The Ellison John Transitional Care Center

Inspectors wroteBased on interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical well-being for one of three sampled residents (Resident 3). The facility failed to:Reassess the need for the continuation of the wound care for Resident 3 who had an actively draining and worsening surgical wound/incision on the right side of head status post right side craniotomy (a surgical procedure where a surgeon temporarily removes a section of bone from the right side of the skull [the protective bone shell that forms the shape of the head] to access the brain). This deficient practice has the potential for delayed wound healing and an increased risk for surgical wound/incision infection. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one (1) of five (5) sampled residents' (Resident 14) drug (medication) regimen was free from the use of unnecessary (any medication in excessive dose, excessive duration, without adequate monitoring) psychotropic (any medication capable of affecting the mind, emotions, and behavior) medications in accordance with the facility policy and procedure (P&P) by failing to provide a detailed clinical rationale documented for continuing Zoloft (a psychotropic medication used to treat depression) as originally prescribed on 8/29/2024 without attempting Gradual Dose Reduction ([GDR] - stepwise tapering of a medication dose to determine if symptoms or conditions can be managed by a lower dose, or if the drug can be safely discontinued). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents with urinary incontinence received appropriate treatment and services to prevent urinary tract infections (UTI- an infection in the bladder/urinary tract) for two of three sampled residents (Resident 183 and Resident 5) reviewed under the Urinary Catheters (indwelling catheter -a hollow tube inserted into the bladder to drain or collect urine) care area by failing to: 1. Ensure the facility's policy and procedure (P&P) was followed for Resident 183, when there was no documentation of measured indwelling catheter output on multiple shifts since resident admission on [DATE]. 2. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Reconcile (the process of comparing transactions and activity to supporting documentation) two (2) medication emergency kits ([eKIT] - kit containing medications needed to be used during emergencies) containing ([CS] - medications which have a potential for abuse and may also lead to physical or psychological dependence, also known as narcotics, drugs or controlled medication) for June 2026, in two (2) of two (2) inspected Medication Rooms (Medication Room Station 1 and 2). 2. Account for two (2) doses of CS for Resident 19 and 74 in one (1) of five (5) inspected medication carts (Medication Cart 2 Station 2). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free of any significant medication errors (the observed or identified preparation or administration of medications or biologicals which are not in accordance with the prescriber's order, manufacturer's specifications, and accepted professional standards) by failing to: 1. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Remove and discard from use one (1) expired insulin (medication used to regulate blood sugar levels) Lispro (rapid-acting insulin) Kwikpen (an injection device containing insulin) for Resident 44, in accordance with manufacturer's requirements and facility policy and procedures (P&P) in one (1) of five (5) inspected medication carts (Medication Cart 2 Station 1).2. Remove and discard from use one (1) expired insulin Novolog (rapid-acting insulin) Flexpen (an injection device containing insulin) for Resident 123, in accordance with manufacturer's requirements and facility P&P in one (1) of five (5) inspected medication carts (Medication Cart 2 Subacute).3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep the call light (an alerting device for patients to call a nursing personnel to assist them when needed) within reach of residents for two (2) of two (2) sampled residents (Residents 39, 110) reviewed under environment task. The deficient practice had the potential to place the residents at risk for delayed assistance, potentially affecting safety and timely care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to immediately notify the primary care physician of a significant change in condition for one of one sampled resident (Resident 183) reviewed under the Urinary Catheters (indwelling catheter -a hollow tube inserted into the bladder to drain or collect urine) care area by failing to ensure notification for an SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition [SBAR] among the residents) when the indwelling catheter was bypassing (urine leaking around the outside of an indwelling catheter instead of flowing through the tube) with no urine output collected in the drainage bag for the day shift (7 a.m. to 3 p.m.) on 6/15/2026. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an environment free from accidents and hazards for two of three sampled residents (Resident 96 and 188) reviewed for accidents by failing to: 1. Ensure Resident 96's room was free from liquid spills while the resident was left unattended by staff. 2. Ensure Resident 188 did not have a chair and trash bin placed on top of the floor mat (a thick, soft pad placed on the floor beside a resident's bed to cushion them if they fall) on the resident's left side of the bed. These deficient practices had the potential to result in resident falls resulting in injuries like fractures (broken bones) and lacerations.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate care for one of one sample resident (Resident 75) receiving enteral feeding (is a feeding tube that provides liquid nutrition directly into the stomach) by failing to label the flushing bag (a bag filled with water that's connected to an enteral feeding pump system) with the name of the correct solution. This deficient practice had the potential for placing Resident 75 at risk for harm when using wrong type or old fluid in the enteral flush bag.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the respiratory care provided to residents was consistent with professional standards of practice for two (2) of three (3) sampled resident (Resident 30, 184) reviewed for respiratory care by failing to ensure Resident 30, and Resident 184's oxygen via nasal cannula (N/C a flexible plastic tube with two tips that go into the nose to give a person extra oxygen and help them breathe easier) tubing was labeled with the date it was last changed. This deficient practice had the potential to result in placing Residents 30 and 184 at risk for infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents' drug regimen included adequate (acceptable) monitoring for HgA1c ([A1C] -a test that measures average blood sugar (BS) levels over a three-month period) levels for one (1) of five (5) sampled residents investigated for unnecessary medications (Resident 7) between 7/13/2025 and 6/16/2026. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one of two sampled residents (Resident 12) received a suitable meal when Resident 12 had a scheduled appointment at lunchtime. This failure had the potential for Resident 12 to have weight loss and dehydration due to missing a meal.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Licensed Vocational Nurse (LVN) 3 followed Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDRO, microorganisms, mainly bacteria, that are resistant to one or more classes of antibiotics] that uses targeted gown and glove use during high contact resident care activities) while administering medications to a resident with wounds) for one of three observed residents (Resident 93) for medication administration. This deficient practice had the potential to place Resident 93 at risk for infections, which could result in impairment or decline in the residents' health and well-being.

Inspectors wroteBased on interview and record review, the facility failed to follow professional standards of nursing practice for three of three sampled residents (Resident 5, Resident 6, and Resident 7) by failing to: 1. Ensure licensed nurses appropriately assessed and monitored Resident 5's medical status following the resident's Change of Condition (COC - any sudden or major shift in a person's physical, mental, or behavioral health compared to their normal baseline) on 6/7/2026 related to the alleged physical aggression with Resident 6.2. Ensure licensed nurses appropriately assessed and monitored Resident 6's medical status following the resident's Change of Condition (COC) on 6/7/2026 related to the alleged physical aggression with Resident 5.3. [...]

Inspectors wroteBased on interview and record review, facility failed to ensure an accurate assessment was conducted for one of three sampled residents (Resident 1) when Resident 1 did not have an accurate assessment of the skin conditions that was conducted on 5/25/2026. This deficient practice has the potential to result in Resident 1's delay in necessary care and treatment.

Inspectors wroteBased on interview and record review, the facility failed to ensure the medical records of one of three sampled residents (Resident 5) was maintained in accordance with accepted professional standards and practice, complete, and accurately documented by failing to ensure licensed nurses documented Resident 5's assessment timely. This deficient practice resulted in inaccurate information on Residents 5's medical records and had the potential for delayed and inaccurate medical interventions.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the comprehensive care plan (a plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs) was revised for one of three sampled residents (Resident 1), when on 5/15/2026, Resident 1 was transferred to the general acute care hospital (GACH) for gastrostomy tube (G-tube, a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) dislodgement (gastrostomy tube has been partially or completely pulled out of the stomach). This deficient practice had the potential to delay provision of care and services for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to follow professional standards of nursing practice for one of three sampled residents (Resident 1 and Resident 2) by failing to:1. Ensure Licensed Vocational Nurse (LVN) 1 created Resident 1's Change of Condition (COC) Evaluation form. Resident 1 was reported wandering in another resident's room on 3/13/2026. Resident 1's Attending physician (MD) 1 and Family Member (FM) 1 were not notified. 2. Ensure licensed nurses appropriately assessed and monitored Resident 1's medical status following the resident's COC on 3/13/2026 related to the resident's new wandering behavior. These deficient practices had the potential to result in the failure to identify continued or worsening clinical deterioration, thereby placing Resident 1 at risk for adverse health outcomes and compromised safety. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a person-centered care plan (a tool that ensures residents receive personalized, comprehensive, and goal-oriented care in a nursing home setting) for one of three sampled residents (Resident 1) by failing to:1. Develop a care plan to address Resident 1's need for maximum assistance from staff for eating as indicated in Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 11/11/1025. 2. Implement the care plan regarding Resident 1's risk of constipation (when your bowel movements become less frequent and stools become difficult to pass).3. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) for one of three sampled residents (Residents 1) by failing to: 1. Follow the physician's order to administer bisacodyl (medication used to treat constipation [when bowel movements become difficult, infrequent or painful, often resulting in hard, dry stool]) and milk of magnesia (MOM-medication that relieves constipation in 30 minutes to six hours) when Resident 1 had no bowel movements on 11/7/2025, 11/8/2025, 11/9/2025, 11/11/2025, and 11/15/2025.2. Ensure bisacodyl administration to Resident 1 on 11/10/2025, indicated the dosage, time of administration and who administered the medication.3. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the call light device (also known as a call bell or nurse call button, is a device typically found near a patient's bed or within reach. consists of a button that, when pressed, sends a signal to the nursing station or a centralized system, alerting healthcare providers that assistance is required in the room) was answered timely for two of three sampled residents (Residents 1, and 3). This failure had the potential to result in a delay in care and not receiving assistance timely.

Inspectors wroteBased on interview and record review, the facility failed to notify one of three sampled residents (Resident 1) Family Member 1 (FM 1), who had Power of Attorney (POA-is a legal document that authorizes a chosen person to act on behalf of another person regarding financial, legal, or medical affairs. It is used to ensure decisions can be made if the principal is unable to do so due to illness, incapacity, or absence) of Resident 1's Coronavirus (COVID-19, highly contagious respiratory disease is thought to spread from person to person through droplets released when an infected person coughs, sneezes or talks. It may also spread by touching the surface with the virus on it and then touching one's mouth, nose, or eyes) result. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain accurate and complete medical record for one of three sampled residents (Resident 1) by failing to complete Resident 1's Change in Condition (COC a-document used to record and report any significant changes in a resident's physical, mental, or psychosocial status), dated 11/10/2025. This failure had the potential to cause confusion in care and causing the medical record to contain inaccurate documentation.

Inspectors wroteBased on interview and record review, the facility failed to follow professional standards of nursing practice for one of three sampled residents (Resident 1) by failing to:1. Ensure licensed nurses appropriately monitored Resident 1 for hypoglycemia (a condition in which the blood sugar level is lower than the standard range). The record revealed Resident 1's blood sugar was not monitored every four hours according to the physician orders for 21 days. 2. Ensure Resident 1's blood sugar level during a documented change of condition (COC) related to hypoglycemia on 12/21/2025 was documented in the Medication Administration Record (MAR). These deficient practices had the potential to result in the failure to identify hypoglycemic episodes, thereby placing Resident 1 at risk for adverse health outcomes and compromised safety.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sample residents (Resident 1) was free from significant medication errors by failing to:1. Ensure licensed nurses document in Resident 1's Medication Administration Record (MAR) the glucagon intramuscular (a fast-acting medication, injected into the muscle, used to treat severe low blood sugar) one milligram (mg - unit of measurement) and glucose gel (a fast-acting medication, given by mouth, used to treat hypoglycemia [a condition in which the blood sugar level is lower than the standard range]) 40 percent (% - unit of measurement) given to Resident 1 during the resident's change of condition (COC) on 12/21/2025.2. Ensure Resident 1 had a physician order for glucose gel 40% before the medication was given to the resident on 12/21/2025. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free of any significant medication error when the facility failed to administer permethrin external cream (treats scabies, a condition caused by tiny insects that irritate your skin. It works by killing the mites and their eggs) as ordered. This deficient practice had the potential to negatively affect Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) was free of any significant medication errors when the facility failed to: 1. 1. Administer amlodipine besylate (a calcium channel blocker, that works by relaxing and widening your blood vessels) 5 milligrams (mg- a unit of measurement) on 12/15/2025 as ordered. 2. 2. Administer 14 medications as prescribed on 12/17/2025. These deficient practices had the potential to negatively affect Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice to meet the resident's physical, mental, and psychosocial (relating to the interrelation of social factors and individual thoughts and behavior) needs for two of three sampled residents (Residents 1 and 2) by failing to: 1. Administer medications to Resident 1 as ordered by the physician. 2. Provide Resident 1 with the correct size of incontinent briefs (a type of absorbent undergarment, essentially an adult diaper with adjustable tabs, designed for individuals who experience incontinence). 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two of three sampled residents (Residents 1 and 2) were free from significant medication error (means the identified administration of medications or biologicals which are not in accordance with the prescriber's order, manufacturer's specifications, and accepted professional standards), by failing to: 1. Administer Bisacodyl rectal suppository (a fast-acting stimulant laxative inserted into the rectum used for short-term relief of occasional constipation) to Resident 1 by the correct route. 2. Ensure Resident 2 received full course of Ertapenem Sodium Injection Solution (antibiotics-medication to treat bacterial infection administered as an intravenous solution) as ordered by the physician. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a comprehensive care plan (a plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs) for one of three sampled residents (Resident 2) regarding Resident 1's two right abdominal Jackson Pratt drains (JP drain-a surgical drain that uses gentle suction to remove fluid from a surgical site to promote healing, consisting of a tube in the body connected to a squeezable bulb reservoir that creates constant suction when compressed). This deficient practice placed Resident 2 at risk for insufficient provision of care and services related to the JP drain care.

Inspectors wroteBased on interview and record review, the facility failed to obtain complete blood count with differential (CBC with differential - a blood test that measures red blood cells, white blood cells, and platelets used to help diagnose and monitor many conditions, such as infection, inflammation, and to evaluate the effectiveness of a treatment) blood test as ordered by the physician for one of three sampled residents (Resident 2). This deficient practice had the potential to delay necessary care and services for Resident 2.

Inspectors wroteBased on interview and record review, the facility failed to ensure the medical records of one of three sampled residents (Resident 2) were maintained in accordance with accepted professional standards and practice, complete, and accurately documented by failing to ensure Resident 2's peripheral intravenous catheter (PIV catheter- a thin, flexible plastic tube inserted into a vein to deliver fluids, medications, blood, or nutrition, using a needle for placement that is then removed, leaving just the tube) removal and placement procedures were documented. These deficient practices had the potential for inaccurate medical interventions for Resident 2.

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Ensure the resident who was repeatedly attempting to get out of bed unassisted, did not fall out of bed and sustained injury for one of four sampled residents (Resident 1). The facility failed to: 1a. Ensure Licensed Vocational Nurse (LVN) 3 responded to Resident 1's family provided caregiver (Companion) 1's report that Resident 1 repeatedly attempted to get out of bed unassisted on 8/26/2025. 1b. Ensure LVN 3 notified Registered Nurse (RN) 2 regarding Companion 1's report that Resident 1 repeatedly attempted to get out of bed unassisted on 8/26/2025. 1c. Ensure Resident 1's bed's pad alarm (a pad with sensors that will alarm when a resident stands up unassisted to help prevent falls by alerting staff) was plugged-in and functioning when Resident 1 was attempting to get out of bed unassisted on 8/26/2025. 1d. [...]

Inspectors wroteBased on interview and record review, the facility failed to immediately notify the primary physician regarding a decision to transfer the resident and a need to alter treatment significantly (a need to stop or commence a new form of treatment to deal with a problem) for one of four sampled residents (Resident 1) when on 8/26/2025 Family Member (FM) 1 refused immediate emergent 911 (phone number called to summon emergency services) transfer of Resident 1 to the General Acute Care Hospital (GACH) after Resident 1 sustained a fall resulting in injuries including swelling to the forehead, a skin tear to the left arm, swelling to the right upper arm, and a change in status of mobility. This deficient practice resulted in a delay of placing an emergent 911 call for approximately 30 minutes potentially resulting in further harm to the resident including internal bleeding and death.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of employee-to-resident abuse to the Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities) as per its policy on abuse for one of five sampled residents (Resident 3). This failure had the potential to place Resident 3 at risk for not having an advocate.

Inspectors wroteBased on interview and record review, the facility staff failed to notify the physician on 9/5/2025 when Resident 1 complained of weakness/numbness (a loss of feeling or sensation in an area of the body) to the right side the face for one of three samples Residents (Resident 1). This deficient practice had the potential to result in a lack of necessary care and treatment to Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe provision of pharmaceutical services for one of three sampled residents (Resident 8) by failing to ensure the resident's medications were not left unattended at bedside. This deficient practice had the potential to cause medication errors and could possibly lead to Resident 8's discomfort.

Inspectors wroteBased on interview and record review, the facility failed to follow the facility's policy and procedure on fall management for one of three sampled residents (Resident 1), when Resident 1 who was admitted to the facility with history of falls, was not assessed for fall risk upon admission. This failure had the potential to place Resident 1 at an increased risk of falls.

Inspectors wroteBased on interview and record review, the facility failed to obtain weekly weights for one of three sampled residents (Resident 1) after Resident 1 was noted with a Change in Condition (COC) on 3/21/2025 regarding a weight loss of 15 pounds (lbs.- a unit of measurement) in one week. This deficient practice had the potential for Resident 1 to have a delay in care.

Inspectors wroteBased on interview and record review, the facility failed to provide laboratory (lab) services for one of three sampled residents (Resident 1) on 3/18/2025. On 4/2/2025 Resident 1 was discharged without the ordered labs being completed. This deficient practice had the potential for a delay in care and treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the room of one of four sampled residents (Resident 3) was free from clutter. This failure had the potential to negatively impact Resident 3's psychosocial well-being (refers to a resident's overall mental, emotional, and social health, encompassing aspects like happiness, life satisfaction, self-esteem, social functioning, and a sense of purpose).

Inspectors wroteBased on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice to meet the resident's physical, mental, and psychosocial (relating to the interrelation of social factors and individual thoughts and behavior) needs by failing to administer medications and treatments as ordered by the physician for one of four sampled residents (Resident 1). This deficient practice had the potential to delay Resident 1's care causing him to experience prolonged, unrelieved muscle spasms (a sudden involuntary muscular contraction, twitch).

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to prevent the development and transmission of communicable diseases (illness that can be transmitted from one person to another) and infections by failing to ensure a sign was posted near the isolation room (a specialized room designed to separate residents with communicable disease to prevent the spread of infection) indicating the type of precaution and personal protective equipment (PPE, specialized clothing or gear worn to minimize exposure to hazards taht can cause serious illnesses) a resident required for one of four sampled residents (Resident 2). The deficient practices had a potential to spread infections and illnesses among residents.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for: 1. Continuous Positive Airway Pressure (CPAP, a machine that uses air pressure to keep airways open during sleep) for one of three sampled residents (Resident 29) reviewed for respiratory care. 2. Humulin R ( is a man-made insulin [a hormone that helps the body use blood sugar for energy] that is used to control high blood sugar) for one of two sampled residents (Resident 29) reviewed for insulin use. 3. Cephalexin (used to treat certain infections caused by bacteria such as pneumonia [lung infection] and other respiratory tract infections; [...]

Inspectors wroteBased on interview and record review, the facility's licensed nursing staff failed to provide care in accordance with professional standards by failing to: 1. Ensure three (3) of 3 sampled residents (Residents 65, 29, and 52) reviewed for insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) and anticoagulant (a substance that is used to prevent and treat blood clots in blood vessels and the heart) use had their subcutaneous (beneath the skin) insulin and heparin (an anticoagulant) administration sites rotated (a method to ensure repeated injections are not administered in the same area). [...]

Inspectors wrotee. During a review of Resident 83's admission Record, the admission Record indicated the facility admitted the resident on 12/23/2024 with diagnoses including Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), speech disturbances, and generalized muscle weakness. During a review of Resident 83's History and Physical (H&P) dated 12/29/2024, the H&P indicated Resident 83 had the capacity to make decisions. During a review of Resident 83's MDS, dated [DATE], the MDS indicated Resident 83 had an intact cognition and required total assistance with sit to stand activities and transfers; partial/moderate assistance with eating, oral hygiene, and personal hygiene; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respiratory care provided to residents were consistent with professional standards of practice for one of three sampled residents (Resident 29) reviewed for respiratory care by failing to ensure Resident 29 ' s home continuous positive airway pressure (CPAP - a machine that uses mild air pressure to keep breathing airways open while you sleep) machine had: A physician ' s order to use in the facility including parameters of oxygen administration and indication for use. An assessment of the home CPAP machine ' s integrity, monitoring of the resident ' s respiratory condition, including response to therapy. A care plan that includes interventions for CPAP therapy. Been cleaned daily per manufacturer ' s guidelines on cleaning the mask and the CPAP tubing. [...]

Inspectors wroteBased on observation interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) by failing to: 1. Accurately account for two doses of controlled medications (medications with a high potential for abuse) affecting Residents 87 and 93 in two of four inspected medication carts on Station 2 Cart 1 and Station 3 Cart 1. This deficient practice increased the risk of diversion (any use other than that intended by the prescriber) of controlled mediations and the risk that Residents 87 and 93 could have received too much or too little medication due to a lack of documentation possibly resulting in serious health complications requiring hospitalization. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to: 1. Respond to the consultant pharmacist's (a medical professional responsible for a monthly review of all residents' medication regimens) recommendation from 11/30/2024 to limit the duration of PRN (as needed) lorazepam (a medication used to treat mental illness) to 14 days or define a specific length of therapy for one of five residents sampled for unnecessary medications (Resident 101). 2. Respond to the consultant pharmacist's recommendation from 12/31/2024 to define the length of therapy with guaifenesin oral liquid (a medication used to treat cough/congestion) for one of five residents sampled for unnecessary medications (Resident 101). [...]

Inspectors wroteBased on interview and record review, the facility failed to: 1. Perform a gradual dosage reduction (GDR - a periodic attempt to lower the dosage of a medication or discontinue a medication in order to control a resident's symptoms with lower doses or fewer medications) for psychotropic medications (medications that affect brain activities associated with mental processes and behavior) in two of five residents sampled for unnecessary medications (Residents 1 and 71.) 2. Limit the duration of PRN (as needed) lorazepam (a medication used to treat mental illness) to 14 days or document a longer, specific duration and clinical rationale in one of five residents sampled for unnecessary medications (Resident 101.) 3. [...]

Inspectors wroteb. During a review of Resident 29 ' s admission Record, the admission Record indicated the facility admitted the resident on 1/22/2025, with diagnoses including type 2 diabetes mellitus (a disorder in which the body does not produce enough or respond normally to insulin, causing blood sugar [glucose] levels to be abnormally high), peripheral vascular disease (the reduced circulation of blood to a body part, other than the brain or heart, due to a narrowed or blocked blood vessel), and atherosclerotic heart disease (the buildup of fats, cholesterol and other substances in and on the artery walls). [...]

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: Two dented cans were found with the non-dented cans. One opened bag of crushed graham crackers did not indicate the date of when it was opened. These failures had the potential to result in harmful bacterial growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) in 128 of 150 medically compromised residents.

Inspectors wroteBased on interview and record review, the licensed nursing staff failed to ensure the residents and/or responsible party (RP) were informed in advance, of the risks and benefits of psychoactive medication (a drug that changes brain function and results in alterations in perception, mood, consciousness or behavior) for one (1) of 1 sampled resident (Resident 34) reviewed for informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) by failing to ensure the Zoloft (also known as sertraline, an antidepressant used to treat mental and mood disorders) informed consent indicated the milligrams (mg - metric unit of measurement, used for medication dosage and/or amount) the resident was on, and the boxes were checked on the informed consent whether the resident consented to take the medication. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, comfortable, and homelike environment for two (2) of 2 sampled residents (Residents 83 and 42) reviewed during a random observation by failing to ensure Resident 83 ' s and 42 ' s floor mats were free from rips and disrepair. This deficient practice had the potential to negatively affect the resident ' s quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignity including the right to be free from physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the resident ' s body that he or she cannot easily remove that restricts freedom of movement or normal access to one ' s body) for one (1) of two (2) sampled residents (Resident 303) reviewed for physical restraints by failing to ensure the resident had a physician ' s order, an informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered), a device use or restraint assessment, and a care plan for bed pad (a pad with sensors that will alarm when a resident stands up unassisted to help prevent falls by [...]

Inspectors wroteBased on interview and record review, the facility failed to: 1. Include a diagnosis of dementia (a group of progressive medical conditions affecting the brain that interfere with the ability to remember, think clearly, and make decisions) on the baseline care plan (an initial set of instructions needed to provide resident-centered care to a newly admitted resident) for one of five residents sampled for unnecessary medications (Resident 68). 2. Include the use of the antipsychotic (a class of medications used to treat mental illness) medication, quetiapine (a medication used to treat mental illness), on the baseline care plan for one of five residents sampled for unnecessary mediations (Resident 68). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the interdisciplinary team (IDT - a group of people from different healthcare disciplines who work together to provide care for a resident) reviewed and revised the comprehensive care plan after each assessment, including both the comprehensive and quarterly review assessments for one of four sampled residents (Resident 73) reviewed for physical restraints (a device or technique that limits a person's movement or access to their body) by failing to conduct an interdisciplinary meeting to review and revise the care plan of the resident having multiple physical restraints. Resident 73 ' s care plan for physical restraints was last reviewed and revised on 8/19/2024. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary services to maintain good grooming and personal hygiene for one (1) of 1 sampled resident (Resident 65) reviewed for activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily) by failing to provide proper perineal (involves cleaning the private areas of a resident) care to the resident per facility policy and procedure (P&P). This deficient practice had the potential to result in a negative impact on Resident 65's psychosocial wellbeing. Cross-reference F697 and F880.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one of one sampled resident (Resident 197), reviewed under General care area, received treatment and care in accordance with professional standards of practice, by failing to identify and assess Resident 197 who had a change in condition, and was not administered three doses of levothyroxine as ordered. This deficient practice had the potential to result in Resident 197 to go unmonitored for symptoms of hypothyroidism such as fatigue, heart problems, and impaired cognitive function.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents with a urinary catheter (also known as an indwelling catheter, a hollow tube inserted into the bladder to drain or collect urine) received appropriate care and services to prevent urinary tract infections (UTI - an infection in the bladder/urinary tract) for two (2) out of 2 sampled residents (Residents 83 and 53 ) reviewed for urinary catheter or UTI by failing to ensure Residents 83 ' s and 53 ' s urinary catheter tubing did not have a loop while hanging on the side the bed. This deficient practice had the potential for the resident ' s urine not to flow freely which may lead to development of UTI.

Inspectors wroteBased on interview and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice related to pain management for one (1) of 1 sampled resident (Resident 65) reviewed for pain management when Certified Nursing Assistant (CNA) 1 failed to recognize and address Resident 65 ' s verbalization of pain while providing activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily) care. This deficient practice had the potential for Resident 65 to be subjected to unnecessary pain affecting the resident ' s quality of life and comfort. Cross-reference F677 and F880.

Inspectors wroteBased on interview and record review, the facility failed to reevaluate or discontinue a PRN (as needed) order for guaifenesin oral liquid (a medication used to treat cough/congestion) after 10 days in one of five residents sampled for unnecessary medications (Resident 101). The deficient practice of failing to stop or reevaluate PRN medications increased the risk that Resident 101 may have experienced adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have) related to the use of guaifenesin possible resulting in a decline in her quality of life.

Inspectors wroteBased on interview and record review, the facility failed to promptly provide dental services for one out of three sampled residents (Residents 89) investigated under dental services by failing to schedule a dental appointment for Resident 89. This deficient practice placed Resident 89 at risk for a delay in the necessary dental and services the resident needs which result in the inability to pain, effectively chew foods, weight changes, lack of energy and loss of muscle mass.

Inspectors wroteBased on observation, interview, and record review, the facility failed to honor resident dietary preferences for one of eight sampled residents (Resident 59) reviewed under the Food care area by failing to ensure the resident was not served fish, a disliked food, at lunch on 2/28/2025. This deficient practice had the potential to result in the resident having a decreased meal intake which could lead to unintentional weight loss and malnutrition (lack of sufficient nutrients in the body).

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections by failing to: 1. Ensure Certified Nursing Assistant (CNA) 2 did not place the nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) from the floor onto the resident's bed for one of three sampled residents (Resident 101) reviewed under the Respiratory care area. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to transmit the Minimum Data Set (MDS-a resident assessment tool) Assessments for one of two sampled residents (Resident 126) reviewed under Resident Assessments facility task by, failing to transmit Resident 126's MDS discharge assessment. This deficient practice had the potential to negatively affect the provision of necessary care and services needed by the resident.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents receive an accurate assessment, reflective of the residents' status at the time of the assessment by: 1. Failing to accurately complete the Minimum Data Set (MDS - a resident assessment tool) on a diagnosis of dementia (a group of progressive medical conditions affecting the brain that interfere with the ability to remember, think clearly, and make decisions) for one of five residents sampled for unnecessary medications (Resident 71.) This deficient practice increased the risk that Resident 71 may not have received care planning and treatment according to her needs possibly leading to a decline in her overall health and well-being. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident received care consistent with professional standards of practice for one of three sampled residents (Resident 1) by failing to ensure Licensed Vocational Nurse 1 (LVN 1) called 911 when Resident 1 had a change in condition on [DATE], at 11:30 p.m. This deficient practice had the potential for a delay in care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program regarding scabies (a contagious skin condition caused by tiny mites that cause itchy skin rash) for one of seven sampled residents (Resident 3) by failing to: 1. Ensure the Resident 3's private caregiver removed the disposable gloves and performed hand hygiene (hand washing with soap and water and use of alcohol-based hand sanitizer) before touching the linens inside the clean linen cart. 2. Ensure the linens inside a resident's room were not returned to the clean linen cart. 3. Ensure soiled personal protective equipment (PPE - equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) were placed inside the trash bin instead of the dirty linen bin. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of six sampled resident's (Resident 5) comprehensive, person-centered care plan with measurable objectives and interventions were created and implemented addressing Resident 5's intravenous line (IV line - a soft flexible tube placed inside a vein) site and the resident's long-term use of oxygen supplement (a medical treatment that provides extra oxygen for people with breathing problems of lung diseases). This deficient practice placed Resident 5 at risk for not receiving the necessary services and assistance that can result in resident injury or serious condition.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of six sampled resident's (Resident 5) intravenous line (IV line - a soft flexible tube placed inside a vein) site was assessed and monitored. As a result of this deficient practice, Resident 5 had an infiltrated (occurs when the fluid leaks out of the vein into surrounding soft tissue) IV site that placed Resident 5 at risk for infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure medical records were complete and accurately documented for one of six sampled residents (Resident 5) by failing to ensure licensed nurses documented Resident 5's respiratory rate (RR - the number of breaths a person takes per minute) and oxygen saturation (O2 sat - the percentage of oxygen in the blood compared to the maximum amount of oxygen the blood can carry) in the resident's flowsheet every shift. This deficient practice resulted in incomplete information on Resident 5's clinical records and had the potential for delayed and inaccurate medical interventions.

Inspectors wroteBased on interview and record review, the facility failed to implement its infection prevention and control program by failing to conduct coronavirus disease 2019, (COVID-19, a highly contagious respiratory illness that can lead to severe symptoms) response testing according to the facility ' s COVID-19 Testing & Quarantine, policy and procedure for three of nine sampled staff (Licensed Vocational Nurse 4 [LVN 4], Registered Nurse 1 [RN 1], and Registered Nurse 2 [RN 2]). This deficient practice had the potential to result in an increased transition of COVID-19 infection among residents and staff.

Inspectors wroteBased on interview and record review, the facility failed to notify the physician of one of three sampled residents (Resident 1) physician, when on 11/3/2024, Resident 1's blood pressure (BP - the measurement of the pressure or force of blood inside your arteries [muscular walled tubes that carries blood from the heart to tissues and organs in the body], normal range less than 120/80 millimeters of mercury [mmHg - unit of pressure measure]) dropped from 118/75 mmHg on 11/2/2024 at 7:03 p.m. to 89/54 mmHg on 11/3/2024 at 1:00 a.m. [...]

Inspectors wroteBased on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan (a written or electronic record containing all the information the resident needs to effectively manage their own health) for one of three sampled residents (Residents 1) by failing to ensure Resident 1 had a care plan on hypotension (low blood pressure). This deficient practice had the potential to result in a delay in or lack of delivery of care and services to Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of three sampled residents (Residents 2 and 3) who were on enteral feeding (a way of delivering nutrition directly to the stomach or small intestine) had their supplies labeled with date and time and changed every 24 hours. This deficient practice had the potential for Resident 2 and Resident 3 to receive inaccurate amount of formula as ordered and for enteral feeding supplies harboring bacteria and transmitting to residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policy and procedure (PnP) titled, Use and storage of food brought to residents, when items were noted without a use by date, resident information, and without a re-sealable container for three of five sampled Residents (Resident 3, Resident 4, and Resident 5). This deficient practice had the potential to result in Residents 3, 4, & 5 to receive food items that are expired and placed these residents at risk for developing foodborne illness (any illness resulting from eating contaminated/spoiled foods) symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever and can lead to other serious medical complications and hospitalization.

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 three sampled residents (Resident 2). On 7/14/2023, at 6:33 p.m., Resident 1 hit Resident 2 on the back of the shoulder. Resident 2 was sitting in his wheelchair and Resident 1, rushed over to Resident 2's wheelchair and hit Resident 2 several times on the back of the left neck and left shoulder. 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 abrasion (scratches or scrapes) to his left shoulder and felt soreness to the neck. The facility transferred Resident 2 to the general acute care hospital (GACH) for further care and evaluation.

Inspectors wrote3. A review of Resident 153's admission Record (a record containing diagnostic and demographic resident information), dated 2/22/24, indicated the facility admitted the resident on 1/30/24 with diagnoses including muscle weakness and a history of falling. A review of Resident 153's Physician Progress Notes, dated 1/30/24, indicated Resident 153 also had diagnoses including anxiety disorder (a mental disorder characterized by persistent feelings of worry, nervousness, or unease strong enough to interfere with daily activities) and major depressive disorder (MDD - a mental disorder characterized by depressed mood and loss of interest in activities). A review of Resident 153's Order Summary Report (a summary of all current physician orders), dated 2/22/24, indicated Resident 153's attending physician prescribed the following psychotropic medications: 1. [...]

Inspectors wroteBased on interview and record review, the facility's licensed nursing staff failed to provide care in accordance with professional standards by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) administration sites of insulin (a hormone that lowers the level of sugar in the blood) for one out of five sampled residents (Resident 94) investigated during review of unnecessary medications. The deficient practice had the potential for adverse effects (unwanted, unintended result) of same site subcutaneous administration of insulin such as lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (a rare disease that occurs when a protein called amyloid builds up in organs).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received adequate supervision and implemented measures to prevent accidents for two of two sampled residents (Resident 96 and 132) reviewed under accidents care area, by failing to: 1. Reassess Resident 96's Smoking Risk Assessment as needed and implement the resident's smoking care plan. 2. Ensure Resident 132's pad alarm device (device that contain sensors that trigger an alarm or warning light when they detect a change in pressure) was turned on/working while the resident was lying in bed. 3. Ensure Resident 132's alarm device head was connected to the pad alarm while the resident was up in the Geri-chair (a special type of chair designed for older adults or people with mobility issues). These deficient practices had the potential to place the resident at risk for falls and serious injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately account for three doses of controlled medication (medications with a high potential for abuse) affecting Residents 151 and 411 in one of four inspected medication carts (Station 1 Cart 1.) This deficient practice increased the risk of diversion (any use other than that intended by the prescriber) of controlled mediations and that Residents 151 and 411 could have received too much or too little medication due to lack of documentation possibly resulting in serious health complications requiring hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents who receive Eliquis (Apixaban, a blood thinner that treats and helps prevent blood clots that are related to certain conditions involving the heart and blood vessels) were monitored for adverse effects (an often harmful and unwanted effect) as indicated in the care plan for one of five sampled residents (Resident 94) investigated during review of unnecessary medications. This deficient practice placed the residents at risk for unnecessary medication and undetected side effects.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Define resident-specific, objectively measurable target behaviors related to the use of lorazepam (a medication used to treat mental illness) in three of five residents sampled for unnecessary medications (Resident 12, 102, and 132.) 2. Ensure the antipsychotic medication haloperidol (a medication used to treat mental illness) was used only for conditions or diagnoses as documented in the clinical record in one of five residents sampled for unnecessary medications (Resident 153.) 3. Define resident-specific, objectively measurable target behaviors related to the use of haloperidol in one of five residents sampled for unnecessary medications (Resident 153) 4. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure residents were free of any significant medication errors by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) administration sites of insulin (a hormone that lowers the level of sugar in the blood) to one out of five sampled residents (Resident 94) investigated during review of unnecessary medications. The deficient practices had the potential for adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin such as lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (a rare disease that occurs when a protein called amyloid builds up in organs).

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement and maintain an infection control program by failing to: 1. Wear proper personal protective equipment (PPE, equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) such as the face shield or goggles while providing care to residents placed on Novel Respiratory Precautions (special measures taken to prevent the spread of new or unfamiliar respiratory illnesses) to two out of eight sampled residents (Residents 40 and 161) identified during screening and was investigated under infection control. 2. Ensure accurate label of the date and time the feeding tube formula was prepared for one out of eight sampled residents (Resident 148) identified during screening and was investigated under infection control. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to obtain informed consent (a process during which residents or caregivers are educated regarding the potential risks and benefits of medication therapy) from the resident or their responsible party (a person delegated to make medical decisions for the resident in the event they are unable to do so) prior to treatment with prochlorperazine (a medication used to treat nausea and vomiting) in one of five sampled residents (Resident 102) reviewed for unnecessary medications. The deficient practice of failing to obtain informed consent prior to initiating treatment with psychotropic medications (medications that affect brain activities associated with mental processes and behavior) could have prevented Resident 102 from exercising his right to decline to take psychotropic medications. [...]

Inspectors wroteBased on observation, interview, and record review, the facility's interdisciplinary team (IDT - a coordinated group of experts from several fields who work together) failed to ensure a resident's self-administration of medications was appropriate and safe for one of one sampled resident (Resident 211) investigated during a random observation by failing to conduct a Medication Self-Administration assessment for Resident 211, who was self-administering medications obtained outside of the facility. This deficient practice had the potential to result in unsafe medication administration or omission (the act of not including something that should have been included).

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep the call light (device used to alert nurses and other facility staff to assist a resident in need) within reach of the resident for one of three sampled residents investigated during review of environment facility task (Resident 41). This deficient practice had the potential to result in the resident not being able to call the facility staff for assistance and delay in the provision of care and services.

Inspectors wroteBased on interview and record review, the facility failed to send a copy of the notification of discharge to the long-term care ombudsman (a resident advocate) for one of three sampled residents investigated during review of closed records (Resident 159) by failing to send a copy of Resident 159's Notice of Transfer/Discharge to the ombudsman on 12/29/2023. This deficient practice had the potential for Resident 159 to have an unsafe discharge.

Inspectors wroteBased on observation, interview, and record review the facility failed to review and revise the resident's care plan regarding resident's refusal to keep the pulse oximeter (provide long-term monitoring of blood oxygen levels) on for one of three sampled residents (Resident 361) reviewed under ventilator (vent, breathing machine)/tracheostomy (trach, a surgical opening through the neck into the windpipe to allow air to fill the lungs) investigative care area. The deficient practice had the potential to result in the resident not receiving the necessary respiratory care and services that is in accordance with professional standards of practice and the resident's choice.

Inspectors wroteBased on interview and record review the facility failed to ensure residents received treatment and care in accordance with professional standards of practice to meet the resident's physical, mental, and psychosocial needs for one of two sampled residents (Resident 132) investigated during review of skin conditions (non-pressure [disease of the skin and/or subcutaneous tissue (fatty tissue)]), by failing to arrange transportation for Resident 132's orthopedic appointment on 2/21/2024, resulting in a missed appointment. This deficient practice placed the resident at risk for not receiving the necessary treatment and services related to the resident's diagnoses of gangrene to left toes.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents with pressure ulcers (or pressure injury, localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) receive necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and precent new ulcers from developing for two of five sampled residents investigated under pressure ulcers (Resident 9 and 97) by: 1. Failing to keep Resident 9's low air loss mattress (LALM - a specialized mattress designed to prevent and treat pressure ulcers) on the correct settings according to the resident's plan of care. 2. Failing to set Resident 97's LALM according to the resident's weight. These deficient practices had the potential for skin breakdown or worsening of pressure ulcers. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide residents with necessary respiratory care and services that is in accordance with professional standards of practice to two out of three sampled residents (Residents 361 and 20) reviewed under the ventilator (vent, breathing machine)/tracheostomy (trach, a surgical opening through the neck into the windpipe to allow air to fill the lungs) investigative care area by failing to: 1. Ensure Resident 361, who is receiving humidified oxygen via a t-piece (an instrument used in weaning of a patient from a ventilator) was using pulse oximeter (provide long-term monitoring of a person's blood oxygen levels) as ordered by the physician's order. [...]

Inspectors wroteBased on interview and record review the facility failed to maintain medical records in accordance with accepted professional standards, by failing to: 1. To document the name of the person who pronounced the resident's death at the facility for one of three sampled residents (Resident 158) investigated during review of closed records. This deficient practice had the potential to result in inaccurate documentation in the medical records regarding the resident's death. 2. Complete Resident 44's change in condition assessment timely when the resident tested positive for coronavirus disease-2019 (COVID-19 - a highly contagious respiratory illness capable of producing severe symptoms) during COVID-19 testing (a way of to check if the person have the virus causing the COVID-19 illness) for one of six sampled residents investigated during review of infection control facility task. [...]

Inspectors wroteBased on interview and record review, the facility failed to transmit encoded, accurate and complete Minimum Data Set (MDS, a standardized assessment and care screening tool) timely for one of two sampled residents (Resident 126) investigated during review of Resident Assessment facility task. The deficient practice had the potential to result in care that does not address the resident's specific care needs.

Inspectors wroteBased on interview and record review, the facility failed to conduct an accurate Minimum Data Set (MDS - a standardized assessment and care screening tool) Assessments, by failing to: 1. Code Resident 130's MDS Quarterly Assessment (a comprehensive assessment and requires care plan review) with the accurate number of days the resident received insulin injections during the observation period for one of two sampled residents investigated during Resident Assessment facility task. This deficient practice had the potential to negatively affect Resident 130's plan of care and delivery of necessary care and services. 2. Code Resident 159's MDS assessment as discharged to home but was coded discharged to general acute care hospital (GACH) for one of three sampled residents during review of closed records. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that one of three sampled residents (Resident 1) who required hemodialysis (process of purifying the blood of a person whose kidneys are not working normally) received treatment and services in accordance with standards of practice by failing to notify the physician timely when Resident 1's hemodialysis catheter (a flexible tube used for dialysis treatment) was dislodge (forced out). Resident 1 was sent to the dialysis center without a hemodialysis access resulting to Resident 1 not receiving a hemodialysis treatment during Resident 1's scheduled hemodialysis session. This deficient practice had the potential to place Resident 1 at risk for fluid overload and other complications of having a delay in receiving a hemodialysis treatment.

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biological) for one of three sampled residents (Resident 1) by: 1. Failing to ensure Licensed Vocational Nurse 1 (LVN 1) and LVN 2 held the medication midodrine (medication used to treat orthostatic hypotension [sudden fall in blood pressure that occurs when a person assumes a standing position]) per physician ' s order on 1/1/2024 and 1/16/2024. 2. Failing to ensure LVN 3 administer the medication midodrine per physician ' s order on 1/15/2024. These deficient practices had the potential to increase and or decrease Resident 1 ' s blood pressure.

Inspectors wroteBased on interview and record review, the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one of three sampled residents (Resident 1) when Resident 1 ' s dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) catheter (a flexible tube used for dialysis treatment) was dislodged (forced out). This deficient practice had the potential to result in confusion in the care and services rendered to Resident 1 and resulted to inaccurate information entered into Resident 1 ' s medical record.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control measures for one of five sampled staff members (Rehabilitation Assistant 1 [RA 1]) while the facility had an on-going Coronavirus Disease 2019 (COVID-19, highly contagious respiratory disease is thought to spread from person to person through droplets released when an infected person coughs, sneezes or talks) and influenza (a contagious respiratory illness caused by influenza viruses that infect the nose, throat, and sometimes the lungs) outbreaks (a sudden rise in the incidence of a disease) by failing to ensure RA 1 was wearing an N95 (a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) mask with strap that were intact behind the neck, while inside the facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the requested medical records to the responsible party of one of three sampled residents (Resident 1). The facility received the request to release Resident 1 ' s medical records on 12/5/2023. The facility provided the requested medical records on 12/20/2023, eight days after the date that the requested medical records were supposed to be released. This deficient practice violated the resident ' s rights to secure personal medical records.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 2) was free from sexual abuse (non-consensual [not agreed by the people involved] sexual contact of any type with a resident) on 12/4/2023 at 8:10 a.m. when Resident 1 sat on Resident 2 ' s bed and touched Resident 2 ' s genitals (the sexual organs; the testicles and penis of a male) while Resident 2 laid in bed as observed by Certified Nursing Assistant 1 (CNA 1) and as communicated by Resident 2. This deficient practice resulted in Resident 2 experiencing non-consensual sexual contact from Resident 1 while under the care of the facility. Resident 2 conveyed he felt sexually assaulted, violated, and humiliated. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sampled residents (Resident 11), who was not prescribed (ordered) an intravenous (IV, given through the vein [blood vessels forming part of the blood circulation system]) medication, was on hospice care (focuses on comfort care when the person is approaching the end of life), and was not wearing an identification (ID) wristband (a band worn by residents that contains important resident data [such as name, date of birth , medical record number, and facility name], allowing residents to be identified). In addition, the facility failed to ensure Resident 11 was not administered in error the IV antibiotic (medicine that fight infections caused by bacteria delivered directly into the bloodstream) ceftriaxone sodium ordered to Resident 12 (Resident 11 ' s former roommate). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure immediate notification to the resident ' representative of a significant change of condition of one of four sampled residents (Resident 11). On 11/22/2023, Family Member 1 (FM 1) was not informed of a medication error that occurred when Registered Nurse (RN 3) administered Ceftriaxone (an antibiotic in the form of an injection that a healthcare provider gives you in a hospital or clinic) to Resident 11 intravenously (within a vein) that was intended for Resident 12 (Resident 1 ' s former roommate). This deficient practice resulted in a violation of FM 1 ' s right to be aware of all pertinent information related to the care of Resident 11.

Inspectors wroteBased on interview and record review, the facility failed to implement its policies and procedures (P&P) on Abuse Prohibition and Prevention Program and Sexual Abuse for one of three sampled residents (Resident 2). On 12/4/2023 at 8:10 a.m., when Resident 1 sat on Resident 2 ' s bed (roommate) and touched Resident 2 ' s genitals (the sexual organs; the testicles and penis of a male) while Resident 2 laid in bed as observed by Certified Nursing Assistant 1 (CNA 1) and as communicated by Resident 2. CNA 1 took Resident 1 to his bed and left the room to report the incident to Licensed Vocational Nurse (LVN 1). LVN 1 after checking on both Residents 1 and 2, left the room with Resident 1 unattended in the same room with Resident 2. This failure placed Resident 2 at risk for further sexual abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program regarding Coronavirus disease 2019 (COVID-19, a viral infection that is highly contagious and easily transmits from person to person, causing respiratory problems and may cause death) for four of eight sampled residents (Residents 2, 3, 6, and 7), by failing to: a. Ensure Certified Nursing Assistant 1 (CNA 1) perform hand hygiene before and after assisting Resident 2 in putting on a N95 mask (respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles). CNA 1 also failed to perform hand hygiene before entering Resident 3 ' s room to take the resident ' s food tray. CNA 1 also failed to perform hand hygiene after touching unclean surfaces. b. [...]

Inspectors wroteBased on interview and record review, the facility failed to monitor for adverse reactions associated with antibiotic (medication used to treat bacterial infections) use for one (Resident 1) of three sampled residents. This deficient practice had the potential for unmanaged side effects of antibiotic use which may lead to adverse reactions (also known as side effects - unwanted undesirable effects related to a drug) such as nausea, diarrhea, dizziness, and headache.