The Gardens Healthcare Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from physical restraints (refers to means of purposely limiting or obstructing the freedom of a person's bodily movement) to one of three sampled residents (Resident 30) investigated under the physical restraints care area by failing to: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a person-centered care plan for three of thirteen sampled residents (Resident 1, 2, and 26) investigated for care plans by failing to ensure:1. Resident 1's Continuous Glucose Monitoring (CGM - a wearable medical device that measures blood sugar levels in real-time via subcutaneous [beneath the skin] sensor) care plan was developed and implemented. This failure had the potential for inadequate care provided to Resident 1's wearable sensor and potential to cause infection.2. Resident 2 had a care plan on the use of the antibiotic (medication used to treat bacterial infections by killing bacteria or stopping them from growing) Amoxicillin-Pot Clavulanate (also known as Augmentin, a type of antibiotic) tablet 875-125 milligrams (mg - a unit of measure for weight). 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents with pressure ulcers/injury (a skin and tissue injury caused by prolonged pressure on the skin, often over bony areas) received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for three of three sampled residents (Residents 54, 4, and 53) reviewed under the pressure ulcer/injury care area by failing to ensure the facility set the residents' low air loss mattress (LALM - a medical bed that blows tiny amounts of air through microscopic holes to keep skin cool, dry, and free of bed sores) according to resident's weight. These failures had the potential for developing or worsening pressure injury on residents. Cross-reference F726.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents' bed rails (metal or plastic bars or guards attached to the sides of a bed to act as a barrier or support) prior to installation were assessed for its use for four of four sampled residents (Residents 54, 25, 26, and 42) reviewed for accidents by failing to ensure: 1. Resident 54's Bed Safety Assessment (BSA), dated 7/4/2026, was followed by not applying the bed rails on the resident as recommended. 2. Resident 25's BSA, date 7/2/2026, was completed. 3. Resident 26's BSA, dated 7/4/2026, was followed by not applying the bed rails on the resident as recommended. 4. Resident 42's BSA, dated 6/22/2026, was assessed for the right bed rails applied to the resident. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the facility had sufficient nursing staff with appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident by failing to ensure: 1. The facility provided documented evidence of the Director of Nursing's (DON's) annual skills competency checklist (yearly evaluation used to verify that employees maintain the specific technical, clinical, or professional proficiencies required for their roles). An unsigned document regarding the DON's annual skills checklist was provided to the State Survey Agency on 7/17/2026 at 5:37 p.m. after the State Survey Agency completed the facility's annual recertification survey and had exited the facility. 2. [...]

Inspectors wroteBased on 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) for two of five sampled resident (Residents 2 and 30) reviewed for unnecessary medications by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (sq, beneath the skin) insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) administration sites. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Follow the recipe for serving egg rolls by not serving the egg rolls at or above 140 degrees Fahrenheit (F, a unit of measure for temperature) for 21 out of 35 residents listed in the diet list. 2. Provide a therapeutic diet (a diet ordered by a physician or delegated registered or licensed dietitian as part of treatment for a disease or clinical condition, or to eliminate or decrease specific nutrients in the diet, or increase specific nutrients in the diet, or to provide food the resident is able to eat) menu and food for a liberal renal diet (a diet designed to reduce the buildup of waste products in blood to protect kidneys) during lunch for one of one sampled resident (Resident 14). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety, on 7/13/2026 during kitchen tour found/observed the following: SEASONINGS -1 container of Granulated Garlic with open date of 7/1/2021, no received date, and no use by date. -1 big container of garlic powder with received date of 4/6, with use by date of 10/17/26, with no open date. -1 container of steak seasoning with use by date of 10/17/2026, no open date, and received date. -1 container of parsley flakes, no received date, no open date, and no use by date. -1 container of ground cummin seed with use by date of 10/17/26, no open date, and no received date. -1 container Ginger ground with received date of 11/25, with use by date of 5/21/26, no open date. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement its antibiotic stewardship program (a coherent set of actions which promote using antimicrobials responsibly) that includes antibiotic (ATB, a medicine that fights bacterial infections by killing bacteria or stopping them from multiplying) use protocols and a system to monitor antibiotic use for two of three sampled residents (Residents 2 and 26) reviewed for antibiotic use by failing to ensure: 1. Resident 2's Amoxicillin-Pot Clavulanate Tablet 875-125 milligrams (mg, a unit of weight) had monitoring for its adverse effects (an unwanted, harmful, or unpleasant physical or mental reaction caused by a medical treatment, such as a medication or surgery). 2. Resident 26's Cephalexin Oral Capsule 500 mg (Cephalexin) had monitoring for its adverse effects. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care in a manner that maintained or enhanced a resident's dignity and respect in full recognition of their individuality for one of five sampled residents (Resident 4) during dining observation task by failing to ensure Certified Nursing Assistant (CNA) 3 was not standing over Resident 4 while assisting them during a meal. This deficient practice had violated the residents' right to be treated with dignity and respect.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the call light (a device used by residents to alert the staff of resident's needs) was within reach for one of four sampled residents (Resident 1) when Resident 1's call light was wrapped around the tube feeding pump pole (medical device used to deliver liquid formula to the resident's stomach via tube), outside of Resident 1's reach. This failure had the potential for Resident 1 to be unable to call for help when needed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to uphold the resident's right to secure and confidential personal and medical records when: 1. Registered Nurse (RN) 1 left Resident 36's electronic health record opened, unattended, and out of RN 1's view. 2. During the kitchen facility task, Dietary Aide (DA) 3 threw meal tickets (a written or digital label containing resident information used by the food and care staff to ensure each resident receives the correct meal) in a regular trash bin during dish washing. These deficient practices had the potential to expose personal and medical information to individuals not involved in the resident's care.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident's drug regimen was free from unnecessary drugs for five of nine sampled residents (Residents 54, 2, 25, 26, and 42) reviewed for unnecessary medications by failing to ensure the facility indicated in the informed consent (a voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) had the reason for the use of psychotropic medications (any prescription drug that changes how a person feels, thinks, behaves, or perceives the world) and benefits. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide written information to the resident or representative the seven (7)-day bed hold notification (notification is a written paper given by a nursing home (SNF) when a resident goes to the hospital) for one of three closed record samples (Resident 48). This failure had the potential for the resident/representative of their right to hold their beds in the facility for a period of time.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment was free of accident hazards for one of four sampled residents (Residents 26) reviewed for accidents by failing to ensure Resident 26's floor mat (a cushioned floor pad designed to help prevent injury should a person fall) did not have equipment or furniture on top of them. This failure increase the risk of accidents such as falls with injuries on residents. Cross-reference F726.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure parenteral fluids (liquids, such as medication or nutrition, that are administered to the body by bypassing the digestive system) were administered consistent with professional standards of practice to one of one sampled resident (Resident 54) reviewed for hydration by failing to ensure Resident 54's midline catheter (a long, soft plastic intravenous [IV - within a vein) tube put into a large vein in the upper arm) was changed per facility policy and procedure (P&P). The midline catheter dressing was observed loose and dated 7/3/2026 observed on 7/13/2026. This failure had the potential for complications associated with intravenous therapy (a medical technique that delivers fluids, medication, or nutrients directly into a person's bloodstream through a vein) and catheter-related infections.

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident's drug regimen must be free from unnecessary drugs for one of one sampled resident (Resident 25), reviewed for anticoagulant (blood thinner) use by failing to monitor for adverse effects of the resident's use of Apixaban (also known as Eliquis, a type of anticoagulant, or blood thinner). This failure placed the resident at risk for bleeding and other adverse effects (harmful, unwanted, and unpleasant results that happen from a medical treatment, drug, or surgery) of the medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare foods in a form designed to meet individual needs for one of one sampled resident (Resident 4) when Resident 4 on soft and bite-sized diet (foods that are soft, tender, moist, but with no thin liquid leaking/dripping from the food) received hard carrots on the plate for lunch service and did not pass the International Dysphagia Diet Initiative ([IDDSI] a framework for categorizing food textures and drink thickness) level six (6) fork pressure test (a test used to check food softness for residents with swallowing difficulties). This failure had the potential to result in difficulty chewing, swallowing, decreased in food and nutrient intake to residents on soft and bite-sized diet.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medical records on a resident were complete and accurately documented for one of five sampled residents (Resident 18) reviewed under medication administration task and in one of two medication carts (Medication Cart 1) by failing to: 1. Accurately document when Flonase (an allergy symptom reliever) nasal spray medication was documented as given when it was not available for Resident 18. This failure had the potential for Resident 18 to not receive the medication as ordered and may compromise his health and safety. 2. Ensure controlled count was completed on multiple shifts and days on Medication Cart 1. There were missing signatures on the audit form: a. 6/27/2026 3 p.m. by the Oncoming Charge Nurse b. 7/7/2026 3 p.m. by the Outgoing Charge Nurse c. 7/8/2026 11 p.m. by the Oncoming Charge Nurse d. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement its policy and procedure on Coronavirus Disease 2019 (COVID-19 -a highly contagious disease spread from person to person through droplets released when an infected person coughs, sneezes, or talks) vaccination (the act of introducing a vaccine [a substance that stimulates the body's immune system to fight disease]) by failing to maintain documentation related to COVID-19 vaccination including offering or providing information on obtaining COVID-19 vaccine and verification of vaccination or documentation of exemption or refusal for Certified Nursing Assistant (CNA) 10. This failure had the potential to result to spread infections such as COVID-19, COVID-19 outbreaks, and risk of severe illness and/or complications especially residents with underlying health among 41 residents that are residing at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the low air loss mattress (LALM, specialty air filled mattress for residents to prevent bed sores) fit the bedframe size and did not have any gaps between the grab bar and the LALM for one in one resident (Resident 53). This failure had potential for Resident 53 to be caught, trapped, or entangled in the gaps and to sustain injuries.

Inspectors wroteBased on interview and record review, the facility failed to respect the rights of five of eight sampled residents (Residents 1, 2, 3, 4, and 5) by:1. Failing to ensure Resident 1 and Resident 2's rights to choose their own attending physician (AP) were followed.2. Failing to ensure Residents 3, 4, and 5 were given an option to choose their own AP while at the facility. These failures violated the rights of Residents 1, 2, 3, 4, and 5 in choosing their own AP while at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free of any significant medication errors when Resident 1's medications were left above a meal tray cart parked in the hallway and documented as administered in the Medication Administration Record (MAR - a report detailing the medication administered to a resident by a healthcare professional). This deficient practice had the potential for Resident 1's condition to worsen.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure one of one sampled resident (Resident 29) with an indwelling catheter (a hollow tube inserted into the bladder to drain or collect urine) received proper care and services by failing to provide indwelling catheter care to the resident as ordered by the physician. This deficient practice had the potential to result in Resident 29 receiving inadequate care and supervision at the facility. 2. Provide a bowel/bladder retraining program (a set of strategies and interventions aimed at helping individuals regain or maintain control over their bowel and bladder functions) for two of two sampled residents (Resident 7 and 21) reviewed under the care area bladder and bowel incontinence (inability to control the flow of urine from the bladder or the escape of stool from the rectum). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that staffing information was posted and placed in a visible and prominent place daily. As a result, the total number of staff and the actual hours worked by the staff were not readily accessible to residents and visitors.

Inspectors wroteBased on interview and record review, the facility failed to ensure the pre and post dialysis (the removing of waste and excess fluid to prevent build up in the body for residents who have loss of kidney [organs that remove waste products from the blood and produce urine] function) assessments were completed accurately for two of two sampled residents (Resident 6 and 24). This deficient practice placed the residents 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 6 and Resident 24.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's urinary catheter bag (device used to collect urine drained from the bladder via a urinary catheter [a hollow tube inserted into the bladder to drain or collect urine]) was covered with a privacy bag (also known as a dignity bag - device used to cover the contents of a urinary catheter bag) for one of three sampled residents (Resident 29) reviewed under the dignity care area. This deficient practice had the potential to negatively affect the resident`s psychosocial wellbeing and dignity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the call light (an alerting device for nurses to assist a patient when in need) was within a resident`s reach while in bed for one of one sampled resident (Resident 18) reviewed under the environment task. This deficient practice had the potential to result in a delay in care, and Resident 18`s inability to ask for assistance.

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents' clinical records were updated about advance directives (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) for one out of the three sampled residents (Resident 147) by failing to maintain a current copy of the resident's advance directives in the resident's active clinical record. This deficient practice had the potential to cause conflict with Resident 147's wishes regarding health care.

Inspectors wroteBased on interview and record review, the facility failed to develop a complete baseline care plan within 48 hours of a resident`s admission to the facility by failing to address a resident`s indwelling catheter (a hollow tube inserted into the bladder to drain or collect urine) for one of one sampled resident (Resident 9) reviewed under the catheter care area. This deficient practice had the potential for Resident 9 to not receive the appropriate care and treatment in the facility.

Inspectors wroteBased on interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a plan of care that summarizes a resident's health conditions, specific care and services facility staff need to provide a resident to promote healing and prevent a worsening of a condition, and current treatments) to meet the resident`s needs for one of one sampled resident (Resident 30) by failing to develop and implement a comprehensive person-centered care plan addressing Resident 30`s use of a continuous glucose monitoring system (CGM-a system that provides glucose readings every minute, allowing users to see their glucose levels in real-time, anytime, and anywhere. It uses a sensor that's worn on the back of the arm for up to 14 days and wirelessly sends glucose data to a smartphone application or reader). [...]

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 one sampled resident (Resident 30) by failing to: 1. Monitor Resident 30`s continuous glucose monitoring system (CGM-a system that provides glucose readings every minute, allowing users to see their glucose levels in real-time, anytime, and anywhere. It uses a sensor that's worn on the back of the arm for up to 14 days and wirelessly sends glucose data to a smartphone app or reader) and ensure that the sensor patches are available in the facility for application. 2. Complete Resident 30`s Admission/readmission Screen and Baseline Care Plan form accurately upon his admission to the facility. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an environment free from accidents and hazards and implement interventions to prevent accidents when Licensed Vocational Nurse 1 (LVN 1) left a bottle of Vitamin C unattended and easily accessible to other residents on top of the medication cart while LVN 1 was inside Resident 30`s room to administer Resident 30's medications. This deficient practice placed other residents at risk to gain access to Vitamin C without staff knowledge resulting in the accidental ingestion possibly causing harm to the residents.

Inspectors wroteBased on interview and record review, the facility failed to follow a physician's order by failing to conduct a weekly weight for one of one sampled resident (Resident 24). This deficient practice had the potential for a delay in care and services and undetected weight loss.

Inspectors wroteBased on interview and record review the facility failed to provide care and services that meet professional standards of quality by failing to assess the continued need for a peripheral intravenous (IV-into or within the vein, a small tub is inserted) catheter (a thin, flexible tube that is inserted into a vein to draw blood and give treatments including IV fluids, drugs, or blood transfusions) if not being used for IV fluids or medications for one of one sampled resident (Resident 198). This deficient practice had the potential for Resident 198 to develop an infection from a prolonged IV that she did not need.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents receive necessary respiratory care and services that is in accordance with professional standards of practice for one of two sampled residents (Resident 4) investigated under the respiratory care area when Resident 4's nasal cannula (a medical device that delivers supplemental oxygen therapy to people with low oxygen levels) oxygen tubing was touching the floor and the tubing cannula (a small flexible tube with two prongs that fit inside the nostrils, used to deliver extra oxygen) was not attached to the resident. This deficient practice had the potential to result in contamination of the resident's care equipment and risk of transmission of bacteria that can lead to infection.

Inspectors wroteBased on observation interview, and record review the facility failed to: 1. Ensure the disposal of medications in a manner that was not retrievable, in one of one inspected Medication Rooms (Medication Room Station 1.) 2. Include three disposed medications with verifying signatures of two licensed nurses on the Medication Disposition Record/Pass Log. As a result, control and accountability of discontinued medications and medications awaiting final disposition (process of returning and/or destroying unused medications) did not follow federal regulations and facility policy and procedures. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper sanitation and food handling practices to prevent the outbreak of foodborne illnesses (also called food poisoning, illness caused by eating contaminated food) when one of five sampled residents (Resident 147) had leftover food that was not removed from the resident's bedside after four hours. These deficient practices had the potential for Resident 147 to ingest (consume) contaminated leftover food and lead to foodborne illness.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Responsible Party (RP) or the Resident Representative (RR) of one of three sampled residents (Resident 1), who had a history of dementia (a progressive state of decline in mental abilities), with moderately impaired cognition for daily decision making, and had no capacity to make medical decisions, signed Resident 1's consent forms for the administration of the following: 1. Citalopram (medication used to treat depression [a common mental health condition characterized by persistent feelings of sadness, loss of interest, and changes in behavior and cognitive function]), 2. Influenza vaccine (also known as the flu shot, protects against the flu [respiratory illness that infect the nose, throat, and sometimes the lungs]), 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) who had a history of dementia (a progressive state of decline in mental abilities), assessed as high risk for fall, had a wandering (moving around without any clear purpose or direction) behavior and had a history of fall, was provided supervision and kept free from accidents by failing to reassess Resident 1 for Elopement Screening (a safety assessment that evaluates a resident's risk of leaving a safe environment without permission) after Resident 1 had triggered (activated) the exit door alarm twice on 12/31/2024 and had a wandering behavior on 1/1/2025. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medical records were complete and accurately documented for one of five sampled residents (Resident 2) by failing to: a. Ensure Resident 2 ' s physician ' s order for surgical wound treatment was documented in the resident ' s clinical record before the surgical wound treatment was performed. b. Ensure Resident 2 ' s physician ' s order to change the resident ' s indwelling urinary catheter (a flexible plastic tube inserted into the bladder [a hallow organ that stores urine] to provide continuous urinary drainage) drainage bag was documented in the resident ' s clinical record before the drainage bag was changed. c. Ensure surgical wound treatments and urinary catheter drainage bag changes provided to Resident 2 were documented in the resident ' s Treatment Administration Record (TAR). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement comprehensive, person-centered care plan (contains relevant information about a resident ' s health conditions, goals of treatment, specific actions that must be performed, and a plan for evaluation) with measurable objectives and interventions for two of five sampled residents (Resident 1 and Resident 2) by failing to: a. Indicate the frequency of Resident 1 ' s neuro-checks after the resident ' s unwitnessed fall. b. Address Resident 2 ' s urinary catheter (a flexible plastic tube inserted into the bladder that helps provide continuous urinary drainage) care. These deficient practices placed Resident 1 and Resident 2 at risk for not receiving the necessary services and assistance that can result in infection and injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident with indwelling urinary catheter (a flexible plastic tube inserted into the bladder that helps provide continuous urinary drainage) received proper care and services that included to anchor (secure) the urinary catheter tubing to the resident ' s thigh for one of five sampled residents (Resident 2). This deficient practice had the potential to result in urinary catheter dislodgement (forcefully pulled out of a secure position) causing urethral (the tube through which urine leaves the body) tearing that may result in pain, bleeding, and infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow infection control procedures for one of five sampled residents (Resident 2) by failing to ensure Registered Nurse 1 (RN 1) changed gloves after touching unclean surfaces while performing wound treatments and changing an indwelling urinary catheter (a flexible plastic tube inserted into the bladder that helps provide continuous urinary drainage) drainage bag. Resident 2 was on enhanced barrier precaution (EBP - an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities). This deficient practice placed Resident 2 at risk for exposure and contracting infections.

Inspectors wrote3. A review of Resident 5's admission Record indicated the facility admitted Resident 5 on 1/25/2021 with diagnoses including, but not limited to, type two diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), and transient cerebral ischemic attack (a brief episode of neurological [relating to the brain] dysfunction resulting from an interruption in the blood supply to the brain or the eye). A review of Resident 5's MDS, dated [DATE], indicated Resident 5 had moderate cognitive impairment (difficulty understanding and making decisions), required supervision with eating, and required maximal assistance or was dependent on facility staff for other activities of daily living, including hygiene, toileting, and surface to surface transfers. [...]

Inspectors wroteb. A review of Resident 11's admission Record indicated the facility admitted the resident on 4/5/2024, with diagnoses including atrial fibrillation (an irregular and often very rapid heart rhythm), heart failure (occurs when the heart muscle does not pump blood as well as it should), and gastritis (inflammation of the lining of the stomach). A review of Resident 11's History and Physical (H&P), dated 4/8/2024, indicated the resident was receiving heparin every 8 hours for deep vein thrombosis (DVT, a blood clot that develops within a deep vein in the body, usually in the leg) prophylaxis (PPX, preventive). The H&P also indicated the resident had the capacity to make needs known but unable to make medical decisions. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide routine drugs to its residents and establish a system of records of receipt and disposition of all controlled drugs (substances that have an accepted medical use, have a potential for abuse, and may also lead to physical or psychological dependence) in sufficient detail to enable an accurate reconciliation when: 1. The facility failed to ensure licensed nursing staff completed documentation indicating reconciliation (a system of recordkeeping that ensures an accurate inventory of medications that have been received, dispensed, and administered) of controlled medications at every change of shift on the Controlled Substance / MAR (Medication Administration Record) Change of Shift Audit form for one of one medication carts (Medication Cart 2) reviewed during the Medication Storage task. 2. [...]

Inspectors wroteb. A review of Resident 11's admission Record indicated the facility admitted the resident on 4/5/2024, with diagnoses including atrial fibrillation (an irregular and often very rapid heart rhythm), heart failure (occurs when the heart muscle does not pump blood as well as it should), and gastritis (inflammation of the lining of the stomach). A review of Resident 11's History and Physical (H&P), dated 4/8/2024, indicated the resident received heparin every 8 hours for deep vein thrombosis (DVT, a blood clot that develops within a deep vein in the body, usually in the leg) prophylaxis (PPX, preventive). The H&P indicated the resident had the capacity to make needs known but unable to make medical decisions. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure each resident's medication regimen was managed and monitored to promote the resident's highest practicable mental, physical, and psychosocial well-being to four out of four sampled residents (Resident 39, 29, 23, and 148)) selected for unnecessary medications review by failing to: 1.a. Ensure the order for (PRN) lorazepam (a psychotropic medication that affects the mind, emotions, and behavior) was limited to a 14-day duration unless longer timeframe was deemed appropriate by the attending physician for Resident 39. 1.b. Identify and define specific measurable target behaviors (behavior that is targeted for change) related to the use of lorazepam for Resident 39. 2. [...]

Inspectors wroteb. A review of Resident 5's admission Record indicated the facility admitted Resident 5 on 1/25/2021 with diagnoses including, but not limited to, type two diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), and transient cerebral ischemic attack (a brief episode of neurological [relating to the brain] dysfunction resulting from an interruption in the blood supply to the brain or the eye). A review of Resident 5's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 3/13/2024, indicated Resident 5 had moderate cognitive impairment (difficulty understanding and making decisions), required supervision with eating, and required maximal assistance or was dependent on facility staff for other activities of daily living, including hygiene, toileting, and surface to surface transfers. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: 1. The staff followed the dress code in the kitchen 2. Food was labeled with a date, stored correctly, and disposed of when contaminated. 3. Kitchen equipment and utensils were kept clean. These failures had the potential to result in harmful bacteria growth and cross contamination (a transfer of harmful bacteria from one place to another or one object to another) that could lead to foodborne illness (an illness caused by food contaminated with bacteria, viruses, and other toxins) in 42 of 44 medically compromised and vulnerable residents who received food from the kitchen.

Inspectors wrote5.a. A review of Resident 13's admission Record indicated the facility admitted the resident on 8/29/2023, and was readmitted on [DATE], with the diagnoses that included, but not limited to chronic obstructive pulmonary disease (COPD - long term lung disease making it hard to breathe), emphysema (a type of COPD that affects the air sac of the lungs), and dependence on supplemental oxygen (a machine that provides oxygen). A review of Resident 13's History and Physical (H&P), dated 5/20/2024, it indicated the resident was readmitted to facility on 5/17/2024 from a general acute care hospital (GACH) for sepsis (a serious condition when the body overreacts to an infection) caused by pneumonia (PNA - an infection that affects one or both lungs). The H&P indicated the resident has the capacity to understand and make decisions. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care in a manner that maintained or enhanced a resident's dignity and respect in full recognition of their individuality for one of two sampled residents (Resident 249) when Resident 249's urinary catheter bag (device used to collect urine drained from the bladder via a urinary catheter [a tube inserted into the bladder through the urethra (duct that lets urine leave the bladder and body) to allow urine to drain]) was not covered with a privacy bag (also known as a dignity bag - device used to cover the contents or a urinary catheter bag). This deficient practice had the potential to negatively affect the resident's psychosocial wellbeing and loss of dignity.

Inspectors wroteBased on interview and record review, the facility failed to offer the resident or their resident representative assistance with formulating an Advance Directive (AD - a legal document telling the doctor one's wishes about their healthcare in the event they cannot make the decision for themselves) upon admission to one out of two sampled residents (Resident 34) investigated during review of advance directive care area. This deficient practice violated the resident and/or their representative the right to be fully informed of the option to formulate an AD and had the potential to delay emergency treatment or the potential to force emergency, life-sustaining procedures against the resident's personal preferences.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents receive care to prevent pressure ulcers (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) for one of one sampled residents investigated under the pressure ulcer care area (Resident 5) when Resident 5's low air loss mattress (LALM - a pressure reducing device) was not set according to the manufacturer's guidelines. This deficient practice had the potential for the resident to develop pressure ulcers.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents received adequate supervision to prevent accidents by failing to ensure medications were not left unattended and readily available for one of four sampled residents (Resident 196) reviewed under the Accidents care area. This deficient practice had the potential to result in residents obtaining medication without staff knowledge resulting in accidental ingestion causing harm to residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents who were incontinent (lacks voluntary control over urination) of bladder (organ in the pelvis that stores urine) received appropriate treatment and services to prevent urinary tract infections (UTI, common infections that happen when bacteria infect the urinary tract) for two out of three sampled residents (Resident 249 and 40) reviewed under the urinary catheter (a tube that is inserted into the bladder, allowing urine to drain) care area by: 1. Failing to keep Resident 249's urinary catheter tubing from coiling and allowing the contents to flow freely into the indwelling urinary catheter bag (container that connects to a urinary catheter and collects urine). 2. Failing to keep Resident 249 and Resident 40's indwelling urinary catheter bag from touching the floor. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to label the intravenous (IV - a tube inserted into the vein that delivers medication) medication bag and tubing for one of one sampled resident (Resident 36). This deficient practice had the potential to increase Resident 36's risk for complications from IV medication administration such as bacteria growth in the tubing, wrong rate (how fast to give), wrong amount and wrong time.

Inspectors wroteBased on observation, interview, and record review the facility failed to assess the risk of entrapment (an event in which a resident is caught, trapped, or entangled in spaces in or about the bed rail) from side rails (adjustable metal or rigid plastic bars that attach to the bed) and obtain informed consent from the resident or the resident representative prior to installation to two of two sampled residents (Residents 11 and 20) investigated during review of accidents care area. These deficient practices had the potential to result in the restriction of residents' freedom of movement, a decline in physical functioning, psychosocial harm, physical harm from entrapment, and death of residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs for one of five sampled facility staff members reviewed under the sufficient and competent staffing care area (Licensed Vocational Nurse [LVN] 2) when LVN 2 did not flush Resident 249's gastrostomy tube (GT - a tube inserted through the wall of the abdomen directly into the stomach used to provide nutrition, hydration, and or medications) via gravity (method of sending fluids through the GT in a downward direction using the force of gravity) and verbalized using a slow push method (using a syringe and pushing the plunger slowly to administer medications or fluids) when administering medications via the GT instead of administering via gravity. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate of less than five percent (%). There were two medication errors out of 25 opportunities resulting in an overall medication error rate of 8% affecting one out of seven sampled residents observed for medication administration (Resident 249) when Resident 249 did not receive cholecalciferol (a medication used to supplement Vitamin D [a nutrient the body needs for building and maintaining healthy bones]) and fluticasone (medication used to relieve seasonal and year-round allergic and non-allergic nasal symptoms) as ordered by the resident's physician. This deficient practice had the potential for the resident's health and well-being to be negatively impacted.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe provision of pharmaceutical services during the inspection of one of one medication carts (Medication Cart 2) reviewed during the Medication Storage and Labeling task by failing to ensure five unpackaged and unlabeled albuterol (a medication that relaxes muscles in the airways and increases air flow to the lungs) nebules (a plastic container that holds liquid medication) were not stored and readily available for use in Medication Cart 2. This deficient practice had the potential to result in medication being administered to the wrong resident or loss of resident medication.

Inspectors wroteBased on interview and record review, the facility failed to maintain clinical records that are complete and accurate for one of seven sampled residents investigated during medication administration (Resident 249) by documenting the administration of cholecalciferol (a medication used to supplement Vitamin D [a nutrient the body needs for building and maintaining healthy bones]) when it was not administered. This deficient practice resulted in inaccurate documentation in Resident 249's medical record.

Inspectors wroteBased on interview and record review, the facility failed to ensure the arbitration (a private process where disputing parties agree that one or several other individuals can make a decision about the dispute after receiving evidence and hearing arguments) agreement (a written contract in which two or more parties agree to settle a dispute out of court) was explained to residents in a form and manner that the resident understands, and the the resident and/or representative acknowledged that they understand the agreement to two of three sampled residents reviewed under the Arbitration care area (Resident 4 and 246) when: a. Resident 246's representative Family Member 1 (FM1), signed the facility's arbitration agreement without knowing the agreement can be rescinded by written notice within 30 days. b. [...]

Inspectors wroteBased on interview and record review, the facility failed to screen eight of ten sampled visitors and three of ten sampled staff (Certified Nursing Assistant 4 [CNA 4], Licensed Vocational Nurse 4 [LVN 4] and Certified Occupational Therapy Assistant 1 [COTA 1]) for Coronavirus Disease 2019 (COVID-19, highly contagious viral respiratory infection that spreads from person to person through droplets released when an infected person coughs, sneezes or talks) from 4/23/2024 to 4/26/2024 while facility is on COVID-19 outbreak. This deficient practice had the potential to result in the spread of the COVID-19 to all residents and staff.

Inspectors wroteBased on interview and record review, the facility failed to provide reasonable accommodations for resident needs and preferences for one of three sampled residents (Resident 4) when Family Member 1 (FM 1) requested for room change. This deficient practice had the potential to negatively impact the psychosocial well-being of the resident.

Inspectors wroteBased on interview and record review, the facility failed to ensure the narcotic and hypnotic record (accountability record of controlled medications that are considered to have strong potential for abuse) was accurately documented for three out of eight sampled residents (Resident 5, Resident 6, and Resident 7). [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the physician of a significant change in the resident's physical health for one of six sampled residents (Resident 2) when Resident 2 had a cognition (a term for the mental processes that take place in the brain, including thinking, attention, language, learning, memory and perception) decline noted by the Director of Rehabilitation (DOR). On 1/25/2024 the DOR informed the Responsible Party (RP) of Resident 2's cognition decline requiring laboratory (lab) procedures in order to be discharged . On 1/30/2024, Resident 2 was discharged with no labs being done and no documentation of a change of condition (COC) for Resident 2' cognition decline. This deficient practice resulted in a delay in care.

Inspectors wroteBased on interview and record review, the facility failed to provide laboratory (lab) services for one of six sampled residents (Resident 2) on 1/25/2024. The Director of Rehab (DOR) informed Resident 2's Responsible Party (RP) that Resident 2 had a cognitive (referring to mental processes that take place in the brain, including thinking, attention, language, learning, memory and perception) decline requiring labs in order to be discharged . On 1/30/2024 Resident 2 was discharged with no labs being done and RP not being notified of labs not being done. This deficient practice had the potential for Resident 2 to receive a delay in care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1), who were wearing a wander guard bracelet (monitoring device that triggers an alarm when the resident gets close to or goes through a door equipped with the alarm; this device is applied to residents at risk for elopement [a patient who leaves the hospital when doing so may present an imminent threat to the patient's health or safety because of legal status or because the patient has been deemed too ill or impaired to make a reasoned decision to leave]), out of a total six sampled resident, did not leave the facility unnoticed by staff. On 1/13/2024 around 3:15 p.m., Resident 1 was noticed missing from the facility. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure confidential personal information for one of six sampled residents (Resident 6) was protected. The clinical records of Resident 6 were left unattended on the receptionist's computer. This deficient practice had the potential to violate Resident 6's rights for privacy and confidentiality of personal and medical records.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive, person-centered care plan with measurable objectives and interventions for one of six sampled residents (Resident 1). The facility failed to develop and implement individualized care plan interventions addressing Resident 1 ' s wandering and elopement (a person who may present an imminent threat to the person ' s health and safety because the person was deemed too ill or impaired to make a reasoned decision to leave) behavior. As a result, Resident 1 eloped on 1/13/2024. Resident 1 fell at the nearby bus stop and sustained a right rib fracture (broken bone).

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 one of eight facility staff members (Licensed Vocational Nurse 1 [LVN 1]), by failing to ensure LVN 1 wore the N95 mask (respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) properly. This deficient practice placed other residents and staff at risk for exposure and contracting COVID-19.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive person-centered care plan for one of three sampled residents (Resident 1) when the facility failed to create a care plan related to Resident 1 ' s contact isolation due to clostridium difficile (c-diff - bacteria that causes diarrhea and colitis [an inflammation of the colon]) infection. This deficient practice had the potential to negatively affect the delivery of necessary care and services and potentially spread of infection to other residents and staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) who was receiving enteral nutrition (also known as tube feeding-a way of delivering nutrition directly to the stomach or small intestine) formula had labels indicating the date and time it was started. This deficient practice had the potential to result in increased risk for gastrointestinal (stomach) problems.

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) who was receiving enteral nutrition (also known as tube feeding-a way of delivering nutrition directly to the stomach or small intestine) and was on antibiotic (medication used to treat infection). This deficient practice had the potential to result in confusion of care and services rendered to Resident 1 and resulted to inaccurate information entered to resident ' s medical record.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control practices for one of five sampled residents (Resident 1) by: 1. Failing to ensure Certified Nursing Assistant 1 (CNA 1) wore eye protection (face shield or goggles) and tie the back of her isolation gown (provides a barrier to prevent clothes and skin underneath from becoming exposed to body fluid splash) while assisting Resident 1 who tested positive for 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) in the bathroom. 2. Failing to ensure the Director of Nursing (DON) wore a mask inside the facility during a COVID-19 outbreak. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the physician of a significant change in the resident ' s physical health for one out of four sampled residents (Resident 1) when: 1. Resident 1 was noted with diarrhea from 10/13/2023 to 10/16/2023. This deficient practice delayed testing for Clostridium difficile (C-diff: a bacterium that can infect the bowel and cause diarrhea). 2. Resident 1 was noted with a blood pressure (the force of your blood pushing against the walls of your arteries [blood vessels that distribute oxygen-rich blood to your entire body]) and heart rate [the number of times your heart beats per minute]) of 93/61. This deficient practice had the potential for a delay in care.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four resident (Resident 1) received treatment and care in accordance with professional standards of practice to meet the resident's physical, mental, and psychosocial needs by failing to document the blood pressure for metoprolol tartrate (a medication that lowers your blood pressure (the force of your blood pushing against the walls of your arteries [blood vessels that distribute oxygen-rich blood to your entire body]) and heart rate [the number of times your heart beats per minute]) in the Medication Administration Record (MAR- is a report detailing the drugs administered to a patient by a healthcare professional at a treatment facility), from 9/22/2023 to 10/27/2023. This deficient practice placed the resident at risk for hypotension that can negatively affect the resident's health status.

Inspectors wroteBased on observation, interview and record review the facility failed to designate a registered nurse to serve as the Director of Nursing (DON) on a full-time basis (40 hours per week) from 9/7/2023 to 11/16/2023. This deficient practice had the potential to result in the provision of substandard quality of care to the residents.

Inspectors wroteBased on interview and record review, the facility failed to provide the resident and the resident representative a written notification for the reason for discharge and the location to which the resident is being transferred or discharged for one of six sampled residents (Resident 1). Resident 1 was transferred to a General Acute Care Hospital (GACH) on 9/14/2023, for evaluation and treatment but was denied the right to return to the facility on the same day, after care at GACH was provided. Upon return from GACH, Resident 1 was considered fully transferred and discharged out of facility displacing Resident 1. This deficient practice prevented Resident 1 the right to return to the facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a resident a safe and orderly discharge from the facility by failing to provide the resident and the resident representative a written notification for the reason for discharge and the location to which the resident is being discharged for one of six sampled residents (Resident 1). Resident 1 was transferred to a General Acute Care Hospital (GACH) for evaluation and treatment but was denied the right to return to the facility after care at GACH was provided. Upon return from GACH, Resident 1 was considered fully transferred and discharged out of facility displacing Resident 1. This deficient practice prevented Resident 1 the right to return to the facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to allow a resident to return to the facility after being sent to a General Acute Care Hospital (GACH) for evaluation and treatment for one of ten sampled residents (Resident 1). This deficient practice prevented Resident 1 the right to return to the facility after care at GACH was provided.

Inspectors wroteBased on observation, interview and record review, the facility's governing body failed to ensure a licensed Administrator (ADM) was responsible for management of the facility and present at the premises enough hours to permit adequate attention to the facility. The Administrator in Training (AIT) was performing administrative tasks without the presence of the ADM at the facility. As a result, there was an increased risk of inadequate management of the facility and affect the safety and overall well-being of the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its infection prevention and control program by leaving a cart dedicated for clean linen open with the clean linen exposed and containing used and soiled items. The cart contained linen and gowns to be used with multiple residents' beds and residents. This deficient practice increased the risk for cross contamination and the spread of infection among residents.