Terrace Post Acute

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled resident's (Resident 1) request for authorization form (form used by the facility to request specialized treatment from the insurance company) for continued physical therapy (PT- treatment designed to restore, maintain, and improve your body's physical function and mobility) as ordered by the physician order was submitted in a timely manner to Resident 1's insurance company. This deficient practice had the potential for Resident 1 to have a decline in range of motion (ROM-the extent or limit to which a part of the body can by moved around a joint or fixed point) and placed Resident 1 at risk for decline in overall health status.

Inspectors wroteBased on interview and record review the facility failed to ensure that one of three sampled residents (Resident 2) had an accurate Medication Regimen Review (MRR- a thorough evaluation of the medication regimen of a resident with the goal of promoting positive outcome and minimizing adverse consequences and potential risk associated with medication completed by the consulting pharmacist) when the facility Pharmacist Consultant 1 (PC 1) did not identify and report that Resident 2 had multiple physician orders for acetaminophen (a medication used to treat mild to moderate pain levels) for pain management. This deficient practice had the potential to result in Resident 2 exceeding the recommended maximum dose of acetaminophen within a 24-hour period (four grams [gm-unit of measurement]), increasing the risk of liver impairment and decline in overall health status. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure two of three sample residents (Resident 1 and Resident 2) received PRN (as needed) medication as prescribed by the ordering physician by:1. Failing to ensure Resident 1's PRN Ketorolac Tromethamine Solution (medication [eye drops] used to treat pain, inflammation or itching) eye drop was available at the time Resident 1 requested the medication.2. Failing to ensure Resident 2's PRN acetaminophen (medication used to treat mild to moderate pain) tablet 325 milligrams (mg- unit of measurement) two tablets were administered as ordered by the physician. These deficient practices had the potential to delay necessary treatment, care and services, increased levels of discomfort, placing Resident 1 and Resident 2 at risk for a decline in overall health status.1. [...]

Inspectors wroteBased on interview and record review, the facility failed to protect residents' personal privacy for three of eight sampled residents (Resident 1, 3, and 4) when an entertainer for the facility posted on her social media the video and pictures of the facility activity that the residents took part of, without obtaining explicit written consent from the residents or representatives. This deficient practice had the potential to result in the resident's privacy being violated and could result in unauthorized exposure of confidential information. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement the facility's infection control policy when one of three sampled staff (Certified Nursing Assistant 2 [CNA 2]) entered the room of a resident who was placed on droplet precautions (infection control measure used to prevent transmission of infectious agents spread through respiratory droplets which are generated by coughing, sneezing, or talking) and contact precautions (infection-control measure used to prevent the spread of germs transmitted through direct or indirect contact), without wearing the appropriate personal protective equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure pain management was provided to residents who require such services consistent with professional standards of practice and the comprehensive person-centered care plan to three of five sampled residents (Residents 6, 109, and 11) investigated for pain management when: 1. The facility failed to ensure licensed nurses attempted nonpharmacological (treatments or therapies that do not involve the use of medications) pain interventions prior to administering as needed pain medication for Residents 6 and 109. 2. The facility failed to ensure Resident 11 was monitored for adverse side effects after receiving a narcotic pain medication (or known as an opioid, a strong prescription drug that relieves severe pain by blocking pain signals in the brain). [...]

Inspectors wroteBased on observation, interview, and record review the facility: 1. Failed to have an available supply of Mounjaro (a medication used for Diabetes Mellitus 2 ([DM2] - a condition of having high blood sugar levels) in the medication cart, affecting one (1) of three (3) observed residents (Resident 128) during the medication administration task. As a result, Resident 128 did not receive Mounjaro on 1/12/2026 at 9 a.m. in accordance with the physician's orders and standards of practice. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five (5) percent (%). Three (3) medication errors out of 28 total opportunities contributed to an overall medication error rate of 10.71% affecting two (2) of three (3) residents observed for medication administration (Resident 2 and 128.) The medication errors were as follows: 1. Resident 2 did not receive ascorbic acid (a supplement used to support and improve the immune system) as ordered by Resident 2's physician. 2. Resident 128 did not receive Mounjaro (a medication used for Diabetes Mellitus 2 [DM2] - a condition of having high blood sugar levels) as ordered by Resident 128's physician and received metformin (a medication used for DM2) at a different time than ordered by Resident 128's physician. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to store medications in accordance with manufacturer specifications, professional standards of practice and facility policy and procedures by failing to: 1. Label one (1) inhalation solution with a date indicating when use began for Resident 46, in accordance with manufacturer's requirements and facility policy and procedures, in one (1) of two (2) inspected medication carts (Medication Cart 5.) 2. Label, remove from use and discard two (2) discontinued medications for Resident 54 and 62, in accordance with manufacturer's requirements and facility policy and procedures, in one (1) of two (2) inspected medication carts (Medication Cart 4.) 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow the dietary menu when the facility failed to include condiments with a meal that required the items for six (Resident 32, Resident 43, Resident 56, Resident 58, Resident 64, and Resident 67) of 73 residents prescribed a regular diet. This had the potential for the food to not be attractive in appearance and taste and increase the risk of a resident not eating the meal.

Inspectors wroteBased on interview and record review, the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards and practices for two of two sampled residents (Resident 46 and 3) by failing to accurately document the insulin (hormone that regulates the amount of glucose [sugar] in the blood) administration injection site and blood sugar test (measures the glucose levels in your blood) result. This deficient practice placed the resident at risk of not receiving appropriate care due to inaccurate resident medical care information and the potential to result in confusion in the care and services for Resident 46 and 3.

Inspectors wroteBased on interview and record review the facility failed to notify the physician of a resident's change of condition for one of one sampled resident (Resident 4) by failing to notify the physician when Resident 4 had signs and symptoms of bleeding and hypoglycemia (low blood sugar in the body). This deficient practice had the potential to result in a delay of care services resulting in serious health complications requiring hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Update a resident's comprehensive care plan (a document that summarizes a resident's needs, goals, and care/treatment) for one of one sampled resident (Resident 4) reviewed under the tube feeding care area by failing to update Resident 4's care plan with the most recent physician's order for enteral feeding (a way of delivering nutrition directly to the stomach or small intestine) This deficient practice had the potential to result in failure to deliver the necessary care and services to meet Resident 4's nutritional needs related to tube feeding. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of one sampled resident (Resident 93) received treatment and care in accordance with professional standards of practice by failing to: 1. Ensure licensed nurses clarify the order for digoxin with the physician and obtain an order to monitor the apical pulse (a pulse point on your chest that gives the most accurate heart rate) or set apical pulse parameters (a specific, pre-set guideline for when to temporarily stop a medication, such as a blood pressure drug, to prevent a patient's blood pressure or heart rate from falling too low) before administering digoxin (medication that slows the heart rate). 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to offer sufficient fluid intake to maintain proper hydration (the process of replacing water in the body) and health by failing to provide a pitcher of water and a cup at the bedside of one of three sampled residents (Resident 20) investigated under the hydration care area. This deficient practice placed Resident 20 at an increased risk for dehydration (a condition caused by the loss of too much fluid from the body).

Inspectors wroteBased on observation, interview and record review, the facility failed to provide two of three sampled residents (Resident 13 and Resident 42) reviewed under the respiratory care area, with necessary respiratory care services consistent with professional standards of practice by failing to: 1. Ensure Resident 13 and Resident 42 had a physician order for oxygen prior to administering oxygen to Resident 13 and 42. 2. Ensure Resident 42's nasal cannula and oxygen set-up was labeled with a date and changed weekly per facility policy. These deficient practices had the potential to place Resident 13 and Resident 42 at increased risk for infection and cause complications associated with oxygen therapy.

Inspectors wroteBased on interview and record review the facility failed to ensure one of three Certified Nursing Assistants (CNA 7) investigated for competency skills, possessed the competencies (a measurable pattern of knowledge, skills, abilities, behaviors that an individual needs to perform work roles successfully) necessary to perform their job roles. This deficient practice had the potential for staff to perform care incorrectly and not according to a resident's plan of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident`s Diet Requisition Form was completed timely for one of five sampled residents (Resident 130) observed during breakfast. This resulted in the facility delivering Resident 130's breakfast tray two hours later than the other residents and only after the facility was informed of the resident`s complaint of not getting her breakfast. This deficient practice had the potential to result in decreased meal intake which could lead to weight loss and malnutrition (lack of sufficient nutrients in the body).

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose garbage and refuse properly by failing to ensure there were no soiled gloves and masks on the floor area and surroundings of the facility's dumpster. This deficient failure had potential to attract birds, flies, insects, pests, and possibly spread infection to 120 of 120 facility residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection control measures by failing to: 1. Ensure Smoker Aid 1 (SA 1) performed hand hygiene (the practice of cleaning and disinfecting one's hands to remove dirt, germs, and bacteria) prior to scooping out ice and serving it to one of one sampled resident (Resident 13). 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident on morphine sulfate (strong pain medication used to treat moderate to severe pain) was not administered the medication after it had expired for one of three sampled residents (Resident 1). This deficient practice resulted in Resident 1 receiving a medication after its expiration date and had the potential for the medication to be ineffective. During a review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on [DATE] with diagnoses that included quadriplegia (paralysis [complete or partial loss of muscle function] of all four limbs) and hypotension (low blood pressure- condition where the force of blood against the artery walls is lower than normal). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that a resident's physician assistant (PA - a licensed healthcare professional who practices medicine on a team with physicians) completed a comprehensive History and Physical (H&P - a formal comprehensive assessment by a healthcare professional that involves a resident interview, physical examination and documentation of findings. The H&P serves as the foundation for diagnosing a resident's condition, formulating a treatment plan, and guiding subsequent medical care.) Examination for one of three sampled residents (Resident 1) by failing to include an assessment of mental status (assessment of a resident's mental capacity which includes cognition, mood behavior and perceptions). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate documentation of the administration of medications for one of three sampled residents (Resident 1), by failing to document the administration and refusal of Resident 1's medications on the Medication Administration Record (MAR - a report detailing the medications administered to a resident by the licensed nurse in the facility). This deficient practice had the potential to result in medication errors and/or drug diversion (illegal distribution or abuse of prescription drug).

Inspectors wroteBased on interview and record review the facility to: 1. Ensure timely communication and management of a resident's pain for one of three sampled residents (Resident 3) when on 5/5/2025 at around 10:00 a.m. Certified Nurse Assistant 1 (CNA 1) failed to report Resident 3's complaint of headache to a licensed nurse. 2. Ensure a pain risk assessment was completed quarterly (12/2024 and 3/2025) for one of three sampled residents (Resident 3) as per facility policy. These deficient practices resulted in a delay in assessment and pain relief for Resident 3 and had the potential to result in Resident 3 experiencing unnecessary pain and discomfort.

Inspectors wroteBased on interview and record review, the facility failed to implement its policy and procedure for Administering Medications for one of three sampled residents (Resident 1) by failing to document Resident 1's medication refusals (total of seven refusals on 4/22/2025) of Golytely (an oral solution indicated for bowel cleansing prior to colonoscopy [a diagnostic procedure used to examine the inner lining of the large intestine using a flexible, lighted tube]) and failing to ensure Resident 1's physician was made aware of Resident 1's refusals of the Golytely Oral Solution on 4/22/2025. This deficient practice may result in inadequate bowel cleansing making it hard to see the colon lining clearly during the colonoscopy which may lead to missed diagnosis such as inflammation and increased risk of procedure complications due to poor visibility.

Inspectors wroteBased interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) who were unable to carry out activities of daily living (ADL-routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) received the necessary services to maintain good personal hygiene. This deficient practiced resulted in Resident 1 having long facial hair and overgrown fingernails and had the potential to negatively impact Resident 1's quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement the facility's infection control policy by failing to ensure staff wore appropriate PPEs (Personal Protective Equipment- equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) while in an isolation room of a resident who tested positive for respiratory syncytial virus (a common respiratory virus that infects the nose, throat, and lungs) for one of two sampled residents (Resident 2) This deficient practice had the potential to result in the spread of infection placing residents, staff, and visitors at risk to be infected with respiratory syncytial virus (a common respiratory virus that infects the nose, throat, and lungs) and becoming seriously ill, leading to hospitalization and/or death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to label and date a resident's intravenous (IV-the infusion of liquid substances directly into a vein) antibiotic (medications used to treat infections) medication bag per the facility's policy for one of three sampled residents (Resident 1). This deficient practice had the potential for medication administration errors.

Inspectors wroteBased on interview and record review the facility failed to ensure one of three sampled residents (Resident 3) received laboratory services as ordered by the physician. This deficient practice had the potential for Resident 3 to have decreased quality of care, delay in care and services, and decreased quality of life.

Inspectors wroteBased on interview and record review the facility failed to maintain medical records in accordance with accepted professional standards for one of three sampled residents (Resident 1) by failing to complete the admission assessment form titled, Nursing Documentation Evaluation (a form that is used by nursing staff to document the initial assessment of a resident) upon Resident 1's admission to the facility. This deficient practice had the potential to negatively affect the overall care provided to Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate documentation of the administration of medications for one of three sampled residents (Resident 1), by failing to document the refusal of Resident 1's medications on the Medication Administration Record (MAR, a report detailing the medications administered to a resident by the licensed nurse in the facility). These deficient practices had the potential to result in medication errors and/or drug diversion (illegal distribution or abuse of prescription drug).

Inspectors wrotec. During a review of Resident 96's admission Record, the admission Record indicated the facility originally admitted the resident on 3/31/2024 and readmitted the resident on 7/12/2024 with diagnoses including acute pyelonephritis (occurs as a complication of an ascending urinary tract infection that spreads from the bladder to the kidneys), type 2 diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), and atrial fibrillation (a heart condition that causes an irregular and often abnormally fast heart rate). The admission Record indicated Resident 96's primary language is Hungarian. [...]

Inspectors wroteBased on interview and record review, the facility failed to monitor a resident for side effects and behavioral episodes for the use of quetiapine (antipsychotic- a medication used to treat psychosis [a mental condition in which thought, and emotions are so affected that contact is lost with external reality]) for one of five sampled residents (Resident 86) investigated under the care area of unnecessary medications. This deficient practice had the potential to place the resident at increased risk of taking an unnecessary medication and experiencing adverse side effects (undesired harmful effect resulting from a medication or other intervention).

Inspectors wroteBased on interview, and record review, the facility failed to ensure residents were free from any significant medication errors for one (Resident 78) of five residents investigated for unnecessary medications by failing to follow the hold parameters (indications when to hold a blood pressure medication because the blood pressure is too low) for lisinopril (medication to treat high blood pressure) as ordered by the physician. This deficient practice had the potential to cause complications such as low blood pressure and syncope (fainting) and, possible requirement of hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper food handling and storage practices by failing to: 1. Ensure a bin full of zucchini and a bin full of cantaloup found inside the walk-in refrigerator were labeled with the date they were received. 2. Ensure an open bag of dry pasta and an open bag of tostadas found inside the dry storage room were labeled with the date they were opened. These deficient practices had the potential to place 114 out of 116 residents who receive food from the facility kitchen at risk for foodborne illness (illness caused by the ingestion of contaminated food or beverages).

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure Licensed Vocational Nurse 9 (LVN 9) removed gloves and performed hand hygiene in between cleaning a resident's eyes and after cleaning a resident's eye and opening a new package of supplies and ensure LVN 9 removed gloves and performed hand hygiene in between administering eye drops to both eyes for one of five sampled residents (Resident 72) investigated under the care area of infection control. These deficient practices had the potential to cause cross contamination (unintentional transfer of bacteria/germs or other contaminants from one surface to another) between Resident 72's eyes and from Resident 72 to other residents. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to keep a copy of a resident's Advance Directive (a legal document indicating resident preference on end-of-life treatment decisions) in the medical record for one (Resident 4) out of 29 sampled residents. This deficient practice had the potential to create confusion, which could lead to conflict with the resident's wishes regarding his/her health care.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from verbal abuse (a type of abuse that uses language) for one of three sampled residents (Resident 89) when on 11/01/2024, Resident 88 screamed at Resident 89 I will kill you. This deficient practice resulted in Resident 89 being subjected to verbal abuse while under the care of the facility. Residents who are subjected to verbal abuse are at increased risk for low self-esteem (when someone lacks confidence in themselves and their abilities), anxiety (a feeling of fear, dread, and uneasiness), depression (mood disorder that causes a persistent feeling of sadness and loss of interest in activities for long periods of time) and social isolation (when someone has few or no social connections or support and lacks relationships with others).

Inspectors wroteBased on interview and record review, the facility failed to ensure two of two sampled residents (Resident 69 and 12) were invited and participated in Interdisciplinary Team (IDT - a group of professionals with different areas of expertise who work together to achieve a common goal for the resident) care plan meetings (a written document that summarizes a resident's needs, goals, and care/treatment) investigated under the care area of care planning. These deficient practices violated the residents' right to be included in developing a resident-centered care plan and a missed opportunity in obtaining the cooperation of the resident which had the potential to result in failure in the delivery of necessary care and services.

Inspectors wroteBased on observation, interview and record review, the facility failed to meet the professional standards of care for one (Resident 72) out of 29 sampled residents by failing to check the resident's respiration rate (a number of breaths a person takes per minute) before administering Gabapentin (medication used to control seizures and for neuropathic pain [a pain caused by damage to the nervous system]) as ordered by the physician. This deficient practice had the potential to result in Resident 72 having unintended complications related to the administration of Gabapentin, such as respiratory depression (condition when breathing is too slow or too shallow).

Inspectors wroteBased on interview and record review, the facility failed to clarify (contacting the physician to obtain additional details about an existing order) fingerstick (a way to check the blood sugar by inserting a small needle into a finger) orders with the physician which indicated the resident was to receive a fingerstick seven times a day instead of the usually prescribed four times a day. This deficient practice had the potential to result in pain from excessive finger sticks.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure a resident's bed was in low position per physician's orders for one of five sampled residents (Resident 32) investigated under the care area of accidents. 2. Provide a resident who was at high risk for falls with a tab alarm (a safety device used primarily in healthcare settings to alert caregivers when a patient attempts to get out of bed or chair without assistance) and floor mats (a cushioned floor pad designed to help prevent injury should a person fall) as ordered by the physician for one of five sampled residents (Resident 51) investigated under the care area of accidents. These deficient practices had the potential to place the residents at increased risk of sustaining a fall with injuries.

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents who needed respiratory treatment (the health care discipline that specializes in the promotion of optimum cardiopulmonary function and health and wellness) were provided such care consistent with professional standards of practice to one out of three sampled residents (Residents 84) when Resident 84's nebulizer (a small machine that turns liquid medicine into mist that can be easily inhaled) tubing was not labeled with the date it was last changed. This deficient practice had the potential to cause respiratory infection to Resident 84

Inspectors wroteBased on observation, interview, and record review the facility failed to implement and maintain an infection control program for one out of six sampled residents (Resident 3) by failing to label the urinal bottle (a container used to collect urine and is made for either male or female anatomy) with the name and room number of Resident 3. This deficient practice had the potential for cross contamination (the physical movement or transfer of harmful bacteria from one person, object, or place to another) and to spread infection among residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to reorder, refill and administer one of three sampled residents (Resident 3) Lidoderm Patch (medication applied to the skin used to treat pain) timely. This deficient practice resulted in delay in the delivery of medication for Resident 3. Resident 3 did not receive the Lidoderm Patch as ordered by the physician which had the potential for Resident 3 to have increased level of pain, discomfort, and decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure laboratory results were communicated with the physician timely for one of three sampled residents (Resident 4). This deficient practice had the potential to delay necessary care and services for the resident.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Medication Administration Record (MAR, a report detailing the medications administered to a resident by the licensed nurses) coincided with the Controlled Drug Record (CDR- accountability record of medications that are considered to have a strong potential for abuse) and entries were accurately documented per facility policy for one of three sampled residents (Resident 1). This deficient practice had the potential to result in medication error and/or drug diversion (illegal distribution or abuse of prescription drug).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure call lights (a device used by a resident to signal his/her need for assistance from staff) were within residents' reach while in bed for two of three sampled residents (Resident 2 and Resident 3). This deficient practice had the potential to delay the provision of services and the residents' needs not being met.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) who is at risk of developing a pressure ulcer/injury (injury to skin and underlying tissue resulting from prolonged pressure on the skin) was repositioned. This deficient practice had the potential to place Resident 1 at risk of developing a pressure ulcer/injury.

Inspectors wroteBased on interview and record review the facility failed to implement the facility's policy on pain as evidenced by failing to ensure a pain risk assessment was completed quarterly (every three months) and for new onset of pain on 9/4/2024 for one of three sampled residents. (Resident 1) This deficient practice had the potential to result in Resident 1 not maintaining Resident 1's highest possible level of comfort.

Inspectors wroteBased on interview and record review, the facility failed to accurately assess one of three sampled residents (Resident 1) for elopement (leaving the facility without notice or permission) risk, when on 8/31/2024, Resident 1 left the facility's premises without staff supervision. This deficient practice had the potential for Resident 1 not to be monitored for elopement and may result in harm, injury and or death.

Inspectors wroteBased on interview and record review, the facility failed to maintain complete and accurate medical records for one of five sampled residents (Resident 2) by failing to follow the documentation instructions for the monitoring of side effects from Buspar (medication indicated to treat anxiety [feelings of worry, or fear that are strong enough to interfere with one's daily activities]). This deficient practice resulted in Resident 2's Medication Administration Record (MAR - a report detailing the medications administered to a resident) for 7/2024 being inaccurate and had the potential to result in confusion regarding Resident 2's condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer medications in a safe manner for one of six sampled residents (Resident 1), by administering an eye drop medication beyond the use date or opened date. This deficient practice had the potential to result in eye infection and cause irritation to the eye due to the administration of eye drop medication beyond the use date or opened date.

Inspectors wroteBased on interview and record review, the facility failed to notify one of three sampled residents (Resident 1) physician, when on 5/19/2024, Resident 1's blood pressure (BP - pressure of circulating blood against the walls of blood vessels, normal range less than 120/80 millimeters of mercury [mmHg - unit of measure]) was low and Licensed Vocational Nurse 1 (LVN 1) failed to administer Atenolol (a medication used to treat hypertension [high blood pressure]) due to parameters (specific measurements or factors used such as to hold medications if out of range) being out of range. These deficient practices had the potential to cause a delay of obtaining appropriate medical treatment and interventions for which could have resulted in a negative impact to Resident 1's well-being.

Inspectors wroteBased on interview and record review, the facility failed to maintain complete and accurate medical records for one of three sampled residents (Resident 1) by failing to ensure licensed nurses did signed the Medication Administration Record (MAR - a report detailing the drugs administered to a resident by a healthcare professional) for Resident 1 on 5/1/2024 during the 3:00 p.m. to 11:00 p.m. shift. This deficient practice resulted in Resident 1's medical records being inaccurate and had the potential to result in confusion regarding Resident 1's condition and what care and services were provided to Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident call system (a tool that allows residents to communicate with nurses that they are in of need assistance)was functioning for five of seven sampled residents (Resident 1, 3, 5, 6, and 7). This deficient practice placed the resident at risk of inability to summon health care workers as needed to receive assistance that may include urgent care.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident ' s right to be free from verbal abuse (harsh and insulting language directed at a person) for one of four sampled residents (Resident 1), when on 5/4/2024, Resident 2 verbally abused and threatened Resident 1. This deficient practice resulted in Resident 1 being subjected to verbal abuse by Resident 2 while under the care of the facility and had the potential to result in Resident 1 ' s emotional distress and restlessness (inability to rest or relax).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 60) maintained acceptable parameters of nutritional status (desirable body weight) and did not experience unplanned severe weight loss (a body weight loss of greater than five [5] percent [% - unit of measure] of weight in one months' time) by: 1. Failing to ensure Resident 60 was immediately seen by the Registered Dietitian 1 (RD 1) when the resident was identified as having experienced a five pounds (lbs.- unit of measure) weight loss on 9/4/2023. RD 1 did not assess Resident 60 until 9/10/2023, six (6) days later. 2. [...]

Inspectors wrote1.c. A review of Resident 27's admission Record indicated the facility admitted the resident on 9/9/2012 and readmitted the resident on 6/9/2023 with diagnoses that included diabetes mellitus, end stage renal disease (a medical condition in which a person's kidneys stop functioning on a permanent basis), and hemiplegia and hemiparesis (mild to severe loss of strength or paralysis on one side of the body) following cerebral infarction (stroke, when blood flow to the brain is blocked or there is sudden bleeding in the brain). A review of Resident 27's MDS dated [DATE], indicated the resident had the ability to make herself understood and had the ability to understand others. During a concurrent interview and record review on 11/29/2023 at 11:05 a.m., with the Social Services Designee (SSD), reviewed Resident 27's Advance Directive Acknowledgement form dated 12/8/2022. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure residents received medications in accordance with professional standards of practice by failing to ensure the medications a resident received before going to a general acute care hospital (GACH, or simply hospital) would also be received upon returning from the GACH for two of 21 sampled residents (Resident 169 and Resident 111). 2. Ensure a resident received the prescribed 9 a.m. scheduled application of Refresh Eye Ointment (an eye medication to keep the eyes from becoming dry) during the medication pass observation on 11/28/2023 for one of five sampled residents (Resident 45). These deficient practices resulted in the omission of medications which could have resulted in severe health complications. 3. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents were free of unnecessary medication for one of five sampled residents (Residents 82) investigated for Unnecessary Medications by failing to ensure carvedilol (medication to treat high blood pressure [the force of the blood pushing on the blood vessel walls is too high]) and midodrine (medication to treat low blood pressure [the force of the blood pushing on the blood vessel walls is too low]) were not scheduled to be administered at the same time. This deficient practice had the potential to result in the resident receiving unnecessary medication potentially causing too low or too high blood pressure and injury to the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from any significant medication errors for one of five sampled residents (Residents 82) investigated for Unnecessary Medications by: 1. Failing to ensure carvedilol (medication to treat high blood pressure [the force of the blood pushing on the blood vessel walls is too high]) was administered in accordance with the physician's order to hold (do not give) for a systolic blood pressure (SBP, measures the pressure in your arteries [pathway that carries blood away from the heart]) less than 110 millimeters of mercury (mmHg, u unit of measurement). 2. Failing to ensure midodrine (medication to treat low blood pressure [the force of the blood pushing on the blood vessel walls is too low]) was administered in accordance with the physician's order to hold for a SBP greater than 110 mmHg. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medication and biologicals were stored with currently accepted professional standards for two of six medication carts (Medication Cart 1 and Medication Cart 2) investigated during the Medication Storage task by failing to: 1. Ensure six unopened insulin (a medication to treat diabetes mellitus [a chronic condition that affects the way the body processes blood sugar]) pens (an injection device with a needle that delivers insulin) were not stored in Medication Cart 2 for four of four sampled residents (Resident 27, 36, 86, and 93). 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to draw (obtain) laboratory (lab) tests in a timely manner as ordered by the physician for two of two sampled residents (Resident 60 and Resident 269) by failing to: 1. Ensure Resident 60's order for a complete metabolic panel (CMP, a group of labs that indicate how the body is functioning including an indication of the nutritive status), was drawn when ordered. The CMP was not drawn until 15 days after it was ordered by the resident's physician. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper and safe food handling practices by failing to: 1. Ensure food items not in their original containers were labeled and dated. 2. Ensure personal belongs of kitchen staff, including bags and food items, were not kept in the kitchen area. These deficient practices had the potential to place 104 out of 109 residents living in the facility at risk for foodborne illnesses (refers to illness caused by the ingestion of contaminated food or beverages).

Inspectors wrotec. A review of Resident 15's admission Record indicated the facility admitted the resident on 7/13/2022 and readmitted the resident on 6/21/2023 with diagnoses that included urinary tract infection (UTI, an infection in the urinary system), major depressive disorder (persistent feelings of sadness and loss of interest that can interfere with daily living), and heart failure (a condition in which the heart cannot pump enough blood to meet the body's needs). A review of Resident 15's MDS dated [DATE], indicated the resident had the ability to make himself understood and had the ability to understand others. The MDS further indicated the resident required moderate assistance with toileting, bathing, dressing, and transferring from chair to bed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote resident`s dignity by failing to ensure resident`s fingernails are trimmed and not dirty for one (Resident 106) of one sampled resident investigated under the Care Area- Dignity. This deficient practice had the potential to affect the resident's sense of self-worth and self-esteem.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow its policy and procedure by failing to notify the physician immediately on 11/28/2023 regarding one of three sampled residents (Resident 269) continued right eye discharge. This deficient practice had the potential to negatively affect the delivery of care and services to Resident 269.

Inspectors wroteBased on observation, 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 seven sampled residents (Resident 15 and 73) by failing to: 1. Develop a comprehensive care plan for Resident 15's oxygen use. 2. Develop a comprehensive care plan for Resident 73's hypertension (high blood pressure [when the force of blood flowing through your blood vessels, is consistently too high]) diagnosis. These deficient practices had the potential to result in a delay in or lack of delivery of care and services and miscommunication among the care team regarding the residents' needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a visually impaired resident was seen by an ophthalmologist (eye care specialist who is a doctor of medicine) as per the optometry (specialized health care profession that involves examining the eyes and relate structures for defects or abnormalities) consult done on 10/4/2023 for one of one sampled resident (Resident 106) reviewed under the care area Communication and Sensory. This deficient practice resulted in a delay in the provision of necessary care and services for Resident 106.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who required assistance with nail trimming was provided care and services to maintain good personal hygiene for one of one sampled resident (Resident 106) investigated under activities of daily living (ADL- activities related to personal care). This deficient practice had the potential to result in a negative impact on the resident's self- esteem due to an unkempt appearance.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two of three sampled residents (Resident 112 and 269) received foot care and treatment. This deficient practice placed residents at risk to acquire a foot infection when toenails were not properly assessed and treated by licensed nurses and podiatrist (a person who treat disorders of the foot, ankle, and related structure of the leg).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received adequate assistance devices and monitoring to prevent accidents for one of four sampled residents (Resident 17) investigated for Accidents, by failing to ensure the floor mats (thick, soft material designed to reduce the impact of a fall) were in place. This deficient practice had the potential to result in injuries from a fall to Resident 17.

Inspectors wroteBased on observation, interview and record review, the facility failed to administer parenteral fluids (medical technique that administers fluids, medications, and nutrients directly into a person's vein) for one of three sampled residents (Resident 271), consistent with professional standards of practice and in accordance with the facility's policy and procedure. This deficient practice had the potential to place Resident 271 at risk for complications and a central line-associated blood stream infection (CLABSI- a serious infection that occurs when germs enter the bloodstream through the central line).

Inspectors wroteBased on observation, 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 15) investigated for Respiratory Care by failing to ensure Resident 15 was monitored for as needed (PRN) oxygen use. These deficient practices had the potential to cause a delay in or lack of delivery of care and services including the treatment of disease processes causing shortness of breath.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident's food preferences are considered and accommodated for one of two sampled residents (Resident 58). This deficient practice placed the resident at risk for decreased meal intake which could result in weight loss or malnutrition (lack of sufficient nutrients in the body).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure left over food brought from outside was stored in the refrigerator or discarded for one of one sampled resident (Resident 73). This deficient practice had the potential to result in foodborne illness (also called food poisoning, illness caused by eating contaminated food) for Resident 73.

Inspectors wroteBased on interview and record review, the facility failed to implement its antibiotic stewardship program (a coordinated program that promotes the appropriate use of drugs used to treat infections, including antibiotics [a medicine that inhibits the growth of or destroys bacteria or germs]) by failing to conduct infection surveillance (a systematic collection of data to track infection which is collected when a resident has certain signs and symptoms that could be a bacterial infection) and complete the infection control reporting form once signs and symptoms of infection were identified and antibiotics were initiated for one of five sampled residents (Resident 271). This deficient practice had the potential for Resident 271 to develop antibiotic resistance from unnecessary or inappropriate antibiotic use for future infections.

Inspectors wroteBased on interview and record review, the facility failed to ensure the quarterly Minimum Data Set (MDS - a comprehensive standardized assessment and screening tool) was completed within the required time frame for one of two sampled residents (Resident 100). This deficient practice had the potential to negatively affect the provision of necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident ' s right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) for one of four sampled residents (Resident 1) when on 9/28/2023, Resident 2 threw a pack of cigarettes at Resident 1 causing skin abrasion (skin scrapes) to the right side of Resident 1 ' s face, adjacent (next to) to Resident 1 ' s right eye which needed first aid (immediate care given to an injured or suddenly ill person) and daily wound treatments. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 5) received the bi-level positive airway pressure (BiPAP, a device that helps with breathing, it delivers air and added oxygen through a mask on the face; the device helps open the lungs with air pressure, it uses a lower pressure when exhaling than when inhaling) machine therapy as ordered by the physician. As a result, on [DATE] at 6:15 a.m. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop a person-centered care plan (a plan for an individual's specific health needs and desired health outcomes) for one of three sampled residents (Resident 5) by: 1. failing to ensure a care plan was developed for Resident 5 ' s noncompliance with the usage of the physician ordered bi-level positive airway pressure (BiPAP, a device that helps with breathing, it delivers air and added oxygen through a mask on the face; the device helps open the lungs with air pressure, it uses a lower pressure when exhaling than when inhaling) machine at night for obstructive sleep apnea (OSA - a disorder in which a person frequently stops breathing due to collapse of the upper airway during sleep). 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the attending physician when one of three sampled residents (Resident 5) was non-compliant with the use of the ordered oxygen (O2) therapy with a bi-level positive airway pressure (BiPAP, a device that helps with breathing, it delivers air and added oxygen through a mask on the face; the device helps open the lungs with air pressure, it uses a lower pressure when exhaling than when inhaling) machine for obstructive sleep apnea (OSA - a disorder in which a person frequently stops breathing due to collapse of the upper airway during sleep). This deficient practice had the potential for the physician not knowing about the resident's unused BiPAP at night and could have potentially delayed necessary interventions.