Stellar Care Center

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on review of the medical record, review of the Self-Reported Incident, review of the facility's investigation, review of facility policy, review of staff education, review of facility plan of correction documentation, and interview, the facility failed to ensure licensed nursing staff appropriately wasted narcotic medications and failed to ensure legible and appropriate documentation related to narcotic administration and wasting. This affected five residents (#7, #10, #12, #18, and #20) of seven reviewed for abuse. Findings Include:Review of the Self-Reported incident (SRI) created 06/05/26 at 1:35 P.M. [...]

Inspectors wroteBased on record review, hospital record review, facility policy review and interview, the facility failed to timely identify a decline in condition and obtain medical intervention for Resident #26 following an injury sustained because of a fall. This affected one (Resident #26) of four residents reviewed for skin conditions. Actual harm occurred on 04/04/26 when Resident #26 complained of pain and had a decline in the ability to transfer. There was no thorough assessment completed to ensure the resident was provided timely and necessary treatment/medical intervention because of this change in condition. On 03/27/26 Resident #26 had sustained an unwitnessed fall. Between 04/04/26 and 04/08/26 the facility failed to complete a comprehensive nursing assessment or physician notification related to the resident's pain and decline in functional status that was identified during this time. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure the food license was renewed timely. This had the potential to affect 31 of 31 residents residing in the facility. The facility census was 31.

Inspectors wroteBased on record review, interview, policy review, and job description review,the facility failed to ensure professional standards of nursing care were provided when nursing staff did not verify and maintain a valid medical practitioner's order for the resident's clinical record prior to administering a controlled psychotropic medication. Although the dispensing pharmacy had a prescription for the medication, the facility did not have the order available or documented within the resident's medical record and medication administration record at the time of administration of the medication. This affected one resident (Resident #11) of four residents reviewed for medications. The census was 31. [...]

Inspectors wroteBased on record review, interview, observations, and policy review, the facility failed to ensure residents did not exit the facility unsupervised, had elopement assessments completed as appropriate and fall interventions were in place. This affected three residents (Resident #5, #26 and #32) of three residents reviewed for accidents. The census was 31.

Inspectors wroteBased on record review, interview and policy review, the facility failed to ensure weights were obtained as ordered. This affected one (#26) of one resident reviewed for edema. The facility census was 31.

Inspectors wroteBased on interview, record review and policy review the facility failed to ensure residents did not receive psychotropic medications without an active order in the medical record. This affected one resident (Resident #11) of four residents reviewed for medication use. The facility census was 31.

Inspectors wroteBased on record review, review of pharmacy receipts, Pyxis spread sheet review, policy review, and interview, the facility failed to ensure residents were free of significant medication errors when medications were not administered per physician orders. This affected one resident (#26) of three residents reviewed for anticoagulant medications. The facility census was 31.

Inspectors wroteBased on medical record review, pharmacy receipt review, interview and policy review the facility failed to ensure medication administration was accurately documented in the medical record for Resident #26. This affected one resident (Resident #26) of three residents reviewed for anticoagulant medication. The facility census was 31.

Inspectors wroteBased on observation and interview the facility failed to ensure the daily posted nursing staff information was current. This had the potential to affect all 31 residents residing in the facility. The census was 31.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure foods were stored under sanitary conditions. This had the potential to affect all residents residing in the facility. The census was 36.

Inspectors wroteThe facility failed to ensure residents, who had resided in the facility for over a year, were offered the opportunity to be vaccinated with the updated Covid-19 vaccine for the 2025- 2026 respiratory season. This affected four residents (Resident #4, #5, #33, and #36) of five residents reviewed for vaccinations.

Inspectors wroteBased on medical record review, policy review, and staff interview the facility failed to document advance directives for a resident. This affected one resident (#2) of eighteen residents reviewed for advanced directives. The facility census was 36.

Inspectors wroteBased on review of beneficiary liability notices and staff interview, the facility failed to ensure residents and/ or their representatives signed the liability notices provided acknowledging their skilled services were ending for coverage under Medicare (MCR) Part A services. This affected two residents (#2 and #36) of three residents reviewed for liability notices.

Inspectors wroteBased on record review, observation, interview, and policy review, the facility failed to ensure residents with the diagnosis of dementia did not receive an anti-psychotic medication without an adequate indication for use. This affected two residents (#5 and #33) of five residents reviewed for unnecessary medications.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure a resident and/ or their representative was provided a transfer notice in writing and a bed hold notice at the time of a transfer to the hospital. This affected one resident (#1) of three residents reviewed for hospitalizations.

Inspectors wroteBased on interviews and record review the facility failed to ensure accuracy of minimum data set (MDS) assessments for residents. This affected two residents (#3, #33) of 18 residents reviewed for accuracy of assessments. The census was 36.

Inspectors wroteBased on record review, interview, and policy review the facility failed to ensure residents received complete treatment for infections including antibiotic therapy and failed to ensure physician prescribed weight loss treatment was completed. This affected two residents (#3, #17) of 16 residents reviewed for quality of care. The census was 36.

Inspectors wroteBased on observation, interview, record review, and policy review the facility failed to ensure catheter care was completed for Resident #17, urinary outputs were monitored as ordered for Resident #27, and Resident #36 completed their full course of prescribed antibiotics for a urinary tract infection (UTI). This affected three residents (#17, #27, #36) of four residents reviewed for urinary catheters and UTIs. The census was 36. Findings Include:1. Record review revealed Resident #17 was admitted to the facility on [DATE] with diagnoses including necrotizing fasciitis, chronic obstructive pulmonary disease, hyperlipidemia, insomnia, morbid obesity, and depression. Review of Resident #17's minimum data set (MDS) completed on 12/26/25 revealed the resident had an indwelling urinary catheter. [...]

Inspectors wroteBased on medical record review, resident observations, and staff interviews, the facility failed to provide adequate hydration for Resident #36. This affected one resident (#36) of two residents reviewed for hydration status. The facility census was 36.

Inspectors wroteBased on record review, observation, interview, and policy review the facility failed to ensure residents received necessary respiratory care and services in accordance with professional standards of practice and the residents care plan. This affected two residents (#10, #17) of three residents reviewed for respiratory care. The census was 36.

Inspectors wroteBased on observation, interview, review of facility contracts and personnel files, the facility failed to provide administration of an intravenous (IV) medication by a competent licensed nurse to Resident #38. This affected one resident (#38) of two residents reviewed for IV medications. The facility census was 36.

Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to ensure pharmacy recommendations that identified irregularities during monthly medication regimen reviews were appropriately addressed by the physician/ nurse practitioner and/ responded to timely. This affected two residents (#5, #33) of five residents reviewed for unnecessary medications.

Inspectors wroteBased on medical record review and staff interviews, the facility failed to obtain ordered laboratory tests and report results to provider for one resident. This affected one resident (#36) of one resident reviewed for laboratory services. The facility census was 36.

Inspectors wroteBased on observations, staff interviews, review of medical records, and facility policies and procedures review, the facility failed to follow infection control practices to prevent the spread of infection. This affected one resident (#38) of five residents reviewed for medication administration and one resident (#10) of one resident reviewed for transmission-based precautions. The facility census was 36.

Inspectors wroteBased on record review, review of the facility's infection control logs, staff interview, and policy review, the facility failed to ensure a resident, who was admitted to the facility on an antibiotic medication, was reviewed to ensure there were laboratory tests that supported the use of an antibiotic to treat a urinary tract infection (UTI), and the resident met criteria under the facility's antibiotic stewardship program for such treatment. This affected one resident (#48) of five residents reviewed for UTI's.

Inspectors wroteBased on record review, review of hospital records, facility policy review and interviews, the facility failed to develop and implement comprehensive and individualized suprapubic catheter (a tube inserted into the bladder through a small cut in the lower abdomen (just above the pubic bone) to drain urine for resident's who can't pass urine normally through the urethra) care/interventions to prevent complications resulting in an acute change in medical condition and hospitalization. This resulted in Immediate Jeopardy and Actual Harm on 09/21/25 when Resident #05 was transferred to a local hospital and then life-flighted to a higher acuity hospital and admitted to the intensive care unit for treatment of sepsis and acute kidney injury secondary to a urinary tract infection. [...]

Inspectors wroteBased on review of facility billing/financial information, review of the Facility Assessment, and interview the facility neglected to operate in a manner to ensure all bills were being paid in a timely manner to prevent potential interruption in services. This had the potential to affect all 35 residents residing in the facility.

Inspectors wroteBased on record review, observation, interview, review of the activity calendar and job description review, the facility failed to assess and meet the activity needs of residents. This affected all 35 residents residing in the facility.

Inspectors wroteBased on observation, interview, record review, and review of the facility assessment tool, the facility failed to ensure sufficiency nursing staff was available to provide timely and appropriate nursing and nursing-related services to residents. This had the potential to affect all residents. The facility census was 35.

Inspectors wroteBased on record review, observation, interview and facility policy review, the facility failed to provide specialized memory care services as advertised. This affected seven residents (#10, #14, #20, #25, #26, #29, and #35) of seven residents residing on the memory care unit. The facility census was 35.

Inspectors wroteBased on review of the Administrator job description, review of vendor invoices, and interviews, the facility failed to have systems in place to ensure it was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Additionally, based on observation, interviews, review of dietary schedules and the facility assessment, the facility administration failed to ensure the facility employed sufficient dietary staff in accordance with the facility assessment. This affected 35 of 35 residents residing in the facility. The facility census was 35.

Inspectors wroteBased on review of the Facility Assessment, interviews, record reviews, and observations the facility failed to conduct an accurate and thorough facility assessment to determine appropriate resources were available to provide necessary care and services the residents required during both day-to-day operations and emergencies, including nights and weekends. This had the potential to affect all residents. The facility census was 35.

Inspectors wroteBased on observation, interview, and record review, they facility failed to ensure residents received comprehensive, resident centered care related to skin assessments, supplement orders, physician orders and physician notification related to weight gain. This affected four residents (Resident #5, #30, #8 and #24) of 24 residents reviewed for quality care. The census was 35.

Inspectors wroteBased on observation, interview, record review, review of facility policy, and material safety data sheet (MSDS) review, the facility failed to ensure fall interventions were in place for Resident #26 and failed to ensure a post-fall assessment was completed after Resident #27's unwitnessed fall. This affected two residents (Resident #26 and Resident #27) out of five residents reviewed for falls. Additionally, the facility failed to properly store hazardous chemicals. This had the potential to affect seven residents (#10, #14, #20, #25, #26, #29, and #35) out of seven residents residing on the memory care unit. The facility census was 35. Findings Include:1. Record review revealed Resident #26 admitted to the facility on [DATE] with diagnoses including major depressive disorder, dementia, hypertension, insomnia, anxiety, and vitamin D deficiency. [...]

Inspectors wroteBased on closed record review and interview the facility failed to ensure comprehensive discharge instructions were provided and failed to ensure documentation of a discharge was located in the medical record. This affected one (Resident #27) of one resident reviewed for discharge process. The census was 35. Findings Include: Closed record review revealed Resident #27 discharged from the facility on 07/24/25 with diagnoses including cerebral infarction, type two diabetes mellitus, cognitive communication deficit, chronic kidney disease, hypertension, hyperlipidemia, heart failure, gastro-esophageal reflux disease, hyperkalemia, and insomnia. Review of Resident #27 Multidisciplinary discharge summary revealed Resident #27 was discharged on 07/24/25 to their home. [...]

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure a baseline care plan was completed within 48 hours of admission to the facility. This affected two (#8 and #27) of two residents reviewed for care planning. The facility census was 35.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure showers were given to residents based on their preferences and shower schedules. This affected two (#24 and #28) of five residents reviewed for activities of daily living (ADLs). The facility census was 35.

Inspectors wroteBased on record review, observation and interview, the facility failed to ensure oxygen was administered under a physician order. This affected one (#8) of one resident reviewed for oxygen. The facility census was 35.

Inspectors wroteBased on record review, interview and facility policy review, interview, the facility failed to ensure that residents receive the treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management. This affected one (Resident #2) of one resident reviewed for pain management. The census was 35.

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents received medically related social services. This affected one resident (#30) of one resident reviewed for psychosocial well-being. The facility census was 35.

Inspectors wroteBased on record reviews, interviews and facility policy review, the facility failed to provide pharmaceutical services to meet the needs of each resident. This affected two residents (#30 and #2) of 24 resident's records reviewed for pharmaceutical services. The facility census was 35.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure residents received nutritive, palatable food. This affected two Residents (Resident #23 and Resident #28) of two residents reviewed for food. The census was 35.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure food was prepared in a form to meet individual resident needs. This affected two residents (Resident #5, and Resident #23 ) of two residents reviewed for food. The facility census was 35.

Inspectors wroteBased on record review and interview, the facility failed to ensure resident records and documentation were accurate. This affected one (#5) of two residents reviewed with an indwelling urinary device. The census was 35.

Inspectors wroteBased on observation and interview, the facility failed to ensure infection control practices were in place when a resident's catheter bag was oberved on the ground. This affected one (#9) of two residents reviewed for catheter care. The facility census was 35.

Inspectors wroteBased on observation, medical record review, policy review and interview, the facility failed to maintain appropriate infection control practices during a wound treatment. This affected one resident (#14) of one observed for a dressing change. The census was 32.

Inspectors wroteBased on observation, record review, policy review and interview, the facility failed to ensure the resident environment remained free of accident hazards when medication carts and treatment carts were left unlocked and unattended. This had the potential to affect seven residents (#26, #27, #28, #29, #30, #31 and #32) residing on the locked memory care unit. The census was 32.

Inspectors wroteBased on medical record review and interview, the facility failed to ensure required components of the comprehensive assessments were completed as required. This affected one resident (#14) of four residents sampled. The census was 32.

Inspectors wroteBased on medical record review and interview, the facility failed to develop comprehensive care plans as required. This affected two residents (#23 and #33) of four sampled residents. The census was 32.

Inspectors wroteBased on observation, medical record review, policy review, wound dressing guideline review and interview, the facility failed to provide appropriate care and services to treat pressure ulcers. This affected one resident (#14) of one reviewed for wound care. The census was 32.

Inspectors wroteBased on medical record review and interview, the facility failed to ensure colostomy care was provided as ordered. This affected two residents (#23 and #33) of four residents sampled. The census was 32.

Inspectors wroteBased on observation, medical record review, policy review and interview, the facility failed to ensure the facility's medication error rate was not 5 percent or greater. This affected two residents (#19 and #30) of three residents observed for medication administration with seven errors out of 26 opportunities resulting in an error rate of 26.9%. The census was 32.

Inspectors wroteBased on observation, record review, facility policy review and interview the facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention program to prevent the development of pressure ulcers for Resident #13 and Resident #22. This affected two residents (#13 and #22) of five residents reviewed. The facility census was 32.

Inspectors wroteBased on observations, interviews, and policy review, the facility failed to ensure foods were stored and served in a sanitary manner. This had the potential to affect 33 of 33 residents who receive food from the facility.

Inspectors wroteBased on observation, interview, and review of facility invoices, the facility failed to ensure the facility floors, walls, air vents and rooms were maintained, clean, and free of insects. This affected five residents (Resident's #5, #24, #29, #30, and #32) out of 24 residents reviewed in the initial pool. The facility census was 33.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure Resident #186 had an order in place for advanced directives and Resident #7's was listed correctly throughout the medical record. This affected two (#7 and #186) of two residents reviewed for advanced directives. The facility census was 33.

Inspectors wroteBased on medical record review, staff interview, and review of facility policy, the facility failed to ensure the Preadmission Screening and Resident Review (PASRR) was accurate regarding a psychiatric diagnosis. This affected one resident (Resident #7) of one resident reviewed for PASRR.

Inspectors wrote2. Review of Resident #4's medical records revealed an admission date of 12/28/22 and diagnoses of cerebral infarction, atherosclerotic heart disease, hypertension and hyperlipidemia. Review of Resident #4's physician orders revealed an order for Eliquis (an anticoagulation medication used to reduce the risk of blood clots) oral tablet 2.5 milligrams (mg) with instructions to administer 2.5 mg by mouth two times a day related to cerebral infarction. Review of Resident #4's care plan revealed there were no care plans present for anticoagulation medications or for the increased risk of bruising and bleeding related to the medications use. Interview on 11/06/24 at 2:30 P.M. with the Director of Nursing (DON) verified that there were no anticoagulation or risk for bleeding care plans present in Resident #4's medical record. [...]

Inspectors wroteBased on record review, observation, interview, and review of policies and procedures, the facility failed to ensure a dependent resident received assistance with bathing, showers, shaving, and oral care. This affected one (Resident #32) of three residents reviewed for activities of daily living. The census was 33.

Inspectors wroteBased on observation, family interview, staff interview, review of the facility assessment, and review of facility policy and procedure, the facility failed to ensure activities were available for resident participation. This affected one resident (Resident #30) out of three residents reviewed for activities. The census was 33.

Inspectors wroteBased on record review, observation, staff interview, and policy review, the facility failed to ensure skin prevention interventions were implemented for a resident with a known pressure ulcer per the plan of care. This affected one resident (Resident #28) of one resident reviewed for pressure ulcers.

Inspectors wroteBased on record review, observation, staff interview, and policy review, the facility failed to ensure fall prevention interventions were implemented for residents at risk for falls. This affected three (Resident #5, #11, and #28) of five residents reviewed for accidents/supervision.

Inspectors wroteBased on record review and interview, the facility failed to adequately assess, monitor, and manage Resident #33's pain after a fall. This affected one (#33) of one resident reviewed for pain. The facility census was 33.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure abnormal involuntary movement scale (AIMS) assessments were completed on a resident receiving antipsychotic medication to monitor for side effects associated with antipsychotic medication use. This affected one (Resident #5) of five residents reviewed for unnecessary medications.

Inspectors wroteBased on observation, record review, review of the daily census, review of staff postings and staff schedules and review of the facility assessment, the facility failed to ensure adequate staffing levels to meet resident needs. This had the potential to affect all 33 residents residing in the building.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure a clean, safe, and homelike environment. This affected 25 residents (#2, #3, #4, #5, #6, #8, #9, #10, #11, #12, #15, #17, #18, #19, #20, #22, #23, #25, #27, #28, #29, #30, #31, #32 and #33) of 33 residents in the facility.

Inspectors wroteBased on interview, record review, and review of the facility policy the facility failed to ensure a resident's physician was provided accurate information regarding a discharge Against Medical Advice (AMA), and failed to provide the resident or resident representative with required documentation upon transfer. This affected two residents (#34, and #36) of three residents reviewed for transfer. The facility census was 33.

Inspectors wroteBased on record review and interview, the facility failed to ensure a discharge summary which included a recapitulation (concise summary) of the resident's stay at the facility, was completed. This affected three residents (#34, #35 and #36) of three residents reviewed for discharge. The facility census was 33.

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident with edema was provided ordered medication for the treatment of edema related to the medical condition of congestive heart failure, skin ointments were applied for open skin lesions, weights obtained for a resident with edema, and intake and output assessed. This affected two residents (#21, #32) of three residents reviewed for medications. The facility census was 33.

Inspectors wroteBased on medical record review, interview, and policy review the facility failed to provide comprehensive pressure ulcer care timely and as ordered. This affected two residents (#14 and #26) of three residents reviewed for pressure ulcer care and services. The facility census was 33.

Inspectors wroteBased on record review, observation, and interviews the facility failed to ensure residents received physician ordered nutritional supplements for identified nutritional needs. This affected two residents (#26 and #32) of four residents reviewed for nutritional care and services. The census was 33.

Inspectors wroteBased on observation, record review, policy review, and interview, the facility failed to ensure respiratory equipment was maintained in a sanitary manner. This affected one resident (#19) of four residents observed for medication administration. The census was 33.

Inspectors wroteBased on observation, manufacturer guidelines, policy review, and interview, the facility failed to ensure a medication error rate of five percent or less when the facility had 26 opportunities for administration with two errors resulting in a 7.69 percent medication error rate. This affected one resident (#19) of four residents observed for medication administration. The facility census was 33.

Inspectors wroteBased on record review and interview, the facility failed to ensure laboratory tests were obtained as ordered. This affected three residents (#3, #19, and #21) of four residents reviewed for laboratory testing. The facility census was 33.

Inspectors wroteBased on closed and open medical record review, hospital record review, review of patient handout information from Medscape.com, emergency medical services (EMS) records, policy review and interviews the facility failed to provide comprehensive, resident centered care to adequately manage and prevent worsening of cardiac conditions for Resident #50. This resulted in Immediate Jeopardy and serious life-threatening harm/death for Resident #50, who was admitted to the facility on [DATE] with a history of chronic heart failure, cardiomyopathy, ventricular tachycardia (with an implanted defibrillator), atrial fibrillation, hypertension, and hypokalemia (low blood potassium level) when the resident did not receive the correct physician ordered dose of diuretics or antiarrhythmic medications for his cardiac conditions upon admission to the facility. [...]

Inspectors wroteBased on record review, observation, review of the daily census and staff postings, review of staff time punches/timecards, review of the facility assessment, review of resident notes, and interviews the facility failed to ensure adequate staffing levels to meet resident needs. This had the potential to affect all 37 residing in the building.

Inspectors wroteBased on review of the staffing schedules, timecard review, review of the daily census and staff postings, review of the facility assessment, and interviews the facility failed to ensure there was eight consecutive hours of Registered Nurse (RN) coverage seven days a week. This had the potential to affect all 37 residents residing in the facility.

Inspectors wroteBased on observation, personnel file review, job description review, facility assessment review, time sheet review, daily census and staff posting review, schedule review, medical record review, infection log review, policy review and interview the facility failed to maintain an effective governing body, legally responsible to establish and implement policies regarding the management and operation of the facility including but not limited to staffing needs, complete and accurate medical records, staff education and certification renewal to ensure the total care needs of all residents, residing in the facility, are met as planned. This had the potential to affect all 37 residents residing in the facility.

Inspectors wroteBased on medical record review, review of e-mail correspondence, observation, and interview the facility failed to ensure medical records were accurate and complete. This affected four (Resident #9, #14, #24, and #50) of four records reviewed but had the potential to affect all 37 residents residing in the building.

Inspectors wroteBased on infection control log review, interviews and policy review the facility failed to maintain a comprehensive infection control program responsible for tracking and trending infections. This had the potential to affect all 37 residents residing in the facility.

Inspectors wroteBased on review of the infection control logs, interview, and policy review the facility failed to ensure infections met criteria for treatment with antibiotics. This affected seven residents (Resident #8, #15, #21, #22, #36, #52 and #53) of 37 residents residing in the facility.

Inspectors wroteBased on review of the certificate of training, review of the facility assessment, and interview the facility failed to ensure the Infection Preventionist (IP) had specialized training in infection prevention and control from 09/23 through 07/02/24. This had the potential to affect all 37 residents residing in the facility.

Inspectors wroteBased on personnel file review, review of the facility assessment, and interview the facility failed to ensure State Tested Nursing Assistants (STNA) received the required 12 hours of in-service training per year. This had the potential to affect all 37 residents residing in the building.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure resident assessments were completed accurately on admission. This affected one (Resident #14) of three residents reviewed for accuracy of assessments. The facility census was 37.

Inspectors wroteBased on medical record review, observation, interview, and policy review the facility failed to provide comprehensive pressure ulcer care timely and as ordered. This affected one (Resident #14) of three reviewed for care and services. The facility census was 37.

Inspectors wroteBased on closed record review and interviews the facility failed to ensure a resident was provided a comprehensive, resident centered plan for urostomy care This affected one (Resident #50) of one residents residing in the facility with a urostomy. The facility census was 37.

Inspectors wroteBased on closed record review and interviews the facility failed to ensure residents received physician ordered nutritional supplements for identified nutritional needs. This affected one (Resident #50) of three residents reviewed for care and services. The census was 37.

Inspectors wroteBased on closed and open medical record review, review of the facility investigation, interview, and policy review the facility failed to ensure medications were administered per physician orders resulting in significant medication errors. This affected two (Resident #6 and #25) of 11 residents reviewed for medications. The facility census was 37.

Inspectors wroteBased on observation, record review and interview the facility failed to store refrigerated food and frozen food in a sanitary method. This had the potential to affect all residents residing in the facility. The facility census was 32.

Inspectors wroteBased on record review and interview, the facility failed to provide evidence or documentation of the Infection Preventionist's (IP) specialized training in infection prevention and control. This had the potential to affect all 32 residents residing in the facility.

Inspectors wroteBased on record review, policy review, and interview, the facility failed to ensure Resident #13's advanced directive form was dated by the physician and failed to ensure Resident #286's advanced directive form was properly signed and matched the physician order. This affected two (Resident #13 and Resident #286) of seventeen residents reviewed for advanced directives.

Inspectors wroteBased on record review, policy review, and interview, the facility failed to notify the resident representative of a change in health status. This affected one (Resident #13) of one resident reviewed for notification of change. The facility census was 32.

Inspectors wroteBased on observations, medical record review and staff interview the facility failed to ensure residents utilizing a reclining wheelchair were assessed to determine if the device was utilized as a potential restraint. This affected one of one residents (Resident #27) reviewed for potential restraint use. The facility census was 32.

Inspectors wroteBased on record review and interview the facility failed to complete a significant change assessment for a resident receiving hospice services. This affected one resident (Resident #23) out of two residents reviewed for receiving hospice services. The facility census was 32.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure resident assessments were completed accurately to reflect physical behaviors, type of falls, medication use and frequency. This affected two (Resident #29 and #30) of twelve residents reviewed for accuracy of assessment. The facility census was 32.

Inspectors wroteBased on record review and interview, the facility failed to revise and update Preadmission Screening and Resident Review (PASARR) for major mental disorder diagnosis and prescribed psychotropic medications. This affected three residents (Resident #31, Resident #284, Resident #286) out of three residents reviewed for PASARR. The facility census was 32.

Inspectors wroteBased on record review and interview the facility failed to ensure resident's nutritional plans of care were revised to include adaptive equipment and/or revised to include the correct adaptive equipment used by the residents. This affected three residents (#10, #27, and #33) of three residents reviewed for adaptive equipment.

Inspectors wroteBased on record review and interview, the facility failed to ensure the physician order indicated a specific topical antibiotic for a wound treatment and failed to discontinue a physician order for one-to-one supervision following readmission from the hospital. This affected two (Resident #13 and Resident #29) of 13 residents reviewed. The facility census was 32.

Inspectors wroteBased on interview, record review and policy review, the facility failed to provide nutritional intervention to facilitate healing to a resident with an unstageable suspected deep tissue injury as ordered by the physician. This affected one Resident (#31) of one resident reviewed for pressure ulcer/injury. The facility census was 32.

Inspectors wroteBased on record review and interview the facility failed to ensure residents with poor nutrition received nutritional supplements as recommended and ordered. This affected two residents (#5 and #25) of three residents reviewed for nutritional supplements.

Inspectors wroteBased on interview, record review and policy review, the facility failed to ensure psychotropic medications were ordered with appropriate diagnoses and Abnormal Involuntary Movement Scale (AIMS) assessments were completed for a resident receiving antipsychotic medications. This affected one resident (#31) of one resident reviewed for Preadmission Screening and Resident Review. The facility census was 32.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure physician's orders for laboratory testing was followed and completed as ordered. This affected one (Resident #29) of five residents reviewed for medication use. The facility census was 32.