Stoney Point Healthcare Center

Inspectors wroteBased on interview and record review, that facility failed to ensure residents' Preadmission Screening and Resident Review Level II (PASRR- an in-depth, mandatory assessment conducted when a PASRR Level I screen [a federal assessment requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care] indicates a potential serious mental illness [SMI], intellectual disability, or related condition) recommendations were provided to two of three sampled residents (Resident 2 and Resident 3). This deficient practice resulted in the facility not arranging specialized services per PASRR Level II recommendations for Resident 2 and Resident 3.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) received care and services in accordance with professional standards of practice by failing to administer Resident 1's Abilify Maintena injection (prescription medicine given as a once-monthly injection to treat schizophrenia [a mental illness that can affect thoughts, mood, and behavior] in adults and bipolar [mental disorder that causes unusual shifts in mood, energy, activity levels, concentration, and the ability to carry out day-to-day tasks]) as prescribed by the physician. This deficient practice resulted in Abilify Maintena injection not being administered on 6/2/2026 and could have resulted in worsening symptoms such as agitation or aggression.

Inspectors wroteBased on interview and record review, the facility failed to ensure an electrocardiogram (EKG- a test that measures the electrical activity of the heart) that was ordered by a physician on 6/20/2026 was completed for one of three sampled residents (Resident 1). This deficient practice resulted in the delay of necessary care and services for Resident 1.

Inspectors wroteBased on interview and record review the facility failed to ensure that one of three sampled residents (Resident 1) had Bioethics Committee (a multidisciplinary group that provides guidance, education and case consultations on complex moral and ethical dilemmas related to resident care) assess the need for continued psychotropic medication (medication that changes how a person, feels, or acts by adjusting brain chemicals) and sign the consent form for a psychotropic medication, Lorazepam (medication used to treat anxiety disorders [a mental health condition featuring excessive, ongoing fear and worry]) upon readmission to the facility. This deficient practice violated Resident 1's right to have bioethics committee make an informed decision regarding the use of psychotropic medications and had the potential for Resident 1 to receive unnecessary medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide proper foot care and treatment to maintain good foot health for one of two sampled residents (Resident 10) by failing to: 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the confidential personal information of residents were protected by failing to ensure documents (menu tickets) containing protected information ([PHI]- any health information that can be used to identify specific individual which must remain confidential to prevent harmful consequences) were shredded prior to disposing in the waste container. This failure had the potential to violate 125 of 126 residents' rights for privacy and confidentiality of personal and medical records.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: Kitchen and storage areas were not free from dirt and food debris. Reach-in freezer vent had dust and dirt buildup. Meat reach-in freezer bottom shelves had dirt, crumbs and other food debris. Walk-in refrigerator floors had food particles, debris and milk spills. Four (4) of 4 vents in the walk-in refrigerator contained dust and dirt buildup. Walk-in refrigerator shelves had food debris Dry storage floor had noodles, oatmeal and dirt debris. Dry foods and condiment container covers had oatmeal, sugar and flour debris. Hot water dispenser spout contained hard water buildup. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose of garbage and refuse properly when: 1. One (1) of two (2) dumpsters (a movable waste container designed to be brought and taken away by special collection vehicles, or to a bin that specially designed garbage truck lifts) was not closed when not actively being used. 2. Two of two trash cans in the kitchen were not properly covered and closed while not actively being used during lunch trayline (an area where foods were assembled form the steamtable [kitchen appliance that keeps food warm at a safe temperature for serving] to resident's plates). 3. The dumpster body had dirt and food debris. 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care in a manner that promoted dignity and respect by failing to: 1. Ensure residents were not served side dishes in paperware during lunch time. 2. Ensure Certified Nursing Assistant 3 (CNA 3) was not standing over one of one sampled resident (Resident 101) while assisting with eating. This deficient practice had the potential to affect 70 of 126, including Resident 39 and Resident 101, residents' self-esteem and self-worth.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of five sampled residents' (Resident 5 and Resident 4) drug regimen were free from the use of unnecessary (any medication with excessive dose, excessive duration, without adequate monitoring) psychotropic (any medication capable of affecting the mind emotions, and behavior) medications in accordance with the facility policies and procedures (P&P) by failing to: 1. Implement the physician's order to obtain orthostatic blood pressures (taking blood pressure measurements when lying, sitting, and standing to detect for significant drop in blood pressure during each position change) for Resident 5, who was receiving risperidone (an antipsychotic [medication that works by changing the effects of chemicals in the brain] medication). 2. a. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure kitchen staff were routinely trained and evaluated for competency skills when: 1. Dietary Aide 3 (DA 3) from Skilled Nursing Facility 2 (SNF 2, a sister facility [a building or location that shares the same parent organization or owner as another place]) did not have facility training and competency verification from the Dietary Supervisor (DS) from SNF 1 before performing the dishwashing job. 2. Dietary Aide 2 (DA 2) did not know the reason why he should not dip his hands in the sanitizer bucket when doing hand hygiene. 3. [NAME] 2 is unable to verbalize when to perform handwashing and identify clean and dirty areas. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the menu and did not meet nutritional needs when dietary staff did not follow the portion size of three (3) ounces (oz, unit of measurement) and served two (2) oz and four (4) oz of roast beef for regular and therapeutic diets (a personalized meal plan prescribed by a doctor to treat medical condition or manage symptoms). This failure had the potential to result in decrease in food flavor, decrease and increase in food and nutrient intake to 70 of 126 residents on regular, therapeutic diets, resulting in unplanned weight loss or unplanned weight gain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to notify the physician of a change in condition for one of one residents (Resident 14) investigated under edema (swelling), by failing to notify the physician of Resident 14's left and right hand edema. This deficient practice had the potential for delay of necessary care and services and worsening of Resident 14's condition.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure resident were free from physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the resident's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) for one of one sampled residents (Resident 121) by failing to ensure that a wedge pillow (special triangle-shaped pillows that raise the top half of the body while sleeping) was not placed under the mattress on the right side at the foot of the bed. This failure had the potential to result in the restriction of Resident 121's freedom of movement, a decline in physical functioning, injuries related to entrapment (a state in which a person is trapped by the bed rail in a position that they cannot move from, or death.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident who had a Preadmission Screening and Resident Review (PASARR - a federal assessment requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care) Level 1 positive received Level II (a resident is assessed on a Level I first which is a determination if a resident is suspected of having a serious mental illness. If a resident is positive for Level 1, then they are referred to Level II; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident unable to carry out activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily) to maintain grooming and personal hygiene was free off yellow/white discharge on her bilateral eyes and cheeks for one of one sampled resident (Resident 54) investigated under the ADL care area. This deficient practice had the potential to negatively affect Resident 113's dignity and placed Resident 113 at risk for eye infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to perform and document an assessment of edema (swelling) of the hands for one of one residents (Resident 14), who has a diagnosis of congestive heart failure (CHF - a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling) and was receiving Lasix (a medication that helps remove extra fluid from the body). This failure had the potential for delay of necessary care and services that places Resident 14's at increased risk of complications, such as shortness of breath that results in hospitalization.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents received the necessary care and services to prevent pressure ulcer (a localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure, or pressure in combination with shear) from developing for one of one sampled resident (Resident 121) by failing to offload (to reduce or remove pressure on the affected area to promote healing and prevent further damage) Resident 121's heels when in bed, in accordance with the Resident 121's care plan titled, At Risk for Skin Breakdown, initiated on 4/30/2026. This failure placed the Resident 121 at increased risk for the development or worsening of pressure ulcers/injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment was free of accident hazards for two of four sampled residents (Resident 10 and Resident 68) investigated under accidents by failing to ensure: 1. Resident 10 did not have a wheelchair on top of the landing pad (a cushioned floor pad designed to help prevent injury should a person fall) on the right side of the bed. 2. Resident 68 wore a soft helmet with a chin strap as ordered by the physician. These deficient practices had the potential to place Resident 10 and Resident 68 at risk for injuries.

Inspectors wroteBased on interview and record review, the facility failed to ensure that a resident who was receiving hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) treatment received services consistent with professional standards of practice by failing to ensure the hemodialysis communication assessment was completed on dates from 3/27/2026, 4/20/2026, and 6/19/2026 for one of one sampled residents (Resident 3). This deficient practice placed Resident 3 at risk for developing complications related to renal disease like swelling, high blood pressure, and shortness of breath.

Inspectors wroteBased on interview and record review, the facility failed to place a duration of therapy for one of one sampled resident's (Resident 4) medication, Lovenox (an anticoagulant [or blood thinner] medication injected through the skin subcutaneously [through the fat of the skin] to prevent blood clots [gel-like clump of blood]). This failure had the potential for Resident 4 to be subjected to unwanted subcutaneous injections and unnecessary medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to label and store drugs and biologicals by not ensuring a resident's carboxymethylcellulose sodium drops 0.5% (over-the-counter artificial tear lubricant) had been labeled with the resident's name for one of five sampled residents (Resident 82). This deficient practice had the potential for residents to receive medication that was not intended for them.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection prevention and control measures for two of four sampled residents (Resident 14 and Resident 34) by failing to: 1. Label Resident 14's nasal cannula (NC - a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) oxygen tubing. This deficient practice had the potential to place Resident 14 at increased risk for infection. 2. Ensure Licensed Vocational Nurse 6 (LVN 6) did not leave Resident 34's room who was on enhanced barrier precautions (EBP, a method of using personal protective equipment [PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments]) during medication administration while still wearing an isolation gown (provides protection against splashing and spraying of body fluids). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the medical records of one of three sampled residents (Resident 1) were released in a timely manner to Resident 1's Responsible Party 1 (RP 1) after receiving a valid request for the medical records from RP 1 on 5/27/2026. This deficient practice resulted in a delay in RP 1's ability to review Resident 1's medical records. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that the medical record for one of three sampled residents (Resident 2) was complete and accurately documented after Resident 2 reported to Licensed Vocational Nurse (LVN) 1 that Resident 2 had hit Resident 2's left eye on the bedside table (a table positioned at the bedside of resident to assist with meals). This deficient practice had the potential to result in delays in care and services, compromise the continuity of care, and negatively affect Resident 2's overall health status. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the proper use of a low air loss mattress (LALM- a specialty bed that alternates pressure to help heal and prevent pressure ulcer/injuries [ PU/PI-injuries that breakdown the skin and underlying tissue when an area of skin is placed under pressure]) for one of five sampled residents (Resident 1) when on 5/28/2026 a cloth pad and a sheet were placed over the mattress surface while Resident 1 was also wearing an incontinence (loss of bowel or bladder control) brief (diaper). This deficient practice had the potential to compromise the effectiveness of the LALM by reducing airflow and pressure redistribution, thereby increasing the risk of skin breakdown, development or worsening of PU/PI, excess moisture retention and delayed wound healing. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure one of three sampled residents' (Resident 1) rights were respected by not changing Resident 1's room assignment as requested by Resident 1's Responsible Party (RP) 1 in a timely manner. This deficient practice violated the resident's right to be treated with respect and dignity, which had the potential to affect the resident's sense of self-worth and self-esteem.

Inspectors wroteBased on interview and record review, the facility failed to maintain privacy and confidentiality of personal and medical records for one of three sampled residents (Resident 2) when Resident 2's personal and medical records were provided to Resident 1's responsible party (RP 1). This deficient practice violated Resident 2's right to personal privacy and confidentiality of the resident's personal and medical records.

Inspectors wroteBased on interview and record review, the facility failed to provide respiratory care services consistent with professional standards of practice for one of three sampled residents (Resident 1) by failing to ensure high concentration oxygen (a compressed gas cylinder containing oxygen at a high-pressure level, delivering pure oxygen with very high purity [up to 99.5 percent {%}] for medical use) was administered and correct oxygen delivery device (a piece of medical equipment that provides supplemental oxygen [a medical treatment that provides additional oxygen to the body when the air we normally breathe doesn't contain enough for organs to function correctly] to a resident who is unable to get enough oxygen on their own) was used when on 8/30/2025 at 9:20 a.m., Resident 1 had an oxygen saturation level (amount of oxygen that is circulating in the blood, normal range: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure three (Resident 12, Resident 65, Resident 121) of 6 sampled residents were free from unnecessary medication by failing to:1. Ensure the following conditions existed for Seroquel (brand name for an antipsychotic medication, a drug that affects brain activities associated with mental processes and behavior) to be prescribed: the symptoms are identified as being due to mania (mental state of an extreme highs or depressive lows) or psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality) or delusions, (having false or unrealistic beliefs such as paranoia [unjustified mistrust of others]/grandiosity [inflated sense of superiority]; the behavioral symptoms (sudden anger outburst) present a danger to the resident or others; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure three of seven sampled residents (Residents 7, 79, and 85) received appropriate services to prevent a decline in range of motion (ROM, full movement potential of a joint) by failing to:1a. For Resident 7, provide Restorative Nursing Aide program (RNA, nursing aide program that help residents to maintain their function and joint mobility) treatment for passive range of motion (PROM, movement at a given joint with full assistance from another person) to both lower extremities (BLE, hip, knee, ankle, foot) seven times a week in May 2025 and June 2025 as ordered by a physician and in accordance with Resident 7's care plan.1b. For Resident 7, complete a quarterly joint mobility screen timely.2. For Resident 79, complete a quarterly joint mobility screen timely.3. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Medication Regimen Review (MRR- review of a resident's drug therapy to assure appropriateness of medication usage completed each month by the consultant pharmacist) was acted upon for three of six sampled residents (Resident 116, Resident 12, and Resident 121 by failing to: Complete an EKG (electrocardiogram - a simple, painless test that measures the heart's electrical activity) for the usage of Quetiapine (antipsychotic medication) for Resident 116. This deficient practice could have resulted in missed dangerous heart rhythms that Quetiapine can cause in high-risk populations such as the elderly. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure leftover food brought from outside by residents' family and visitors were labeled with a resident identifier and use-by-date in one of one resident refrigerator (Refrigerator 1). This deficient practice had the potential to result in foodborne illness (also called food poisoning, illness caused by eating contaminated food) for the residents.

Inspectors wroteBased on interview and record review the facility failed to maintain accurate clinical records in accordance with accepted professional standards and practices for four (Resident 7, Resident 79, Resident 85, and Resident 12) of 32 sampled residents by failing to:1.a. Ensure therapy staff did not accurately document a late Rehab Joint Mobility Screen, for Resident 7, dated 4/3/2025 and completed on 7/1/2025.b. Ensure therapy staff did not accurately document a late Rehab Joint Mobility Screen, for Resident 79, dated 4/30/2025 and completed on 7/1/2025.c. Ensure therapy staff did not accurately document a late Rehab Joint Mobility Screen, for Resident 85, dated 4/9/2025 and completed on 7/1/2025. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a facility staff knocked and asked permission prior to entering a resident's room for two of two sampled residents (Resident 18 and 44). This deficient practice violated the residents' rights to be treated with respect and dignity, which had the potential to affect the residents' sense of self-worth and self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a call light (a device used by a resident to signal his/her need for assistance from staff) was within a resident's reach while in bed for one of one sampled resident (Resident 25). This deficient practice had the potential to delay the provision of services and the resident's needs not being met.

Inspectors wroteBased on interview and record review, the facility failed to ensure a copy of the resident's Advance Directive (AD- a legal document indicating resident preference on end-of-life treatment decisions) was kept in the resident's medical chart and easily retrievable for two of eight sampled residents (Resident 40 and 81). This deficient practice had the potential to create confusion which could lead to conflict with the resident`s wishes regarding their health care.

Inspectors wroteBased on interview and record review, the facility failed to develop a complete baseline care plan (a document designed to facilitate communication among members of the care team that summarizes a resident's health conditions, specific care needs, and current treatments) within 48 hours of a resident`s admission to the facility by failing to address the resident`s indwelling catheter (a hollow tube inserted into the bladder to drain or collect urine) for one of two sampled residents (Resident 81). This deficient practice had the potential for Resident 81 to not receive appropriate care and treatment in the facility.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a person-centered care plan (a document designed to facilitate communication among members of the care team that summarizes a resident's health conditions, specific care needs, and current treatments) for two of four sampled residents (Resident 75 and 114) by failing to: 1. Develop a care plan addressing Resident 75's use of olanzapine (medication used to treat schizophrenia (mental disorder in which people interpret reality abnormally) and bipolar disorder (mental disorder that causes unusual shifts in mood, energy, activity levels, concentration, and the ability to carry out day-to-day tasks). 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to update and revise a resident`s dental care plan (a document that summarizes a resident's needs, goals, and care/treatment) after the resident`s upper dentures went missing for one of three sampled residents (Resident 69). This deficient practice had the potential to result in Resident 69 receiving inadequate care and services.

Inspectors wroteBased on interview and record review, the facility failed to:1. Ensure fall risk assessments were completed accurately for one of ten sampled residents (Resident 7). This deficient practice had the potential to place Resident 7 at an increased risk of falling.2. Ensure a fall risk assessment was completed for one of ten sampled residents (Resident 119) after the resident`s fall on 6/25/2025. This deficient practice placed Resident 119 at an increased risk for recurrent falls and injuries.

Inspectors wroteBased on interview and record review, the facility failed to ensure the hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) center completed a post-dialysis assessment (evaluation done after hemodialysis by the hemodialysis licensed nurses) by failing to ensure the dialysis center recorded a resident's post dialysis weight (the weight after fluid is removed during the dialysis treatment) on 6/25/2025. This deficient practice had the potential for Resident 46 to have unidentified complications after dialysis treatment such as abnormal vital signs (pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions).

Inspectors wroteBased on interview and record review, the facility failed ensure resident's drug regimen was free from unnecessary drugs by failing to adequately monitor potential adverse effects of amphetamine-dextroamphetamine (stimulant medication to treat ADHD [differences in how the brain develops and works causing problems with a person's attention, ability to sit still, and practice self-control]) for one of one sampled resident (Resident 114). This deficient practice had the potential for adverse effects including psychosis (hallucinations, delusions, paranoia, aggression, hostility) and heart issues such as fast heartbeat and hypertension.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accommodate a resident's food allergies and preferences for one of six residents (Resident 7) investigated under nutrition by:1. Failing to document Resident 7's allergy to eggs on the tray ticket (a document that accompanies a meal tray with essential information about the meal and the resident receiving it).2. Failing to ensure Resident 7 received a substitution for breakfast when eggs were not served. These failures placed Resident 7 at risk of:1. Being served eggs and having a reaction such as a rash, hives, diarrhea, vomiting, dehydration (occurs when your body loses too much water and other fluids), and/or anaphylactic shock (severe allergic reaction including closure of airways). 2. Not receiving the needed nutrition, they require.

Inspectors wroteBased on interview and record review, the facility failed to accurately assess the Minimum Data Set (MDS - a resident assessment tool) of two of seven sampled residents (Resident 123 and 7) by failing to: 1. Accurately document Resident 123's discharge to reflect the correct disposition. 2. Accurately document Resident 7's current active diagnoses to reflect a diagnosis of anxiety (intense, excessive, and persistent worry and fear about everyday situations). These deficient practices had the potential to negatively affect the residents' plan of care and the delivery of necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure the provision of medically-related social services to meet one of five sampled residents (Resident 4) needs by failing to follow up the status of Resident 4's missing rollator walker (a mobility aid designed for residents who need support while walking) and ensure timely replacement of Resident 4's missing rollator walker. On 10/26/2024, Resident 4 was discharged from the facility without providing Resident 4's rollator walker. This deficient practice placed Resident 4 at risk for health and safety impacts such as impairing Resident 4's ability to walk safely leading to fall and injury, reduced mobility (movement), and loss of independence which can lead to decreased self-esteem (confidence in one's own abilities or worth) and a sense of helplessness.

Inspectors wroteBased on interview and record review the facility failed to ensure one of three sampled residents (Resident 1) discharge planning process included, providing Resident 1 and Resident 1 ' s Responsible Party (RP) 1 with information including services and quality measures (quantify healthcare processes, outcomes, patient perceptions, and organizational structure and/or systems) of the accepting skilled nursing facility Resident 1 was transferred to. This deficient practice had potential for decreased quality of care, decreased quality of life and continuity of care.

Inspectors wroteBased on interview and record review, the facility failed to obtain an informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) verification from a resident responsible party (RP - a person who makes medical decision for a resident) for one of four sampled residents (Resident 1) regarding the administration of antipsychotic (a medication used to treat psychosis [a severe mental condition in which thought, and emotions are so affected that contact is lost with reality] related symptoms and conditions) medication known as Olanzapine (a medication used to treat and manage psychosis) from Resident 1's RP. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a person-centered care plan (a document designed to facilitate communication among members of the care team that summarizes a resident's health conditions, specific care needs, and current treatments) for seven of 30 sampled residents (Resident 34, 117, 65, 7, 72, 59, and 27) by failing to: 1. Develop a care plan addressing Resident 34, 117, and 65's insulin (hormone that regulates the level of glucose [sugar] in the blood) use. 2. Develop a care plan addressing Resident 7's use of psychotropic medications (medications capable of affecting the mind, emotions, and behavior). 3. Develop a care plan addressing Resident 72's diagnosis of viral hepatitis C (a viral infection that causes liver inflammation (swelling). 4. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Ensure medication administration was supervised and medications were not left at bedside for one of 30 sampled residents (Resident 7). This deficient practice had the potential to allow Resident 7 to miss a dose of medications and allow other residents to consume the medications. 2. Ensure a resident's bed was positioned in the lowest position while the resident was in bed, as ordered by the physician, for one of 30 sampled residents (Resident 22). This deficient practice had the potential to place the resident at increased risk of sustaining a fall with injuries. 3. Ensure one of one resident (Resident 118), who was at high risk for falls, had bilateral landing mats placed in her room next to her bed as ordered by physician. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure licensed nurses documented that they attempted non-pharmacological interventions (any type of healthcare intervention which is not primarily based on medication) prior to administering as needed (prn) opioid medications (medication used to treat moderate to severe pain) on multiple days for one of 30 sampled residents (Resident 29). This deficient practice had the potential to place the resident at increased risk of experiencing adverse side effects (undesired harmful effect resulting from a medication or other intervention) from opioid pain medication.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident was free from significant medication error by failing to administer several medications as ordered by the physician for one of 30 sampled residents (Resident 7). This deficient practice resulted in Resident 7 receiving her medications late and had the potential to result in Resident 7 missing a dose of her medications.

Inspectors wrote2. A review of Resident 7's admission Record indicated the facility readmitted the resident on 4/30/2024 with diagnoses that included end stage renal disease (ESRD- a condition in which the kidneys [organs that remove waste products from the blood and produce urine] no longer function normally). A review of Resident 7's MDS dated [DATE], indicated Resident 7 had severely impaired cognition. A review of Resident 7's Order Summary Report, dated 7/25/2024, indicated an order for oxygen inhalation at two (2) liters per min (LPM, unit of measurement) via nasal cannula as need for shortness of breath and comfort with a titration (adjusting the dose of a medication) of three (3) to five (5) liters as needed, ordered 5/8/2024. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents' call lights (a device used by patients to call for assistance from hospital staff) were within reach for two of 30 sampled residents (Resident 27 and 28) . This deficient practice had the potential to result in the residents not being able to call for facility staff assistance and delay in the provision of necessary care and services that can negatively affect the residents' comfort and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Licensed Vocational Nurse 3 (LVN 3) provided privacy to a resident before administering medications via gastrostomy tube (g-tube - a tube that's surgically inserted through the abdomen and into the stomach used for medication and nutrition) for one of 30 sampled residents (Resident 62). This deficient practice violated the resident's right to privacy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow safe food handling practices by failing to discard two bags of hotdog buns 12 days past their best by date. This deficient practice had the potential to place 24 out of 121 residents living in the facility at risk for foodborne illnesses (refers to illness caused by the ingestion of contaminated food or beverages).

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure a resident's Minimum Data Set (MDS - a standardized assessment and care screening tool) section regarding falls was accurate for one of 30 sampled residents (Resident 65). 2. Ensure a resident's MDS section regarding the presence of an advance directive (a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) was accurate for one of 30 sampled residents (Resident 45). This deficient practice had the potential to delay care and services for the residents.

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 five sampled residents (Resident 2) when on 7/3/2024 Resident 1 hit Resident 2's face. This deficient practice resulted in Resident 2 being subjected to physical abuse by Resident 1 while under the care of the facility. Resident 2 sustained a cut (a break in skin due to injury) on the left eye area of Resident 2's face, redness (red discoloration [a change in natural skin tone] to the skin) on the left eye area of Resident 2's face and swelling (accumulation of fluid in the skin tissues due to injury) on the left eye area of Resident 2's face. [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to follow the facility ' s policy related to smoking for two of five sampled residents (Resident 3 and 4) when they allowed Resident 3 to share a cigarette with Resident 4. This deficient practice has the potential for Resident 4 to be place at risk for accidents such as burns.