Sunset Drive - a Prospera Community

Inspectors wroteBased on observations, review of facility policy, and staff interviews, the facility failed to ensure sanitization of dishware (utensils, dishes, pots/pans) used to serve residents, staff, and visitors for 2 of 5 dishwashers (main kitchen and Edgewater). Failure to ensure the mechanical dishwashing machine maintains the correct hot water temperature to destroy pathogens may result in the spread of illness and/or foodborne illness to residents, staff, or visitors. During the on-site recertification survey, the team determined a potential Immediate Jeopardy (IJ) situation existed on 07/08/26 at 12:55 p.m. when the dishwasher rinse cycle failed to reach 160 degrees Fahrenheit (F) at plate level. The survey team consulted with the State Survey Agency (SSA) and determined an IJ situation existed. *07/08/26 at 1:55 p.m. [...]

Inspectors wroteBased on record review, review of facility policy, and staff interview, the facility failed to maintain acceptable parameters of nutritional status for 1 of 8 sampled resident (Resident #81) with weight loss. Failure to document post-dialyzed weights, complete a dietary assessment, and identify/implement nutritional interventions for a resident at nutritional risk, resulted in a significant weight loss.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure emergency equipment remained in operating condition on 4 of 4 resident care units (Sunset, Edgewater, Grandview, and [NAME]). Failure to ensure the suction machines are identifiable and ready for use may result in delayed emergency airway and suctioning treatment for all residents.

Inspectors wroteBased on observation, review of facility policy, and resident representative and staff interview, the facility failed to ensure a safe, clean, comfortable, homelike environment for 3 of 4 days of survey (July 6, 7, and 9). Failure to maintain a safe, clean, sanitary environment may result in falls and does not provide a homelike living area for residents.

Inspectors wroteBased on record review, review of facility policy, and staff interview, the facility failed to review and revise the comprehensive care plans to reflect the residents' current status for 6 of 25 sampled residents (Resident #6, #8, #12, #13, #80 and #119). Failure to update care plans limited staffs' ability to communicate needs and ensure continuity of care for each resident.

Inspectors wroteBased on observation, review of facility documents, and staff interview the facility failed to ensure the environment remained free of hazards for 2 of 2 dryers in the main laundry room. Failure to clean dryer lint from the behind the machines may result in fires and places all residents at risk for injury.

Inspectors wroteBased on observation, record review, review of facility policy, staff, resident and family interviews, the facility failed to ensure sufficient nursing staff and related services are available to meet the residents' needs for 3 of 25 sampled residents (Resident #8, #44, and #81) and 2 supplemental residents (Resident #106 and #116) who required staff assistance. Failure to provide sufficient staffing does not promote each resident's rights, physical, mental, and psychosocial well-being, and/or provide a safe environment for the residents.

Inspectors wroteBased on observation, record review, review of facility policy and staff interviews, the facility failed to follow standards of infection control and prevention for 4 of 25 sampled residents (#1, #6, #81, and #86) and two supplemental residents (#9 and #36) observed during cares. Failure to practice infection control standards related to hand hygiene, glove use, enhanced barrier precautions (EBP), and personal protective equipment (PPE) with transmission-based precautions (TBP) has the potential to spread infection throughout the facility.

Inspectors wroteBased on record review, review of a facility reported incident (FRI), review of facility policy, and resident and staff interviews, the facility failed to ensure residents remained free from abuse for 1 of 1 supplemental residents (Resident #96) who experienced unwanted sexual contact from another resident (Resident #43). Failure to protect residents from sexual abuse placed Resident #96 and all residents at risk for mental and emotional distress.

Inspectors wroteBased on observation, record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.20.1), and resident and staff interviews, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 3 of 25 sampled residents (Residents #11, #80, and #113). Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status and may affect the accurate development of a comprehensive care plan and the care provided to the residents.

Inspectors wroteBased on record review, review of facility policy, and resident and staff interview, the facility failed to ensure residents received the necessary services to maintain personal hygiene for 2 of 25 sampled residents (Resident #44 and #81) and 1 supplemental resident (Resident #106) who required staff assistance for bathing. Failure to provide assistance to residents who cannot perform the bathing task independently may result in poor hygiene, skin issues and decreased self-esteem.

Inspectors wroteBased on observation, record review, review of professional reference, and staff interview, the facility failed to provide care and services in accordance with physician's orders for 1 of 25 sampled residents (Resident #8) and one close record (Resident #127). Failure to follow physician orders for daily weights and verify significant weight differences, may result in adverse health effects for the residents.

Inspectors wroteBased on record review, review of facility policy, and staff interview, the facility failed to provide care and services to prevent nutritional deficits for 1 of 2 sampled residents (#8) reviewed for tube feedings. Failure to provide nutritional needs as ordered may lead to malnutrition, dehydration, and other complications.

Inspectors wroteBased on record review, review of facility policy, and staff interview, the facility failed to ensure the resident's medication regimen remained free of unnecessary medications for 1 of 4 sampled residents (Resident #80) reviewed for antipsychotic medications. Failure to establish a baseline by assessing for abnormal involuntary movements before starting an antipsychotic and to monitor periodically while on the medication may result in the resident experiencing adverse consequences related to the antipsychotic medication.

Inspectors wroteBased on observations, record review, review of facility policy and resident and staff interviews, the facility failed to store drugs and biologicals securely for 2 of 2 sampled residents (Resident #8 and #76) with medications at the bedside. Failure to securely store medications may result in unauthorized use, adverse reactions, or ineffective treatment.

Inspectors wroteBased on observation, review of facility policy, resident and family interviews, the facility failed to ensure a safe, clean, comfortable, homelike environment for 4 of 14 sampled residents (Resident #2, #3, #8. and #17) and 9 supplemental residents (Resident #30, #31, #32, #33, #34, #35, #36, #37, and #39) observed during survey. Failure to maintain a clean, comfortable, and sanitary environment does not provide a homelike environment for residents and fails to promote dignity. Review of the facility policy titled Environmental Cleaning Principles occurred on 05/28/26. This undated policy, stated, . Environmental cleaning plays an important role in an infection control program. the spread of infections from contaminated surfaces is significant and supports the need for good procedures and practices related to cleaning and disinfecting of surfaces. [...]

Inspectors wroteBased on record review, review of facility policy, and resident representative interview, the facility failed to notify the resident's representative of a discharge for 1 of 1 sampled resident (Resident #19) who left the facility and did not return. Failure to notify a resident's representative of a discharge does not allow the representative to make informed decisions regarding the resident's care.

Inspectors wroteBased on record review, review of the facility reported incident (FRI), facility policy review, staff interview, and family interview, the facility failed to thoroughly investigate a fall for 1 of 1 closed resident record (Resident #20) reviewed who reported a fall and injury. Failure to thoroughly investigate Resident #20's reported fall from a mechanical lift and potential causes of a compression fracture, placed Resident #20 and all residents at risk for possible neglect and/or injury.

Inspectors wroteBased on observation, record review, and review of facility policy, the facility failed to properly utilize assistive devices necessary to prevent accidents and/or injury for 1 of 1 sampled resident (Resident #2) observed without wheelchair footrests. Failure to use the wheelchair footrests placed the resident at risk for falls and/or injury.

Inspectors wroteBased on record review, review of facility policy, and staff interview, the facility failed to provide respiratory services consistent with professional standards of practice for 1 of 1 closed record (Resident #18) who received oxygen therapy. Failure to clarify physician's orders regarding oxygen administration and failure to adequately monitor respiratory status have contributed to Resident #'s compromised respiratory status and subsequent hospitalization.

Inspectors wroteBased on observations, record review, and review of facility policy, the facility failed to follow standards of infection control and prevention for 2 of 4 residents (Resident #8 and #21) on enhanced barrier precautions and observed during cares. Failure to practice infection control standards related to personal care and use of shared equipment has the potential to spread infection throughout the facility.

Inspectors wroteBased on record review, review of the facility reported incident (FRI) investigation, and staff interview, the facility failed to ensure residents received adequate supervision and/or monitoring to prevent elopements from the facility for 1 of 1 closed resident record reviewed (Resident #1). Failure to provide adequate supervision and monitoring and respond to door alarms immediately resulted in Resident #1's elopement from the facility and may result accidents, such as hit by a car, and injury from prolonged exposure to cold temperatures. This citation is considered past non-compliance based on review of the corrective actions the facility implemented immediately following the elopement.

Inspectors wroteBased on record review, review of the facility reported incidents (FRI) and investigations, and review of facility policy, the facility failed to ensure residents remained free from abuse for 2 of 2 sampled residents (Resident #2 and Resident #4) who displayed physical behaviors towards other residents. Failure to protect residents from abuse resulted in physical abuse to Resident #1 and #3 and placed all residents at risk for injury and mental and emotional distress. This citation is considered past non-compliance based on review of the corrective actions the facility implemented immediately following the incidents.

Inspectors wroteBased on observation, record review, review of facility policy, review of professional reference, and staff interview, the facility failed to follow professional standards of practice for 2 of 10 sampled residents (Resident #1 and #3) observed during mealtime. Failure to follow physician orders for dietary modifications may result in adverse consequences such as choking or aspiration for all residents.

Inspectors wroteBased on review of facility policy and resident and staff interviews, the facility failed to ensure residents remained free from accident hazards during 2 of 2 severe weather events (06/20/25 and 06/27/25). Failure to ensure facility staff took appropriate action/precautions to protect residents during severe weather events placed all residents at risk for physical and emotional harm. During an on-site complaint survey, the survey team consulted with the State Survey Agency (SSA) on 07/24/25 and determined an Immediate Jeopardy (IJ) situation existed on 06/20/25. [...]

Inspectors wroteBased on record review, review of facility policy, and staff interview, the facility failed to ensure residents received the necessary services to maintain oral hygiene for 2 of 2 sampled residents (Resident #1 and #2) dependent on staff for oral cares. Failure to provide oral care for a dependent resident may result in poor hygiene, increased oral/dental problems, and potential for adverse health effects.

Inspectors wroteBased on observations, review of facility policy, review of facility assessment, review of call light logs, and confidential staff interview, the facility failed to provide sufficient nursing staff and related services necessary to meet the needs for 5 of 7 sampled residents (Resident #3, #4, #5, #6, and #7) who required staff assistance. Failure to provide sufficient nursing staff may result in residents experiencing unmet needs, poor hygiene, incontinence, and skin issues and may negatively affect the residents' mental, physical and psychosocial well-being.

Inspectors wroteBased on record review, review of professional reference, and staff interview, the facility failed to follow professional standards of practice for timely medication administration for 7 of 7 sampled residents (Resident #1, # 2, #3, #4, #5, #6, and #7). Failure to administer medications in a timely manner may cause adverse effects for the residents.

Inspectors wroteBased on record review, review of the facility reported incident (FRI) and investigation, and resident and staff interviews, the facility failed to provide appropriate supervision and/or assistance to prevent an accident for 1 of 1 sampled resident (Resident #55) injured during a facility van transport. Failure to ensure the power control to the motorized scooter (wheelchair) is turned off during transport resulted in an injury to Resident #55's foot and placed all residents with motorized wheelchairs at risk for injury during transports. This citation is considered past non-compliance based on review of the corrective actions the facility implemented immediately following the incident.

Inspectors wroteBased on record review, review of facility policy, and staff interview, the facility failed to ensure the code level status accurately reflected the resident's wishes for 5 of 27 sampled residents (Resident #19, #80, #108, #111, and #119) reviewed for advance directives. Failure to ensure the medical record and other forms of communication accurately reflected the resident's code status limited the facility's ability to communicate to direct care staff and emergency personnel the resident's choice in the event of a medical emergency.

Inspectors wroteBased on observation, review of facility policy, and staff interview, the facility failed to ensure a safe, clean, comfortable, and homelike environment for 4 of 27 sampled residents (Resident #14, #67, #69, and #99) and 2 supplemental residents (Resident #70 and #284). Failure to maintain a safe, clean, and sanitary environment may lead to injury from unsafe equipment, does not provide a homelike living area for residents, and does not promote quality of life.

Inspectors wroteBased on record review, review of facility policy, and staff interview, the facility failed to review and revise care plans to reflect the residents' current status for 6 of 27 sampled residents (Resident #2, #27, #55, #66, #67, and #119) and 1 supplemental resident (#59). Failure to update care plans limited the staff's ability to communicate needs and ensure continuity of care.

Inspectors wroteBased on observation, record review, and resident and staff interview, the facility failed to ensure residents received the necessary services to maintain personal hygiene for 4 of 27 sampled residents (Resident #2, #29, #55, and #76) and 2 supplemental residents (Resident #88 and #120) who required staff assistance for bathing. Failure to aid residents who cannot perform the bathing and nail care task independently may result in poor hygiene, skin related issues, and decreased self-esteem.

Inspectors wroteBased on review of resident council meeting minutes, confidential resident interviews, and staff interviews, the facility failed to ensure sufficient nursing staff and related services are available at all times to meet the residents' needs for 7 of 27 confidential residents (Resident A, B, E, H, I, J, and K) who required staff assistance. Failure to provide sufficient staffing does not promote each resident's rights, physical, mental, and psychosocial well-being, and/or provide a safe environment for the residents.

Inspectors wroteBased on observation, review of facility policy, review of resident council meeting minutes, and resident and staff interviews, the facility failed to serve foods at palatable temperatures in 4 of 4 units (Sunset, Edgewater, Grandview, and [NAME]). Failure to serve foods at a temperature acceptable to residents may result in decreased intake, weight loss, and inadequate nutrition.

Inspectors wroteBased on observation, record review, review of facility policy, and staff interview, the facility failed to follow standards of infection control and prevention for 9 of 10 sampled residents (Resident #2, #3, #6, #19, #26, #29, #67, #107, and #281) observed during cares. Failure to practice infection control standards related to enhanced barrier precautions (EBP), catheter care, dressing changes, glove use, hand hygiene, and disinfecting of shared equipment has the potential to spread infection throughout the facility.

Inspectors wroteBased on observation, record review, review of facility policy, and staff interview, the facility failed to complete an assessment and obtain a physician's order for self-administration of medications for 1 of 1 sampled resident (Resident #108) observed with medications at the bedside. Failure to evaluate the resident's ability to safely self-administer medications may result in medication errors and/or harm to the resident.

Inspectors wroteBased on observations, record review, and staff interview, the facility failed to promote care in a manner that maintained or enhanced residents' dignity for 1 of 27 sampled residents (Resident #2) and 1 supplemental resident (Resident #32) who required assistance with personal hygiene. Failure to ensure the residents face and positioning devices are clean, and doors are closed during toileting does not promote the resident's mental well-being or dignity.

Inspectors wroteBased on observation, record review, review of facility policy, and resident interview, the facility failed to ensure reasonable accommodation of needs regarding call lights for 1 of 1 sampled resident (Resident #2). Failure to place call lights within reach may result in an inability to call for help, discomfort, increased falls, and/or incontinence.

Inspectors wroteBased on record review, review of facility policy, and staff interview, the facility failed to provide a written notice of room change for 1 of 1 sampled resident (Resident #1) reviewed with a recent room change. Failure to provide the resident and/or resident's representative a written explanation of why a move is required prevents the resident and/or representative from making informed decisions significant to the resident's care.

Inspectors wroteBased on observation, record review, review of facility policy, and resident and staff interview, the facility failed to honor resident choices for 2 of 2 sampled residents (Resident #55 and #99) who had personal food items stored in the resident fridge. Failure to honor the resident's choice of personal food items at meals or when requested does not respect their autonomy or right to determine what is significant to their care and well-being.

Inspectors wroteBased on record review, review of a facility reported incident (FRI), review of facility investigative reports, and staff interview, the facility failed to ensure residents remained free from abuse for 2 of 2 sampled residents (Resident #47 and #76) with impaired cognition who displayed sexual behaviors towards other residents. Failure to protect residents from sexual abuse may result in fear, anxiety, mental anguish, and physical injury.

Inspectors wroteBased on record review and review of facility policy, the facility failed to report incidents of potential abuse to the State Survey Agency (SSA) for 2 of 2 sampled residents (Resident #47 and #76) who displayed sexual behaviors towards other residents. Failure to report events of potential sexual abuse to the SSA placed Resident's #47 and #76 and all other residents at risk for possible abuse, mental and emotional distress, and/or physical injury.

Inspectors wroteBased on record review and review of facility policy, the facility failed to provide the resident or their representative and the State Long Term Care Ombudsman a written notice of transfer and bed-hold notice for 1 of 5 sampled residents (Resident #37) reviewed for hospitalizations. Failure to provide a notice of transfer and a bed-hold notice does not allow the resident and/or their representative to make informed decisions regarding their rights, or inform the Ombudsman of the transfer.

Inspectors wroteBased on record review, staff interview, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, and review of the federal database for Long-Term Care Survey, the facility failed to ensure timely electronic data submission of required Minimum Data Set (MDS) assessments for 1 of 27 sampled residents (Resident #281). Failure to follow the MDS data submission specifications does not meet the intended regulatory requirements.

Inspectors wrote1. Based on observation, review of facility policy, and staff interview, the facility failed to ensure staff followed standards of practice for 1 of 1 supplemental resident (Resident #284) observed during insulin preparation. Failure to properly prime insulin pens may result in the resident receiving an inaccurate dose of insulin.

Inspectors wroteBased on record review, review of facility policy, and resident and staff interviews, the facility failed to provide an ongoing program of meaningful activities designed to meet the interests and preferences for 1 of 27 sampled residents (Resident #76) and 1 confidential resident (Resident I). Failure to provide meaningful activities for residents limits their ability to reach their highest practicable level of physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, record review, and staff interviews, the facility failed to ensure 1 of 2 sampled residents (Resident #6) reviewed for limited range of motion received restorative services as per care plan. Failure to consistently provide restorative nursing/therapy services may adversely affect the resident's ability to maintain their range of motion (ROM).

Inspectors wroteBased on observation, record review, review of facility policy, and resident interview, the facility failed develop an effective pain management regimen and schedule routine pain medications to meet residents' needs for 1 of 3 sampled residents (Resident #67) reviewed for pain management. Failure to develop and implement an acceptable and manageable pain management plan resulted in unresolved pain and discomfort.

Inspectors wroteBased on record review, review of facility policy, and staff interview, the facility failed to ensure residents remained free from significant medication errors for 1 of 1 sampled resident (Resident #67) with a medication not held prior to scheduled surgery. Failure to accurately transcribe and follow physician's orders may result in adverse health consequences and/or delayed treatment for the resident.

Inspectors wroteBased on observation, review of facility policy, and staff interview, the facility failed to store and serve food properly in 1 of 4 units (Grandview) observed during/after meal service. Failure to ensure food is stored at proper temperatures and served in a sanitary manner may result in foodborne illness to residents, staff, and visitors.

Inspectors wroteBased on record review, review of facility policy, and resident and staff interviews, the facility failed to ensure residents remained free from abuse from 2 of 2 sampled residents (Resident #1 and #2) who displayed sexual behaviors towards other residents. Failure to protect residents from sexual abuse may result in fear, anxiety, mental anguish, and physical injury.

Inspectors wroteBased on record review, review of facility policy, and staff interview, the facility failed to report incidents of resident-to-resident abuse to the administrator and State Survey Agency (SSA) for 2 of 2 sampled residents (Resident #1 and #2) who exhibited sexual behaviors. Failure to report incidents of sexual abuse may result in unwanted physical and/or sexual contact and may cause all residents to experience fear, anxiety, and psychosocial harm.

Inspectors wroteBased on record review, review of facility policy, and staff interview, the facility failed to notify the resident's physician of a change in condition for 1 of 2 closed record residents (Resident #6) reviewed. Failure to notify the physician of increased abdominal pain, tenderness, rigidity, and vomiting may have prevented the physician from altering the treatment/care provided to the resident.

Inspectors wroteBased on observation, record review, review of facility policy, and staff interview, the facility failed to follow standards of infection control and prevention for 1 of 1 sampled residents (Resident #2) with an indwelling suprapubic catheter observed during cares. Failure to practice infection control standards related to enhanced barrier precautions has the potential to spread infection throughout the facility.

Inspectors wroteBased on observation, review of facility policy, and resident interview, the facility failed to ensure reasonable accommodation of needs regarding call lights for 5 of 10 sampled residents (Residents #2, #3, #4, #5, #6). Failure to place call lights within a resident's reach may result in an inability to call for help, increased falls, discomfort and/or incontinence.

Inspectors wroteBased on observation, review of the North Dakota Long Term Care Ombudsman Program Guide to Resident Rights, and resident interview, the facility failed to provide care for 2 of 10 sampled residents (Resident #1 and #2) in a manner that promotes, maintains, or enhances their quality of life. Failure to cover a urinary catheter bag (Resident #1) and failure to provide care in a dignified manner (Resident #2) does not preserve the resident's personal dignity and/or enhance their quality of life and has the potential to affect the resident's psychosocial well-being.

Inspectors wroteBased on observation, record review, professional reference review, resident interview, and staff interview, the facility failed to provide appropriate toileting for 1 of 4 sampled residents (Resident #2) observed for toileting. Failure to provide toileting assistance as care planned may result in a loss of dignity and placed the resident at risk for skin breakdown, poor grooming/hygiene, decreased self-esteem, and urinary tract infections.

Inspectors wroteBased on observation, review of facility policy, review of the facility call light logs, resident interview, and staff interview, the facility failed to promptly respond to residents' call lights for 2 of 2 sampled residents (Resident #1 and #8) observed with prolonged call light wait times. Failure to promptly respond to calls for assistance may result in falls and residents experiencing unmet needs and may negatively affect the residents' physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, review of facility policy, and staff interview, the facility failed to follow standards of infection control for 3 of 3 sampled residents (Resident #2, #9, and #10) observed receiving toileting assistance. Failure to follow infection control practices regarding hand hygiene during cares has the potential for transmission of communicable diseases and infections to residents, staff, and visitors.

Inspectors wroteBased on record review, review of a facility reported incident (FRI), review of facility policy, and staff interview, the facility failed to ensure a resident's right to be free of physical restraints imposed for purposes of convenience for 1 of 2 sampled residents (Resident #1) reviewed for restraints. Failure to use a restraint only if required to treat a resident's medical symptoms placed Resident #1 at risk for an unnecessary restraint and injury. This citation is considered past non-compliance based on review of the corrective action the facility implemented immediately after learning of the incident.

Inspectors wroteBased on observation, review of facility policies, review of professional reference, and staff interview, the facility failed to ensure food is prepared and stored in a clean and sanitary manner in 1 of 1 kitchen and 1 of 4 kitchenettes (Unit 2). Failure to ensure cleanliness of food preparation and storage areas has the potential to result in a foodborne illness to residents, visitors, and staff.

Inspectors wroteTHIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED ON 05/11/23. Based on observation, record review, facility policy review, and staff interview, the facility failed to follow standards of infection control for 7 of 26 sampled residents (Resident #7, #23, #40, #58, #73, #80, and #83) observed during cares. Failure to follow infection control standards with use of personal protective equipment (PPE), during toileting, and colostomy care has the potential to spread infection throughout the facility.

Inspectors wroteBased on record review, review of facility policy, and staff interview, the facility failed to notify the physician of a change in condition for 1 of 1 sampled resident (Resident #67) reviewed who experienced low blood sugars. Failure to notify the physician of blood sugar results below the ordered parameters may result in complications to the resident and prevent the physician from evaluating/prescribing an appropriate treatment plan.

Inspectors wroteBased on observation, record review, review of facility policy, and staff interview, the facility failed to assess the use of a wheelchair lap belt as a possible restraint for 1 of 4 sampled residents (Resident #52) observed with a wheelchair lap belt. Failure to assess the wheelchair lap belt as a possible restraint, monitor the use, and evaluate the need for continued use, placed Resident #52 at risk for an unnecessary restraint and injury related to its use.

Inspectors wroteBased on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.18.11), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 3 of 25 sampled residents (Resident #12, #25, and #40). Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status/needs and may affect the accurate development of a comprehensive care plan and the care provided to the residents.

Inspectors wrote1. Based on observation, record review, review of professional reference, and staff interview, the facility failed to follow professional standards for 1 of 1 sampled resident (Resident #316) with intravenous (IV) administrations. Failure of staff to label, date, and time the IV solution bags may result in medication errors and adverse reactions.

Inspectors wrote1. Based on observation, record review, review of facility policy, and staff interview, the facility failed to provide care and services for 1 of 1 sampled resident (Resident #417) observed during a PICC [peripherally inserted central catheter] line dressing change. Failure to follow physician's orders regarding dressing changes may result in delayed treatment and the resident experiencing adverse consequences.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to provide the necessary care and services to minimize the potential for the worsening of pressure ulcers for 1 of 4 sampled resident (Resident #98) with pressure ulcers. Failure to consistently implement dressings and pressure relief interventions on pressure ulcer may result in the worsening of Resident #98's current foot/heel pressure ulcer or the development of new pressure ulcers.

Inspectors wroteTHIS IS A REPEAT DEFICIENCY FROM THE SURVEY COMPLETED ON 05/11/23. Based on observation, record review, review of facility policy, and staff interview, the facility failed to ensure residents received adequate supervision/assistance to prevent accidents for 2 of 20 sampled residents (Resident #30 and #40) observed during transfers. Failure to ensure proper use of a mechanical sit-to-stand lift and/or wheelchair placed Resident #30 and #40 at risk for possible accidents with/without injury.

Inspectors wroteBased on observation, review of facility policy, and staff interview, the facility failed to provide safe and secure storage of medications for 1 of 8 medication/treatment carts (Unit 2) observed during medication pass. Failure to store all medications securely may result in unauthorized access to medications.

Inspectors wroteBased on record review, review of facility policy, and staff interview, the facility failed to follow professional standards of practice for 1 of 1 sampled resident (Resident #3). Failure to perform neurological checks following a head laceration/suspected head injury may result in delayed identification and treatment of the resident's medical condition.