/2025 Resident 2 reported to the Administrator (Adm) that staff started fighting with me (Resident 2) physically (deliberately aggressive or violent behavior with the intention to cause harm by one resident towards another) was investigated for events that may constitute abuse. This deficient practice resulted in a delayed investigation of an alleged abuse and had the potential to place Resident 2 at risk for further abuse and psychosocial harm.

Inspectors wroteBased on interview and record review, the facility failed to implement its policy and procedure (P&P) titled, Abuse, Reporting and Investigations, by failing to report an allegation of physical abuse (deliberately aggressive or violent behavior with the intention to cause harm by one resident towards another) to the State Survey Agency (SSA) no later than two hours for one of three sampled residents (Resident 2) when on 8/24/2025 Resident 2 reported to the Administrator (Adm) that staff started fighting with me (Resident 2) physically. This deficient practice had potential to result in unidentified abuse and placed Resident 2 at risk for further abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure a thorough investigation was completed following an allegation of physical abuse (deliberately aggressive or violent behavior with the intention to cause harm by one resident towards another) for one of three sampled residents (Resident 2) when on 8/24/2025 Resident 2 reported to the Administrator (Adm) that staff started fighting with me (Resident 2) physically. This deficient practice had the potential to place Resident 2 at risk for further abuse.

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 three sampled residents (Resident 2) by failing to respect Resident 2's right to refuse care. This deficient practice had the potential to result in Resident 2's rights to be violated.

Inspectors wroteBased on interview and record review, the facility failed to implement its policy and procedure (P&P) titled, Change of Condition Notification, last reviewed on 4/4/2025 for one of three sampled residents (Resident 1) by failing to notify Medical Doctor 1 (MD 1) when on 7/19/2025 at 4 a.m., Resident 1 who had a diagnosis of type 2 diabetes mellitus (DM - a disease that occurs when your blood sugar [BS] is too high), had a change of condition (COC - a major decline in a resident's status). Resident 1 complained of nausea (a feeling of sickness in the stomach that can be accompanied by an urge to vomit), had one episode of vomiting, a documented blood sugar of 382 milligrams per deciliter (mg/dl - unit of measurement) obtained by Licensed Vocational Nurse 1(LVN 1), and had a physician's order dated 7/15/2025, instructing staff to notify the MD if the BS is greater than 350 mg/dl. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide treatment and care in accordance with professional standards of practice for one of three sampled residents (Resident 1) who had a diagnosis of type 2 diabetes mellitus (DM - a disease that occurs when your blood sugar [BS] is too high), had a change of condition (COC - a major decline in a resident's status) on 7/19/2025 at 4 a.m., when Resident 1 complained of nausea (a feeling of sickness in the stomach that can be accompanied by an urge to vomit), had one episode of vomiting, and a documented blood sugar of 382 (normal range is between 70 to 99) milligrams per deciliter (mg/dl - unit of measurement) obtained by Licensed Vocational Nurse 1(LVN 1), and had a physician's order dated 7/15/2025, instructing staff to notify Medical Doctor 1 (MD 1) if the BS is greater than 350 mg/dl. The facility failed to: 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure staff were competent when providing care for one of three sample residents (Resident 1), by failing to:1. Ensure License Vocational Nurse (LVN 1) notified the physician when Resident 1 had a change of condition on 7/19/2025, at 4 a.m. when Resident 1 felt nauseated, had one episode of vomiting and had a blood sugar of 382 milligram per deciliter (mg/dl-unit of measurement).2. Ensure LVN 1 follows physicians order when physicians order indicated to notify physician if Resident 1 blood sugar was greater than 350 mg/dl.3. Ensure LVN 1 obtains Resident 1 vital signs (include body temperature, pulse (heart rate), respiration rate (breathing), and blood pressure. These measurements help healthcare professionals assess a person's overall health and identify potential problems) when Resident 1 had a change of condition.4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a call light's request for assistance were answered promptly for one of three sampled residents (Residents 4). This deficient practice had the potential to not meet Resident 4's needs.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the facility's License Vocational Nurse (LVN) 1 were competent to follow the current plan of correction to endorse to incoming nurse using the shift-to-shift report. This deficient practice placed Resident 1 at risk of dehydration due to delay of care.

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 (Residents 5) by failing to follow the physician's order to hold (temporarily suspending its administration) midodrine (medication used to treat low blood pressure) for systolic blood pressure (sbp- the top number in a blood pressure reading, representing the pressure in your arteries when your heart beats) more than 110 millimeter of mercury (mmHg-unit of measurement). This failure had the potential to result in unnecessarily elevating Resident 5's blood pressure.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an accurate and complete medical record for two of three sampled residents (Resident 1 and Resident 6) when: 1. The facility failed to ensure Licensed Vocational Nurse (LVN) 1 accurately documented Resident 1's glipizide (medication used to treat type two diabetes [DM - a disorder characterized by difficulty in blood sugar control and poor wound healing]) and Protonix (also known as pantoprazole, a medication used to decrease the amount of acid in the stomach) administration, and blood sugar check. 2. The facility failed to document the time and the physician's response after the physician (MD) was notified of Resident 6's urine test result on 8/6/2025. These failures had the potential to cause confusion in the care and the medical records containing inaccurate documentation.

Inspectors wroteBased on interview and record review, the facility failed to ensure Licensed Vocational Nurse (LVN) 1 followed an infection control policy and procedure for one of three sample residents (Resident 1) by offering a trash can when Resident 1 had an episode of vomiting. This deficient practice had the potential risk of transmission of bacteria that can lead to infection of Resident 1. During a review of Resident 1's admission Record, the admission Record indicated the facility initially admitted Resident 1 on 12/3/2021 and readmitted on [DATE] with a diagnosis of type 2 diabetes mellites with hyperglycemia (body isn't using insulin properly, causing blood sugar and hypertension (high blood pressure). During a review of Resident 1's History and Physical (H & P), dated 9/13/2024, the H & P indicated that Resident 1 had the capacity to understand and make decisions. [...]

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 four of five sampled residents (Residents 13, 43, 19, and 2) reviewed for physical restraints by failing to ensure Residents 13 and 43's bed with bolsters/ concave mattress (a type of mattress designed with raised sides to prevent residents from rolling or falling out of bed) had a/an: 1. Physician's order 2. [...]

Inspectors wrote3. During a review of Resident 47's admission Record, the admission Record indicated the facility originally admitted the resident on 7/19/2024 and readmitted in the facility on 10/30/2024 with diagnoses including dementia (a progressive state of decline in mental abilities), type 2 diabetes mellitus, and history of falling. During a review of Resident 47's H&P, dated 10/30/2024, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 47's MDS, dated [DATE], the MDS indicated Resident 47 was able to understand others and make her needs known but with severely impaired cognition (mental action or process of acquiring knowledge and understanding). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment was free of accident hazards for three six of six sampled residents (Residents 13, 43, 36, 34, 47, and 61) reviewed for accidents by failing to ensure: 1. Residents 13 and 43's fall mattress (a cushioned floor pad designed to help prevent injury should a person fall) did not have any furniture or medical equipment on top of them. 2. Resident 36 did not have any medications left at the bedside. These deficient practices increased the risk of accidents such as falls with injuries and medication overdose. 3. Resident 34's left floor mat did not have the overbed table placed on the top. 4. Resident 47's bilateral floor mats did not have heavy equipment or furniture on the top. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were incontinent of bladder received services and assistance for one of two sampled residents (Resident 41) reviewed for bladder and bowel incontinence by failing to label the urinal bottle (a container used to collect urine and is made for either male or female anatomy) with the name and room number of the resident. The deficient practice had the potential for residents to cross-contamination (the physical movement or transfer of harmful bacteria from one person, object or place to another) and to develop urinary tract infection (UTI - an infection of the urinary system, which includes the kidneys, ureters, bladder, and urethra) due to switching of urinals.

Inspectors wrote3. During a review of Resident 47's admission Record, the admission Record indicated the facility originally admitted the resident on 7/19/2024 and readmitted in the facility on 10/30/2024 with diagnoses including dementia (a progressive state of decline in mental abilities), type 2 diabetes mellitus, and history of falling. During a review of Resident 47's H&P, dated 10/30/2024, the H&P indicated the resident had the capacity to understand and make decisions. During a review of Resident 47's MDS, dated [DATE], the MDS indicated Resident 47 was able to understand others and make her needs known but with severely impaired cognition (mental action or process of acquiring knowledge and understanding). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the menu and did not meet nutritional needs of three of four sampled residents (Residents 19, 47, and 60) by: 1. Failing to follow the menu for fiesta corn and green chili rice during lunch service on 5/19/2025 for Residents 19, 60, and 47. 2. Failing to ensure Resident 19 ' s chicken fajita was served with cheese sauce and shredded lettuce topping as indicated in the meal ticket during lunch service on 5/19/2025. 3. Failing to ensure Resident 60 ' s chicken fajita was served with shredded lettuce and diced tomato topping during lunch service on 5/19/2025. 4. Failing to ensure Resident 47 was served with sugar cookie instead of a square of cake during lunch service on 5/19/2025. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were served with quality and palatable (pleasant or agreeable to the sense of taste) food for one of 1 sampled resident reviewed for food when Resident 32 was served a quesadilla with a hard tortilla as observed during lunch service on 5/19/2025. This deficient practice placed 77 of 82 facility residents at risk of unplanned weight loss, a consequence of poor food intake, getting food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure to store, prepare, and serve food in accordance with professional standards for food service safety by failing to ensure: 1. To label one (1) container of coffee with received date and open date. 2. A metal cooking pan with multiple kitchen tools were not soiled/dirty with food debris. 3. A basting brush, scooper, ladle, measuring cup, and knife sharpener were free of food debris and residues. 4. One (1) blender jar was free of brownish liquid substance at the bottom of the jar and the blender machine was free of food residue. 5. The walk-in refrigerator's blower was free of black oily substance. 6. The ice machine cleaning log was initialed and completed daily. 7. Chicken was not stored on top of the ground beef in the Kitchen Freezer. 8. The Resident Refrigerator did not contain: a. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure garbage and refuse in the facility were disposed of properly. This deficient practice had the potential to attract pests that can bring diseases to the residents.

Inspectors wrotec. During a review of Resident 81's admission Record, the admission Record indicated the facility originally admitted the resident on 4/6/2025, and readmitted on [DATE], with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease that causes difficulty in breathing), pneumonia (an infection/inflammation of the lungs), acute respiratory failure (a life-threatening condition where there is not enough oxygen or too much carbon dioxide in the body) with hypoxia (low levels of oxygen supply to the body's organs and tissues). During a review of Resident 81's H&P, dated 4/25/2025, the H&P indicated the resident can make needs known but cannot make medical decisions. During a review of Resident 81's MDS, dated [DATE], the MDS indicated the resident makes self-understood and has the ability to understand others. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement its policy for antibiotic (medication used to treat infection) stewardship (efforts in doctors' offices, hospitals, long-term care facilities, and other health care settings to ensure that antibiotics are used only when necessary and appropriate) for two of three sampled residents (Resident 186 and 236) by: 1. Failing to monitor Resident 186 for antibiotic use, signs and symptoms, side effects or adverse reaction (unintended pharmacologic effects that occur when a medication is administered correctly while a side effect is a secondary unwanted effect). 2. Failing to monitor Resident 236 for antibiotic use, signs and symptoms, side effects or adverse reaction. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure resident's medical records were updated to show documented evidence that advance directives (AD - a legal document indicating resident preference on end-of-life treatment decisions) were discussed with two (2) of three (3) sampled residents (Residents 30 and 72). These deficient practices violated the resident's rights and/or representative's right to be fully informed of the option to formulate their advanced directives.

Inspectors wroteBased on observation, interview, and record review, the facility failed to directly notify the primary physician of a significant change in condition (major decline or improvement in a resident's status that will not resolve itself without intervention) for one of four sampled residents (Resident 9) with limited range of motion [ROM, full movement potential of a joint (where two bones meet)] and mobility (ability to move) on 2/14/2025 for Resident 9's decreased mobility and increased pain with swelling in the right arm. This failure resulted in Resident 9 not receiving intervention to determine the cause and provide treatment of the right arm pain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, comfortable, and homelike environment for one (1) of three (3) sampled residents (Resident 34) reviewed for environment care area by failing to ensure Resident 34's left floor mat did not have tears. This deficient practice had the potential to negatively affect the resident's psychosocial well-being and make the resident feel uncomfortable in their living space.

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete a significant change (major decline or improvement in the resident's status that will not normally resolve itself without further intervention by staff or by implementing standard disease-related clinical interventions, that has an impact on more than one area of the resident's health status, and requires interdisciplinary review or revision of the care plan, or both) assessment for one of four sampled residents (Resident 9) with limited range of motion [ROM, full movement potential of a joint (where two bones meet)] and mobility (ability to move) after Resident 9 was discharged from Hospice care (compassionate care for people who are near the end of life provided at the person's home or within a health care facility) on 3/24/2025. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and/or implement person-centered care plans (tool that ensures residents receive personalized, comprehensive, and goal-oriented care in a nursing home setting) for eight of 35 sampled residents (Resident 9, 13, 17, 43, 47, 186, and 236) by failing to: 1. Implement Resident 9's care plan to elevate the right arm to a pillow and to monitor the right arm for any skin changes including discoloration. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to revise the person-centered care plans (tool that ensures residents receive personalized, comprehensive, and goal-oriented care in a nursing home setting) for three of 35 sampled residents (Resident 9 and 17) by failing to: a. Revise Resident 9's care plan after experiencing a significant change (major decline or improvement in the resident's status that will not normally resolve itself without further intervention by staff or by implementing standard disease-related clinical interventions, that has an impact on more than one area of the resident's health status, and requires interdisciplinary review or revision of the care plan, or both), including discharge of Hospice care (compassionate care for people who are near the end of life provided at the person's home or within a health care facility) on 3/24/2025. b. [...]

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, the breakdown of skin integrity due to pressure) for one of one sampled resident (Resident 336) investigated under pressure injury by failing to ensure Resident 336'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 according to resident's weight or comfort. This deficient practice had the potential for the development and worsening of pressure injuries to residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respiratory care provided to residents were consistent with professional standards of practice for one of one sampled resident (Resident 81) reviewed for respiratory care by: 1. Failing to ensure the oxygen via nasal cannula (NC - a device that gives additional oxygen [supplemental oxygen or oxygen therapy] through the nose) was administered as ordered for Resident 81. 2. Failing to ensure humidification (the process of adding moisture to the air) of oxygen was provided when oxygen therapy was set at 5 LPM. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure nurse staffing information was posted and updated on a daily basis. This failure resulted in staffing information not readily accessible to residents and visitors.

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 two of four sampled residents (Residents 236 and 5) by: 1. Failing to ensure Resident 236 received complete doses (measured quantity of a drug to be taken at one time or within a specific period) of antibiotic (medication used to treat infection) as per physician order. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five (5) percent (%). Three (3) medication errors out of 30 total opportunities contributed to an overall medication error rate of 10% affecting three (3) of four (4) residents observed for medication administration (Resident 13, 56 and 286.) The medication errors were as follows: 1. Resident 13 did not receive a dose of tiotropium (a medication used for Chronic Obstructive Pulmonary Disease [COPD -a disease that blocks air flow and makes breathing difficult]) oral inhalation as ordered by Resident 13's physician. 2. Resident 56 did not have previous lidocaine (a medication used to relieve pain) topical (on the skin) patch removed 12 hours after application, as ordered by Resident 56's physician. 3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to prepare foods in a form designed to meet individual needs for one of nine sampled residents (Resident 19) reviewed under dining observation task when Resident 19, who was on a regular standard portion and dysphagia advanced mechanical soft texture (also known as ground foods that are almost regular textured but have lumps that are easily mashing using the tongue) diet, received cubed chicken pieces on the plate for lunch service. This deficient practice had the potential to cause coughing, choking (to keep from breathing the normal way) and even death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medical records on each resident are complete, accurately documented, and readily accessible for one of four sampled residents (Resident 9) reviewed under the mobility care area, one of one sampled resident (Resident 67) reviewed under the care planning care area, and one of one sampled resident (Resident 45) reviewed under the vision and hearing care area when the facility failed to: 1. Record the provision of a Restorative Nursing Aide (RNA nursing aide program that helps residents to maintain their function and joint mobility) feeding program (focuses on improving or maintain a resident's ability to feed themselves) for Resident 9. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain mechanical, electrical, and patient care equipment in safe operating condition for two of 2 sampled residents (Residents 336 and 33) reviewed under the Environmental Task by: 1. Failing to ensure the Resident 336 ' s bed controller (device used to change the height and angle of the bed) cord did not have exposed wires. 2. Failing to ensure there were no frayed/exposed electrical wires on Resident 33 ' s bed remote control cord. These deficient practices had the potential to place Residents 336 and 33 at risk of incurring injuries.

Inspectors wroteBased on interview and record review, the facility failed to ensure timely submission of a completed discharge Minimum Data Set (MDS - a resident assessment tool) assessment for one of one sampled resident (Resident 76) reviewed for Resident Assessment Task. The deficient practice had the potential for delay of necessary care and services to residents.

Inspectors wrote3. During a review of Resident 61's admission Record, the admission Record indicated the facility originally admitted the resident on 5/26/2023 and readmitted on [DATE] with diagnoses including orthopedic aftercare (follow-up treatment required after surgeries, fractures, or other interventions related to bones and muscles) following surgical amputation (removal of a specified limb), acquired absence of left leg above knee, acquired absence of right leg below knee, and dementia. During a review of Resident 61's MDS, dated [DATE], the MDS indicated the resident makes self understood and has the ability to understand others. The MDS indicated the resident had no injury, with injury, and with major injury. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure bedrooms accommodate no more than four residents for three (3) of 16 rooms (room [ROOM NUMBER], 21, and 32). This deficient practice had the potential for residents to not have adequate space to meet their daily needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide 80 square feet per resident in multiple resident bedrooms for 16 of 33 rooms. This deficient practice had the potential to negatively impact the resident's privacy and not have adequate space for nursing care.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident ' s right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) for one of four sampled residents (Resident 1). On 4/22/2025 at 8:40 p.m., Resident 1 and Resident 2, who were both inside Room A (Residents 1 and 2 ' s room), had a verbal altercation (a noisy argument or disagreement) that led to a physical altercation (a confrontation or fight involving physical contact or force) in which Resident 2 punched Resident 1 on the left side of the face with a left closed fist. This deficient practice resulted in Resident 1 being subjected to physical abuse by Resident 2 while under the care of the facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the medical records of two of three sampled residents (Resident 1 and Resident 2) were maintained in accordance with accepted professional standards and practice, complete, and accurately documented by failing to: 1. Ensure Licensed Vocational Nurse (LVN) 1 documented the actual time of Resident 1 and Resident 2 ' s Change of Condition (COC). 2. Ensure LVN 1 documented the actual time Resident 1 and Resident 2 ' s representative and Attending Physician (MD) 1 were notified. 3. Ensure Licensed Nurses documented the level of care provided to Resident 1 and Resident 2 after the resident ' s COC. 4. Ensure the Social Services Director (SSD) documented the level of psychosocial (the interrelation of social factors and individual thoughts and behavior) care and monitoring provided for Resident 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled resident ' s (Resident 1) room change request was accommodated and followed through. This deficient practice had the potential for Resident 1 ' s decreased feelings of self-worth.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the physician was notified regarding unrelieved pain for one of three sampled residents (Resident 1), who had a diagnosis of pain due to internal orthopedic prosthetic devices, implants and grafts (surgically implanted medical devices used to replace damaged or not functional body parts, such as joints, bones, or ligaments) and presence of right artificial hip joint (a surgical procedure was done where the damaged or diseased hip joint is replaced with an artificial implant). This deficient practice resulted to Resident 1 experiencing unrelieved pain on 4/11/2025. Cross reference F697.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one of three sampled residents (Resident 1), who had a diagnosis of pain due to internal orthopedic prosthetic devices, implants and grafts (surgically implanted medical devices used to replace damaged or not functional body parts, such as joints, bones, or ligaments) and presence of right artificial hip joint (a surgical procedure was done where the damaged or diseased hip joint is replaced with an artificial implant), received care and services to prevent and manage the pain. This deficient practice resulted to Resident 1 experiencing unrelieved pain on 4/11/2025. Cross Reference F580.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one of three sampled staff (Case Manager 1) had specific competencies and skills sets necessary to perform the principal responsibilities of a case manager. This deficient practice had the potential for residents to not receive the necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a written or electronic record containing all the information the resident needs to effectively manage their own health) for one out of three sampled residents (Resident 1) by failing to ensure Resident 1 had a care plan regarding alleged sexual abuse. This deficient practice had the potential to result in failing to address Resident 40's allegations that may lead to a delay in or lack of delivery of care and services.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident ' s right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm by one resident towards another) for one of two sampled residents (Resident 1) when on 3/21/2025 at 7 a.m., Resident 2 scratched Resident 1 ' s right lower foot. This deficient practice resulted in Resident 1 being subjected to physical abuse by Resident 2 while under the care of the facility. Resident 1 had a scratched mark measuring 10 centimeters (cm- a unit of measurement) in length and 0.3 cm in width on Resident 1 ' s right lower foot that needed first aid (initial assistance and care given to a resident who has been injured) and daily wound treatments. Resident 1 was visibly upset. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement its policy and procedure (P&P) titled, Reporting Abuse, by failing to report a physical abuse (deliberately aggressive or violent behavior with the intention to cause harm by one resident towards another) to the State Survey Agency no later than two hours for two of four sample residents (Resident 1 and Resident 2) when on 3/21/2025 at 7 a.m., Certified Nursing Assistant (CNA) 1 witnessed Resident 2 scratched Resident 1 ' s right lower foot. This deficient practice had the potential to result in unidentified abuse and placed Residents 1 and 2 at risk for further abuse. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop a care plan (CP) that addressed resident ' s activity preferences for two of three sampled residents (Residents 1 and 2). This failure had the potential to negatively impact Residents 1 and 2's psychosocial (relating to the interrelation of social factors and individual thought and behavior) well-being.

Inspectors wroteBased on interview and record review, the facility failed to provide the resident representative (RR - An individual chosen by the resident or authorized by State or Federal law to act on behalf of the resident) with resident ' s Notice of Proposed Discharge form in a language they understand for one of three sampled residents (Resident 1). This deficient practice had the potential to result in the RR being unaware of how to contact the State agency and how to appeal a discharge if necessary.

Inspectors wroteBased on interview and record review, the facility failed to ensure Flu vaccine was offered and/or re-offered to one of six sampled residents (Resident 1) per facility policy. This deficient practice resulted in Resident 1 with a diagnosis of Influenza (flu- a common, sometimes deadly viral infection of the nose, throat and lungs).

Inspectors wroteBased on observation, interview, and record review, the facility failed: A. To have a system in place to ensure safeguarding of all prescribed medications (a drug that can be obtained only by means of a physician ' s order) including controlled medications (medications with a high potential for abuse) for three of ten sampled residents (Resident 1, Resident 2, and Resident 3), by failing to: 1. Implement its policy and procedure titled, Medication Dispensing Controlled Substances, that indicated an inventory count of all Controlled Dangerous Substances (CDS, a drug or chemical whose manufacture, possession, or use is regulated by a government because it may be abused or cause addiction) medications stored in each nursing unit shall be performed at each change of shift. [...]

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure one of six sampled residents (Resident 1) was medicated for pain as per physician ' s order. On 7/17/2024 at 5 a.m., Residen1 was medicated with acetaminophen (medication used to treat mild to moderate pain and to reduce fever) for a pain level of eight out of ten (a score of 0 means no pain, and 10 means the worst pain you have ever felt) when physician's order was to medicate Resident 1 with hydrocodone-acetaminophen (medication used to relieve moderate to severe pain) for severe pain level of eight to nine. This deficient practice had the potential to result in Resident 1 ' s uncontrolled pain. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure its governing body, who was responsible for establishing and implementing policies and procedure regarding the management of the facility, had a policy and procedure on security cameras before they were installed in nurse station 1 and nurse station 2. This deficient practice had the potential to violate the residents ' right for privacy.

Inspectors wroteBased on interview and record review, the facility failed: 1. To ensure Controlled Dangerous Substance (CDS, a drug or chemical whose manufacture, possession, or use is regulated by a government because it may be abused or cause addiction) records were maintained in accordance with accepted professional standards and practice, complete, and accurately documented on four of four facility medication carts, by failing to: a. Ensure the licensed nurses sign the CDS signature sheet before and after the shift. On 8/28/2024 at 10:11 a.m., Licensed Vocational Nurse 5 (LVN 5), who worked the 7 a.m. to 3 p.m., signed in advance the outgoing shift on Station 1 medication cart ' s (Cart 1) CDS sign in sheet. b. Ensure CDS records were not signed later. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to: A. Implement infection control measures for one of five sampled staff (Sitter- trained professionals who cater to clients requiring constant monitoring) when the facility had seven positive residents with Coronavirus Disease 2019 (COVID-19, highly contagious respiratory disease is thought to spread from person to person through droplets released when an infected person coughs, sneezes or talks, causing respiratory problems and may cause death) by: 1. Failing to ensure Sitter wore N95 (is a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) mask upon entering the facility and walking in the hallway towards the employee lounge. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe provision of pharmaceutical services for one of four medication carts (Cart 4 - Station 2 middle cart) by failing to ensure the medication cart was locked. This deficient practice had the potential for unauthorized access to the resident ' s medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services to maintain mobility (ability to move) for one of three sampled residents (Resident 7) with limited range of motion [(ROM) full movement potential of a joint (where two bones meet)] and mobility. The facility failed to: 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received an accurate assessment for one of three sampled residents reviewed under the hospitalization care area (Resident 64), one of one sampled resident investigated during review of the hospice and end of life care area (Resident 12), and one of three sampled residents investigated with range of motion [ROM, full movement potential of a joint (where two bones meet)] and mobility (ability to move) concerns (Resident 7): 1. The facility failed to indicate in Resident 64's Minimum Data Set (MDS - a standardized assessment and care screening tool) the resident was using bed rails (adjustable metal or rigid plastic bars that attach to the bed that are available in a variety of types, shapes, and sizes ranging from full to one-half, one- quarter, or one-eighth lengths). 2. [...]

Inspectors wroteBased on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan to: 1. Three out of three sampled residents (Residents 15, 74, and 64) investigated during review of side rails (metal rails that normally hang on the side of the patient's bed)/restraints (devices that limits a patient's movement). 2. One out of one sampled resident (Resident 7) investigated during review of anticoagulants (medicines that help prevent blood clots). 3. One out of two sampled residents (Resident 74) investigated during review of pressure ulcers/injuries (damage to an area of the skin caused by constant pressure on the area for a long time). These deficient practices placed the residents at risk for not receiving the necessary services and treatment to meet their medical, physical, mental, and psychosocial needs. 4. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide care in accordance with professional standards to one out of two sampled residents (Resident 6) investigated during review of insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) use by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) insulin administration sites. The deficient practice had the potential for adverse effects (unwanted, unintended result) of same site subcutaneous administration of insulin such as lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide treatment and services to maintain the ability to perform activities of daily living for one of three sampled residents (Resident 7) with limited range of motion [(ROM) full movement potential of a joint (where two bones meet)] and mobility (ability to move) by failing to transfer Resident 7 out-of-the-bed daily and dress Resident 7 in clothing. This failure limited Resident 7's participation in activities outside of the room from 1/2024 to 6/2024 and had the potential to contribute to Resident 7's decline in ROM, mobility, activities of daily living (ADLs, tasks related to personal care including bathing, dressing, hygiene, eating, and mobility), which could affect Resident 7's quality of life. Cross reference F688.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide three of four sampled residents (Resident 71, 41, and 80) reviewed under accidents care area, an environment free from accidents and hazards, ensure residents received adequate supervision, and implement and modify interventions to prevent accidents by failing to: 1. Ensure two single-use DermaSeptin (Trademark) ointment (a topical [on the surface of the body] medication to treat or prevent skin irritation) packets were not left unattended and readily available to Resident 71 in Resident 71's room. This deficient practice had the potential to result in residents obtaining topical medication without staff knowledge resulting in accidental ingestion causing harm to residents. 2. Ensure Resident 41 and 80, who used tobacco had a smoking safety risk assessment upon admission. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Provide one of three sampled residents (Resident 7) with limited range of motion [(ROM) full movement potential of a joint (where two bones meet)] and mobility (ability to move) who was fed through a gastrostomy tube (G-tube, tube placed directly into the stomach for long-term feeding) with services to restore oral (by mouth) eating skills. 2. Check the Percutaneous Endoscopic Gastrostomy ([PEG] - a tube surgically inserted in the stomach to receive nutrition and medications) Tube placement (ensure tube is inside the stomach,) patency (ensure tube is open and unobstructed,) residuals (ensure liquid drained from tube is within normal limit,) and flush the PEG-Tube with water prior to medication administration, for one of five sampled residents (Resident 295) observed for medication administration. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the safe and appropriate use of bed rails to three of three sampled residents (Residents 15, 74, and 64) investigated during review of restraints by: 1. Failing to obtain a physician's order prior to use of bed rails. 2. Failing to conduct an accurate resident assessment including risks of entrapment from bed rails prior to installation. 3. Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five percent (%). Four medication errors out of 32 total opportunities contributed to an overall medication error rate of 12.5 % affecting three of five residents observed for medication administration (Resident 11, 36 and 295.) The medication errors were as follows: 1. Resident 11 did not receive a dose of apixaban (a medication used for Deep Vein Thrombosis [DVT - a condition when a blood clot forms in one or more of the deep veins in the body] by reducing blood clots) as ordered by Resident 11's physician. 2. Resident 36 did not receive a dose of Oyster Shell calcium (a medication used as a dietary supplement to provide support to bones) as ordered by Resident 36's physician. 3. [...]

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) to: 1. One out of two sampled residents (Resident 6) investigated during review of insulin use (a hormone that lowers the level of glucose [a type of sugar] in the blood) by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) insulin administration sites. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Label two insulin (a medication used to treat high blood sugar) Novolog Flexpens (type of insulin injection device) for Residents 21, with an open date in accordance with the manufacturer's requirements, in one of two inspected medication carts (Medication Cart Station 1). 2. Store one insulin Lantus (long-acting insulin) Solostar (type of insulin injection device) pen and one insulin Humalog (fast-acting insulin) Kwikpen (type of insulin injection device) for Resident 295, in the refrigerator or label at room temperature in accordance with the manufacturer's requirements in one of two inspected medication (Medication Cart 1). 3. [...]

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 by: 1. Failing to label and date an open bag of shredded cabbage in the walk-in refrigerator. 2. Failing to wash multiple measuring cups and spoons in a plastic bag used for thickening powder. 3. Failing to dispose one (1) chipped plate lid during lunch tray line. 4. Failing to ensure low temperature dishwasher test strip was not used beyond the expiration date of 6/1/2024. 5. Failing to ensure Certified Nursing Assistant 12 (CNA 12) wore a hair restraint and washed hands when entering the kitchen. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections by failing to: 1. Ensure nasal cannulas (NC, a medical device to provide supplemental oxygen therapy to people who have lower oxygen levels) were changed weekly and labeled with the date last changed for two of three sampled residents (Resident 81 and 20) reviewed under the respiratory care area and one out of two sampled residents (Resident 15) reviewed under the oxygen care area. 2. [...]

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 the Certified Nursing Assistants (CNA) sat at eye level while providing feeding assistance for two of two sampled residents (Resident 4 and 36) reviewed under the dignity care area. This deficient practice had the potential to result in a decrease in psychosocial well-being for Residents 4 and 36.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide reasonable accommodation of resident needs and preferences by failing 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 two of three residents (Resident 56 and 15) reviewed under 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 housekeeping services necessary to maintain a sanitary, orderly, and comfortable interior for one of three sampled residents reviewed under the environment care area (Resident 297) when Resident 297's bathroom was not thoroughly cleaned. This deficient practice had the potential to increase the risk for cross-contamination, spread of infection, and/or negatively affect the resident's psychosocial wellbeing.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents were treated with dignity and respect 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) to two of three sampled residents (Residents 15 and 74) investigated during review of physical restraints care area by failing to: 1. Obtain an order prior to use of bed side rails (rails placed along the side of the bed to prevent a person from falling or getting out of bed). 2. Conduct a safety assessment on the use of bed side rails prior to use. 3. Obtain a consent from the resident or resident representative prior to use of bed rails. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident's transfer was documented in the resident's medical record for one of three sampled residents reviewed under the hospitalization care area (Resident 64) when the reason for transfer was not indicated in Resident 64's Notice of Proposed Transfer/Discharge, dated 5/6/2024. This deficient practice had the potential for the resident and their representative or the ombudsman (a resident advocate) to not know the reason for the transfer and to not determine if the reason for transfer was appropriate.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were made aware of the facility's bed-hold policy upon transfer to a general acute care hospital (GACH) for two of three sampled residents reviewed under the hospitalization care area (Resident 64 and Resident 33) when the facility failed to complete and provide the seven (7) day bed hold agreement to Resident 64 and Resident 33. These deficient practices had the potential to result in the resident and/or resident's responsible party being unaware of the bed hold policy and can lead to a transfer of the resident to another nursing facility not of the resident's or responsible party's preference.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident's care plan was reviewed after each assessment and revised based on changing goals, preferences, and needs of the resident in response to current interventions to one out of three sampled residents investigated during review of restraints care area (Resident 15) by failing to review and update the care plan to reflect the family's preference to have the call light hanging on the wall away from Resident 15's reach. This deficient had the potential to negatively affect the provision of care and services for Resident 15.

Inspectors wroteBased on interview and record review, the facility failed to implement their policy and procedure on cardiopulmonary resuscitation (CPR, an emergency procedure used to restart a person's heartbeat and breathing after one or both have stopped) by failing to maintain American Red Cross (an organization led by volunteers that provide relief to victims of disasters and help people prevent, prepare for and respond to emergencies) or American Heart Association (AHA, a non-profit organization that aims to reduce disability and death from cardiovascular diseases and stroke) CPR certification for one of nine sampled employees (Licensed Vocational Nurse 1 [LVN 1])investigated during review of sufficient and competent nurse staffing task. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide residents with an ongoing activity program that is resident centered for one of one resident (Resident 43) investigated under the activities care area. This deficient practice had the potential to affect the residents' sense of self-worth and psychosocial well-being through a feeling of usefulness, self-respect, and self-satisfaction.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 7) with limited range of motion [(ROM) full movement potential of a joint (where two bones meet)] and mobility (ability to move) was properly assessed for the provision and application of a left elbow splint (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion) in accordance with professional standards of practice for Occupational Therapy (OT, profession aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]). [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide care consistent with professional standards of practice to prevent pressure ulcer/injury (ulcers that happen on areas of the skin that are under pressure from lying in bed, sitting in a wheelchair, or wearing a cast for a long period) to two out of two sampled residents (Residents 7 and 74) investigated during review of pressure ulcers by failing to: 1. Turn Resident 7 every 2 hours in bed and follow the turning clock (an interactive tool placed at resident's bedside that outlines the individual positioning plan including frequency of positioning and time for next position change) schedule posted on the resident's wall. 2. Set Resident 74's low air loss mattress (LALM, designed to distribute the resident's weight over a broad surface area and help prevent skin breakdown) according to the resident's weight. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident's indwelling urinary catheter (a device inserted into the bladder to drain urine form the body) bag was not touching the floor to one out of one sampled resident (Resident 6) investigated during review of urinary catheter care area. The deficient practice had the potential Resident 6 to develop catheter associated urinary tract infection (CAUTI, an infection of the urinary tract caused by a tube [urinary catheter] that has been placed to drain urine from the bladder [an organ inside the body that stores urine until it is can be excreted]).

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure maintenance of equipment (nebulizer, an electrically powered machine that turns liquid medication into a mist so that it can be breathed directly into the lungs through a face mask or mouthpiece) for respiratory care in accordance with the manufacturer specifications and consistent with federal, state, and local laws and regulations for one out of one sampled resident (Resident 15) investigated during review of respiratory care area. The deficient practice had a potential for Resident 15 to have respiratory infections and shortness of breath that could lead to hypoxemia (a low level of oxygen in the blood) due to ineffective operating condition of the nebulizing machine.

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents who receive care and services for the provision of dialysis (a type of treatment that helps remove extra fluid and waste products from the blood when the kidneys [organ that removes waste and extra water from the body] are not able to) are consistent with professional standards of practice for one of one sampled resident reviewed under the dialysis care area (Resident 21) when Resident 21's care plan was not revised to include the resident's additional day of dialysis. This deficient practice had the potential for facility staff to not know when the resident receives dialysis and when to perform pre- and post-dialysis care.

Inspectors wroteBased on interview and record review, the facility failed to complete a performance review (also known as performance evaluation [PE] - a formal and productive procedure to measure an employee's work and results based on their job responsibilities) at least once every 12 months for one of three sampled Certified Nursing Assistants [CNA] (CNA 5) reviewed under sufficient and competent nurse staffing task. This deficient practice had the potential to result in missed opportunities to address CNA 5's performance issues that could impact resident safety and satisfaction.

Inspectors wroteBased on observation, interview, and record review the facility failed to administer a medication on time for one of five sampled residents (Resident 11.) for medication administration. As a result, Residents 11 did not receive apixaban (a medication used for Deep Vein Thrombosis [DVT - a condition when a blood clot forms in one or more of the deep veins in the body] by reducing blood clots) in accordance with the physician's orders and standards of practice. This failure had the potential to cause Resident 11 to experience serious health complications due to improper management of DVT, possibly resulting in DVT, stroke or heart attack causing hospitalization and/or death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a Physical Therapy (PT, profession aimed in the restoration, maintenance, and promotion of optimal physical function) evaluation to one of three sampled residents (Resident 19) who had range of motion (ROM, full movement potential of a joint [where two bones meet]) and mobility (ability to move) concerns in accordance with Resident 19's physician order, dated 4/25/2024. This failure resulted in Resident 19 not receiving PT intervention to improve ROM in both legs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three Restorative Nursing Aides (RNA, certified nursing aide program that helps residents to maintain their function and joint mobility) did not perform job duties out of the State certification, including managing feeding through a gastrostomy tube (G-tube, tube placed directly into the stomach for long-term feeding) for one of three sampled residents (Resident 7) with limited range of motion [(ROM) full movement potential of a joint (where two bones meet)] and mobility (ability to move). This failure had the potential for Resident 7 to have complications related to the G-tube, including clogging (causing a blockage) and dislodging (being removed from a fixed position) of the G-tube, which can lead to weight loss and hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility did not provide accurate documentation for one of three sampled residents (Resident 7) with limited mobility (ability to move) and range of motion [ROM, full movement potential of a joint (where two bones meet)]. This failure resulted in the inaccurate provision of care recorded in Resident 7's clinical record.

Inspectors wroteBased on interview and record review, the facility failed to arrange provisions of hospice services (a program designed to provide a caring environment for meeting the physical and emotional needs of the terminally ill) in a consistent manner to one of one sampled resident (Resident 12) investigated during review of hospice services by failing to: 1. Ensure hospice staff, including registered nurse (RN), licensed vocational nurse (LVN), and hospice aide (HA), provided nursing and visitation notes to the facility. 2. Ensure the calendar of visits from 5/19/2024 to 6/13/2024 was provided by Hospice Provider 1 (HP 1). 3. Ensure there is a designated facility staff to coordinate the hospice care and services for Resident 12. 4. Ensure Resident 12's comprehensive care plan on hospice services was developed and implemented. 5. [...]

Inspectors wroteBased on interview and record review the facility failed to educate each resident or the resident's representative regarding the benefits and potential side effects of and offer pneumococcal vaccines (medications used to prevent serious lung infections caused by streptococcus pneumoniae [a type of bacteria]) and influenza vaccines (medication used to prevent a highly contagious respiratory illness, which spreads easily through the air or when people touch contaminated surfaces) for two of five sampled residents (Resident 20 and 81) reviewed during the Infection Control task. This deficient practice had the potential to result in increased risk for residents to develop complications from pneumonia and influenza.

Inspectors wroteBased on interview and record review the facility failed to educate each resident or the resident's representative regarding the benefits and potential side effects of and offer coronavirus disease -2019 vaccines (COVID-19, a highly contagious viral infection that can trigger respiratory tract infection) for two of five sampled residents (Resident 20 and 81) reviewed during the Infection Control task. This deficient practice had the potential to result in increased risk for residents to develop complications from pneumonia and influenza.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure bedrooms accommodate no more than four residents for three of 16 rooms (room [ROOM NUMBER], 21, and 32). This deficient practice had the potential for residents to not have adequate space for their daily needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide 80 square feet per resident in multiple resident bedrooms for 16 of 33 rooms. This deficient practice had the potential to negatively impact the resident's privacy and not have adequate space for nursing care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medications of two of three sampled residents (Resident 2 and Resident 3) were administered according to the physician's orders. The facility failed to: a. Administer Resident 2's valproic acid solution (an anticonvulsant medication used to control seizures [a sudden, uncontrolled burst of electrical activity in the brain]) at the scheduled time on multiple dates. b. Administer Resident 3's pro-stat sugar free oral liquid (a medication used to increase protein in low volume) at the scheduled time on multiple dates. These deficient practices placed Resident 2 at risk for seizures and placed Resident 3 at risk for decreased protein in the body. c. Ensure Resident 2 and Resident 3's medications were not left at the bedside unattended. [...]

Inspectors wroteBased on interview and record review, the facility failed to prevent a fall and injury for one of eight sampled residents (Resident 1), who was identified as a high fall risk. On 12/4/2023, the facility failed to provide Resident 1, who was assessed as needing extensive assistance with bed mobility (how a resident moves from lying position, turning side to side, or positioning of body), with two-person physical assistance when Certified Nursing Assistant 1 (CNA 1) did a one-person assistance while giving care and turning Resident 1 in his bed. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive care plan on Coronavirus 2019 (COVID-19- highly contagious respiratory disease is thought to spread from person to person through droplets released when an infected person coughs, sneezes or talks) for one of five sampled residents (Resident 9) who tested positive for COVID-19. This deficient practice had the potential for delayed provision of necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure the safety of one of three sampled residents (Resident 1) by failing to provide a facility staff to accompany the resident to the scheduled appointment. This deficient practice resulted to cancellation of Resident 1 ' s scheduled medical appointment and rescheduled for a later date and had the potential to negatively impact Resident 1 ' s safety and prevent the residents from attaining or maintaining their highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy and procedure of meeting the staff posting requirements. This deficient practice had the potential to keep residents and visitors unaware of the total number of staff and the actual hours worked by staff in the facility.

Inspectors wroteBased on interview and record review, the facility failed to honor residents' right to meet in a group for resident coucil for 4 of 26 sampled residents ( Residents 17, 21, 33 and 41). The facility staff was performing resident council by going room to room and speaking with the residents individually. This deficient practice had the potential to result in Residents 17, 21, 33 and 41 to feel socially isolation with high risk of depression and not been able to speak freely without fear of retaliation

Inspectors wroteBased on interview and record review, the facility failed to ensure residents had specific choices and treatments communicated through an advance directives (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) and copies of the advance directives maintained in the Resident's clinical record for two of 24 sampled Residents (Residents 1 and 4). This deficient practice had the potential for Residents 1 and 4 not be given the right to accept or refuse specific medical treatments and have those options honored.

Inspectors wroteBased on observation, interview, and record review, the facility failed to inform Medicaid eligible residents of changes made to services covered by Medicare and/or Medicaid for three of three sampled residents (Residents 22, 39, and 104). This deficient practice had the potential for Residents 22, 39, and 104 not be given the information needed to decide to continue or refuse receiving the specific skilled services and have those options honored.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide services that promoted the prevention of pressure ulcer injury for 2 of 25 sampled residents (Residents 13 and 18) as evidenced by: 1. Failing to maintain proper weight settings for the low air loss mattress (LALM-mattress designed to treat and prevent pressure ulcers) of Resident 13. 2. Failing to monitor repositioning and perform weekly skin assessments for Resident 13 and Resident 18. This deficient practices had the potential to cause harm to Residents 13 and 18 by not providing services to promote the prevention pressure ulcer development.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure facility staff adhered to facility`s infection control policy and procedures to help prevent the spread of Covid-19 infection ( Coronavirus disease, a severe respiratory illness caused by virus and transmitted from person to person) and shingles (infection caused by varicella zoster virus , the same virus that causes chickenpox [a highly contagious disease]) by failing to: 1. Ensure facility staff conducted hand washing prior to setting up meal trays and after exiting contact isolation (used for infections, diseases, or germs that are spread by touching the resident or items in the resident room, healthcare workers are required to wear gloves, gown and optional mask during care) room [ROOM NUMBER] for shingles. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care for two of 25 sampled Residents (Residents 13 and 26) in a manner that promoted or enhanced the resident's dignity and respect by: 1. Failing to ensure the staff was not standing and bending over while assisting Resident 13 to eat during lunch time. 2. Failing to ensure Resident 26's urinary drainage bag (designed to collect urine drained from the bladder via a catheter) was covered with a privacy bag (a bag used to cover the urinary drainange bag). These deficient practices had the potential to cause psychosocial harm to the residents and violated the residents' right to be treated with dignity.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement an individualized person-centered plan of care to meet one of one sampled resident (Resident 25)`s needs for indwelling urinary catheter (a flexible tube for draining urine from the bladder). This deficient practice had the potential to negatively affect the delivery of necessary care and services concerning indwelling urinary catheter, causing health issues including UTI (urinary tract infection -such as bladder and kidney infection).

Inspectors wroteBased on interview and record review, the facility failed to ensure that one of five residents (Resident 14) was able to get to his physician ordered GI (gastrointestinal-bowel and intestine) consult in a timely manner. This deficient practice placed the resident at risk to develop complications of severe gastrointestinal bleeding.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement the facility's Out on Pass policy and procedures (P&P), monitor and ensure the safety and where abouts for one sampled resident (Resident 254) who had an appointment with a surgeon (a physician who performs surgery). These deficient practices resulted in Resident 254 leaving the facility unnoticed, and was gone from the facility for six and a half hours.

Inspectors wroteBased on observation, interview, and record review the facility failed to check the apical heart rate (pulse located to the left center of the chest over the top of the heart, typically heard through a stethoscope [medical instrument used to listen to the heart or lungs]) and check the Digoxin blood level prior to administration of Digoxin (medication used to treat heart failure and abnormal heart rhythms)for one of 25 sampled residents (Resident 3). These deficient had the potential to increase the risk for Digoxin toxic (harmful) effects such as frequent bradycardia (abnormal slow heart rate) and life threatening arrhythmias (abnormal heart rhythm) for Resident 3.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure bedrooms accommodate no more than four residents for three of 16 rooms, room [ROOM NUMBER], 21 and 32. This deficient practice had the potential for residents not to have adequate space for their daily needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide 80 square feet of space per resident in multiple resident rooms for 16 of 33 rooms. This failure had the potential to negatively impact the resident's privacy and not to have adequate space for nursing care.