The Grove Post-Acute Care Center

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 ensure licensed nurses appropriately assessed and monitored Resident 1's medical status following the resident's Change of Condition (COC) on 5/28/2026 related to the resident's fall. This deficient practice had the potential to result in the failure to identify continued or worsening clinical deterioration and increase risk for falls, thereby placing Resident 1 at risk for adverse health outcomes and compromised safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policy and procedure regarding individualized care planning for one of three sampled residents (Resident 1), by: 1. Failing to ensure Resident 1 had a care plan to address refusal of care. 2. Failing to ensure Resident 1 had a care plan to address Resident 1's needs for assistance with going to and from activities. These deficient practices increased Resident 1's potential risks for deterioration in health conditions related to refusal of care and need for assistance with going to and from activities.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the menu and did not meet nutritional needs of 59 of 63 residents on regular (diet with no restriction) and therapeutic diets (a meal plan tailored to a resident's specific medical condition to treat or manage it) including Resident 71 when [NAME] 1 did not follow the recipes for regular and puree corn bread for lunch. This failure had the potential to result in decrease in food flavor, decrease in food and nutrient intake resulting in unintended weight loss. Cross-reference F804.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents' rights to formulate an Advance Directive (AD - a legal document that outlines an individual's wishes regarding medical care in the event they become incapacitated and unable to communicate their preferences) for three of three sampled residents (Resident 2, 11, and 59) reviewed under the AD care area by failing to: 1. Provide written information concerning the right to formulate an AD for Resident 2 and 11. 2. Ensure a copy of advance directive was readily available in the medical chart for Resident 59. These deficient practices had the potential to violate the resident's right to have their wishes honored regarding health care decisions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and support for daily living safely for four of six sampled residents (Residents 20, 55, 19, and 69) reviewed under environment facility task by failing to ensure: 1. Resident 20's bed remote control cord did not have exposed/frayed wires. 2. Resident 55's hot water bathroom temperature was within 105 to 120 degrees Fahrenheit (F, a method of measuring temperature). 3. Residents 19 and 69's room wall clocks were maintained with accurate time readings. The deficient practices had violated the resident's right to a safe, clean, comfortable and homelike environment.

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 three of three sampled residents (Residents 62, 11, and 59) reviewed for physical restraints care area by failing to ensure: 1. A. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from unnecessary psychotropic medication (medications that affect the mind, emotions, and behavior) and the use of chemical restraints (any drug that is used for discipline or staff convenience and not required to treat medical symptoms) by: 1. Failing to provide ongoing re-evaluation of the need for psychotropic medication and ensure as needed (PRN) lorazepam (medication to relieve symptoms of anxiety [a mental health condition that may result in restlessness, irritability, feelings of nervousness, panic, and fear]) was ordered with an end date (time at which a medication will no longer be dispensed and will be required to be re-prescribed) for two sampled residents (Residents 5 and 32). 2. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure one of eight sampled residents (Resident 29) was afforded the opportunity to participate in the development of the resident's care plan (a document outlining a detailed approach to care customized to an individual resident's need). This deficient practice had the potential to result in Resident 29 receiving inadequate care and supervision at the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure professional standards were met by failing to: 1. Rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (sq, beneath the skin) insulin administration sites for two of two sampled residents (Residents 6 and 4) reviewed for insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) use. The deficient practice had the potential for adverse effect (unwanted, unintended result) of the same site subcutaneous administration of insulin such as excessive bruising, lipodystrophy (abnormal distribution of fat), and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin). Cross reference F760. 2. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide care consistent with professional standards of practice to prevent pressure ulcer/injury (ulcers that happen on areas of the skin that are under pressure from lying in bed, sitting in a wheelchair, or wearing a cast for a long period) for three of three sampled residents (Residents 75, 9,10 ) reviewed for pressure ulcers by failing to ensure: 1. Resident 75's low air loss mattress (LALM, a special type of air mattress that uses a constant, gentle flow of air through microscopic holes to keep the skin dry and prevent pressure wounds) had a physician's order. 2. Low air-loss mattresses were set at the accurate pressure setting for wound healing for Residents 9 and 10. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were incontinent of bladder received services and assistance for three of four sampled residents (Residents 11, 42, and 15 ) reviewed for urinary tract infection (UTI - a common infection that occurs when bacteria enters and multiplies in the urinary system, which includes the kidneys, bladder, and urethra) by failing to ensure residents urinal bottles (portable container for collecting urine) were labeled with the name, room number, and date it was provided to the residents. The deficient practice had the potential for residents for cross-contamination (the physical movement or transfer of harmful bacteria from one person, object or place to another) and to develop UTI due to switching of urinals.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free of any significant medication errors (means 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 two sampled residents (Residents 6 and 4) reviewed for insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) use by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (sq, beneath the skin) insulin administration sites. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe handling of medications and maintain safe and secure storage for two of two medication carts (Med Cart 3 and Med Cart 1) reviewed under Medication Storage and Labeling task, by: 1. Failing to store Resident 32 and 5's lorazepam (a psychotropic medication that affects the mind, emotions, and behaviors) oral solution in the medication refrigerator according to manufacturer's instructions in Med Cart 3. 2. Failing to store Resident 18's diclofenac gel (a topical pain relief medication) and lidocaine cream (numbing cream) separately from orally administered medications in Med Cart 3. These deficient practices had the potential to result in the use of ineffective medications for the resident 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare food by methods that conserved flavor and temperature for lunch when: a. Puree turkey was at 136 degrees Fahrenheit ( F, a degree of temperature) at the start of trayline (an area where foods were assembled from the steamtable to resident's plate), puree (foods that are soft with pudding like consistency) cauliflower at 105 F and salad with dressing was at 46 F during test tray (a process of tasting, temping, and evaluating the quality of food) b. [NAME] 1 did not follow the recipes corn bread for all diets. This failure had potential to result in 59 of 63 facility residents at risk of unplanned weight loss, a consequence of poor food intake, getting food from the kitchen. Cross-reference F803.

Inspectors wroteBased on observation, interview and record review, the facility failed to prepare foods in a form designed to meet individual needs when residents on puree diet (foods that are smooth with pudding like consistency)/International Dysphagia Diet Initiative ([IDDSI] a framework for categorizing food textures and drink thickness) level four (4) received puree cauliflower and puree corn bread that did not hold it shape on the plate and were weeping liquid. This failure had a potential to result in difficulty eating, coughing, choking (to keep from breathing the normal way) and death for 13 of 63 residents on puree/IDDSI level 4 diet.

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: a. Food preparation surfaces and kitchen equipment were not cleaned and sanitized. 1. The walk-in refrigerator vent had dust and dirt build up 2. Two (2) silver racks in the walk-in refrigerator had dust and dirt buildup. 3. Soiled towel was on the walk-in refrigerator floor b. Shredded jack cheese at 44 degrees Fahrenheit ( F, a degree of temperature) and shredded cheddar cheese at 43 F in the walk-in refrigerator. c. Kitchen equipment and utensils were not in good condition and repaired 1. Black rack paint was peeling off in the walk-in freezer 2. [NAME] and brown chopping boards had scratches 3. Can opener blade had amber discoloration d. The refrigerator had no internal thermometer. e. [...]

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 and to help prevent the development and transmission of communicable diseases and infections by: 1. Failing to ensure ice scoopers were placed in a closed container when not in use reviewed under infection control facility task. 2. Ensure the cart used for distributing linens was covered with non-permeable (any surface material that will not allow water-vapor, air, small particles to pass through) cover to prevent exposure of the clothing from environment contaminants reviewed under infection control facility task. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement its policy for antibiotic (medication used to treat infection) stewardship (efforts in long-term care facilities to ensure that antibiotics are used only when necessary and appropriate [means prescribing the right drug at the right dose at the right time for the right duration]) program and infection prevention and control program for two of seven sampled residents (Residents 8 and 29) by: 1. Failing to complete Resident 8's Surveillance Data Collection Form (a checklist used in nursing homes to help healthcare workers identify if a resident actually has a significant infection, rather than just having symptoms) for Urinary Tract Infection (UTI - an infection in the bladder/urinary tract) that the resident met the criteria for the use of antibiotic. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide reasonable accommodation of resident needs and preferences by failing to ensure the call light (CL, an alerting device for nurses or other nursing personnel to assist a resident when in need) was within reach for one of five residents (Resident 56) reviewed during the Environment task. This deficient practice had the potential to result in a delay of care and services and possible injury to residents when they are unable to summon health care workers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents' rights to forms of communication with privacy by failing to ensure one of seven sampled residents (Resident 5) present during the Resident Council task received their personal mail unopened. This deficient practice resulted in Resident 5 feeling upset that mail was delivered opened and had the potential to result in psychosocial harm to the resident.

Inspectors wroteBased on interview and record review, the facility failed to inform the resident's physician when a significant change in the resident's physical condition had deteriorated for one of three sampled residents (Resident 75) by failing to inform the primary physician of the resident's newly inserted peripherally inserted central catheter (PICC - a long, thin, flexible tube inserted into a vein in your upper arm, threaded up to a large vein near your heart, used for long-term IV fluids, meds [like chemo], nutrition, or blood draws, avoiding many needle sticks) line bleeding from the insertion site on 9/30/2025. The deficient practice had the potential for further complications of PICC line insertion and harm to resident.

Inspectors wroteBased on interview and record review, the facility failed to provide in writing the completed Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN - a notification to the resident or responsible party [RP] of the potential liability charges for services not covered when the resident was discharged from Medicare Part A services with benefit days remaining) and the Notice of Medicare Non-Coverage (NOMNC - a notification to inform the resident or RP of the pending termination of coverage and of his/her right to an expedited review of service determination) for two of three sampled residents (Residents 10 and 72) reviewed during the Beneficiary Notification task. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the confidential personal information of residents were protected by failing to ensure documents containing protected health information ([PHI]- any health information that can be used to identify a specific individual which must remain confidential to prevent harmful consequences) were shredded prior to disposing in the waste container. These failures had the potential to violate 59 of 63 residents' rights for privacy and confidentiality of personal and medical records.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan (is a tool that ensures residents receive personalized, comprehensive, and goal-oriented care in a nursing home setting) for two of two sampled residents (Residents 37 and 75) reviewed for peripherally inserted central catheter (PICC - is a thin, flexible tube that is inserted into a vein in the upper arm and guided [threaded] into a large vein above the right side of the heart called the superior vena cava) lines. This deficient practice had a potential for delays in the delivery of necessary care and services related to PICC line management and care.

Inspectors wroteBased on observation, 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 33) who had a diagnosis of diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and was on blood sugar checks by failing to ensure that glucometer (GLM- a small, portable medical device used to measure the concentration of glucose [sugar] in the blood) 1 and GLM 2 were working properly by performing any calibration or checks as instructed by the manufacturer or this facility. This deficient practice had the potential to result in false high or low blood sugar readings which could result in adverse consequences (unintended or unwanted effects caused by medication) such as hospitalizations.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment was free of accident hazards for one of two sampled residents (Resident 52) reviewed for accidents by failing to ensure Resident 52 did not have creams/ointments left at the bedside. This deficient practice increases the risk of accidents such as accidental ingestion of harmful chemicals/biologicals of residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure acquiring, receiving, dispensing, and administering of all drugs and biologicals) for one of one sampled resident (Resident 73) reviewed under the Medication Storage and Labeling task by failing to ensure the insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) emergency kit (e-kit - a small quantity of medications that can be dispensed when pharmacy services are not available) was replaced within 72 hours according to facility's policy and procedure. This deficient practice had the potential to result in delayed or inadequate response to emergency situations.

Inspectors wroteBased on interview and record review the facility failed to ensure the resident's drug regimen was free from unnecessary drugs for two of two sampled residents (Residents 1 and 55) investigated under anticoagulants (a substance that is used to prevent and treat blood clots in blood vessels and the heart) by failing to ensure there was adequate monitoring for adverse effects (an unfavorable, unintended, or harmful outcome that results from a medical treatment or procedure) on: Resident 1's use of rivaroxaban (commonly known by the brand name Xarelto, is a type of medicine called a blood thinner [anticoagulant]). Resident 55's use of warfarin ([brand names Coumadin, Jantoven] is a medicine that acts as a blood thinner [anticoagulant]). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain medical records in accordance with accepted professional standards for one of six residents (Resident 11) reviewed during medication administration facility task when the facility documented Resident 11's docusate sodium (also known as Colace, medication used to soften stool) as administered on 12/2/2025 when Resident 11 refused the medication. This deficient practice had the potential to result in delay in necessary care and treatment.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure on pneumonia (an infection/inflammation in the lungs) vaccination by failing to offer the pneumococcal vaccine (helps protect against some types of bacterial infections that can cause serious lung illnesses) to one (1) out of five (5) sampled residents (Resident 59). This deficient practice placed Resident 59 at a higher risk of acquiring and transmitting pneumonia to other residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the electrical resident care equipment was in safe operating condition for one of six sampled residents (Resident 59) reviewed under environmental task by failing to ensure the Resident 59 in Bed A had a functional call light (a bedside button, typically tethered to the wall in a resident's room directing signals to the nursing station to indicate when residents have perceived a need requiring the attention of the nurses on duty) and the alternate call light provided did not have a broken/ frayed wires on them. The deficient practice had the potential for residents to be unable to call for help and sustain accidents such as electrical shock and falls.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nurse staffing information was posted and updated on a daily basis. This failure resulted in staffing information not readily accessible to residents and visitors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet the requirement for no more than four (4) residents per room for one out of 25 rooms (room [ROOM NUMBER]). This deficient practice had the potential to result in inadequate space to provide safe nursing care, privacy for the residents, and limit the residents' ability to maneuver personal care devices.

Inspectors wroteBased on interviews and record review, the facility failed to report the allegation of a visitor-to-resident sexual abuse (sexual behavior or a sexual act forced upon a woman, man, or child without their consent) to the State Survey Agency (SSA) for one of three sampled residents (Resident 1). On 7/3/2025, Resident 1 reported an allegation of abuse by the transportation company personnel to the Social Services Director (SSD). The Abuse Coordinator reported the allegation to the SSA on 7/30/2025, 27 days after the allegation of abuse was made. This deficient practice had the potential to result in unidentified abuse and failure to protect other residents from abuse.

Inspectors wroteBased on interview and record review, the facility failed to follow professional standards of practice for one of three sampled residents (Resident 1) by failing to ensure licensed nurses and social services monitored Resident 1's psychological (anything concerning the mind, mental processes, or emotions) and psychosocial (a person's mental, emotional, social, and spiritual health) health after Resident 1's reported allegation of being inappropriately touched by the transportation company personnel. This deficient practice placed Resident 1 at risk of not being provided necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to report allegation of staff-to-resident abuse within two hours to the State Survey Agency (SSA- the agency that inspects long-term care facilities for the purposes of survey and certification) for one of three sampled residents (Resident 1). This deficient practice had the potential to place Resident 1 at risk for abuse.

Inspectors wroteBased on interview and record review, the facility failed to maintain accurate and complete medical record for one of four sampled residents (Resident 1). This deficient practices had the potential to cause confusion in care and the medical records containing inaccurate documentation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare food in a form designed to meet individual needs (requirements that a person has in order to be well such as food) for one of 62 sampled residents (Resident 214) on puree diet (a texture modified diet that consists of smooth, moist foods that are easy to swallow) by not following the recipes for puree oatmeal, puree scrambled eggs, and puree wheat breads and in accordance with the International Dysphagia Diet Initiative (IDDSI - a framework made up of levels and describes food textures and drink thickness) Level Four (pureed foods and extremely thick drinks) Standards when on 12/29/2024 Resident 214 was served bread soaked in milk, oatmeal with lumps, and scrambled eggs that were not smooth and not pureed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose garbage and refuse properly by: a. Not putting a plastic liner in the trash can used in the kitchen. b. Not completely closing 1 (one) of 2 black dumpsters (large trash container designed to be emptied into a truck). These failures had a potential to result to attracting birds, flies, insects, pest and possibly spread infection to 62 of 63 facility residents.

Inspectors wroteBased on interview and record review the facility failed to ensure the Infection Preventionist (IP) was competent in implementing the facilities infection control program by failing to: 1. Follow the facility's policy titled, Scabies [a parasitic infestation caused by tiny mites (a group of insect-like organisms, some of which bite or cause irritation to humans) that burrow into the skin and lay eggs, causing intense itching and a rash] Identification, Treatment and Environmental Cleaning, when Resident 52 was removed from isolation prior to the completion of treatment and or it was determined the resident was free from scabies. 2. Follow facility's policy titled, Unusual Occurrence Reporting , when Resident 52 was positive for scabies and it was not reported to the state agency. These failures had the potential to spread scabies infestation to other residents and staff.

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: 1. Failing to destroy medications discontinued by the physician for Residents 25, 63, and 64. 2. Failing to label multidose medication bottle per facility policy with open date for two of four medication cart (Station 2 Medication Cart 2 and Station 1 Medication Cart 2) and one of two medication room (Medication room [ROOM NUMBER]) 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure kitchen staff were routinely trained and evaluated for competency (measurable pattern of training, skills, experience, and knowledge in order to perform occupational tasks successfully) skills when staff: a. Failed to follow recipes and portion sizes for coffee cake for regular diet (diet with no restriction). b. Failed to blend the food, follow recipes, and portion sizes for puree diet (foods that are smooth with pudding like consistency)/International Dysphagia Diet Initiative ([IDDSI] a framework for categorizing food textures and drink thickness) Level four (4) for all breakfast food items. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to follow the menu and did not meet nutritional needs of 62 of 63 residents on regular (diet with no restriction) and puree texture diets (foods that are smooth and pudding like consistency) when: 1. Cook 1 was unable to find the menu spreadsheet for 12/29/20224 breakfast. 2. Cook 1 did not prepare puree baked Western omelet for residents on puree diet/ International Dysphagia Diet Initiative ([IDDSI] a framework for categorizing food textures and drink thickness) Level 4. 3. Cook 1 did not prepare coffee cake and used regular cake for all the residents for breakfast. 4. Cook 1 used scoop size number (#) 10 (3/8 cup) instead of #12 (1/3 cup) scoop for puree eggs and bread soaked in milk. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare food by methods that conserved flavor and appearance for breakfast when: a. Cook 1 did not follow the recipe for coffee cake and prepared plain cake instead. b. Cook 1 did not follow the recipe and cut the baked Western omelet to 3x2 ½ inches serving and used number (#) 10 scoop (3/8 cup) instead. This failure had a potential to result in 62 of 63 facility residents at risk of unplanned weight loss, a consequence of poor food intake, getting food from the kitchen.

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: a. Expired items were stored in the kitchen refrigerator and undated foods were stored in the refrigerator. 1. Expired hotdog buns dated 12/22/2024 and hamburger buns dated 12/28/2024 in the kitchen and staff foods were stored in the kitchen refrigerator. 2. Resident foods were not labeled and dated in the resident's refrigerator and staff's foods were stored in the resident's refrigerator. b. Staff did not wash her hands after touching the paper towel dispenser button and before returning to work. c. Food preparation surfaces and kitchen equipment were not cleaned and sanitized. 1. Walk-in freezer's roof had ice crystals. 2. Canned food racks were dusty and dirty to touch. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to designate a Medical Director (MD) for 12 months of 12 months (12/30/2023 to 12/30/2024) whose responsibilities were outlined in a job description or facility policy in coordinating of medical care in the facility and failed to submit a MD application to State Agency 1 (SA 1). This failure had the potential to lead to confusion among staff regarding clinical decision-making and accountability.

Inspectors wrote2. During a review of Resident 39's admission Record, the admission Record indicated the facility admitted Resident 39 on 8/6/2024 with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness or the inability to move on one side of the body, making it hard to perform everyday activities like eating or dressing) following cerebral infarction (a serious medical condition that occurs when blood flow to the brain is blocked, leading to brain cell death) affecting right dominant side, and essential (primary) hypertension (HTN - high blood pressure). During a review of Resident 39's H&P, dated 8/6/2024, indicated Resident 39 had the capacity to understand and make decisions. During a review of Resident 39's MDS, dated [DATE], the MDS indicated Resident 39 had the ability to usually understand and was understood. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement infection control measures by: 1. Failing to ensure water management plan was followed as per policy to prevent legionella (a bacteria that causes Legionnaires' disease -a serious type of pneumonia [lung infection] that can be life-threatening if left untreated. Legionella is found in [NAME] and soil, but it's usually spread through the air when water droplets containing the bacteria are inhaled. This can happen in places that hold or process warm water, like hot tubs, showers, fountains, and cooling towers.) 2. Failing to ensure one of two medication rooms (Medication room [ROOM NUMBER]) was maintained in a sanitary environment. These deficient practices may result in unidentified case of legionella and the spread of infection. 3. [...]

Inspectors wroteb. During a review of Resident 39's admission Record, the admission Record indicated the facility admitted Resident 39 on 8/6/2024 with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness or the inability to move on one side of the body, making it hard to perform everyday activities like eating or dressing) following cerebral infarction (a serious medical condition that occurs when blood flow to the brain is blocked, leading to brain cell death) affecting right dominant side, and essential (primary) hypertension (HTN-high blood pressure). During a review of Resident 39's H&P dated 8/6/2024, the H&P indicated Resident 39 had the capacity to understand and make decisions. During a review of Resident 39's MDS, dated [DATE], the MDS indicated Resident 3 usually understands and was understood by others. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to inform residents and their responsible party about their right to formulate an advance directive (a written statement of a person's wishes regarding medical treatment) upon admission for one of one sampled resident (Resident 14) investigated for advance directives. This deficient practice violated the resident's and/or the representative's right to be fully informed of the option to formulate their advance directives and had the potential to cause conflict with the resident's wishes regarding their health care.

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician was notified that azithromycin (antibiotic-medication used to treat infection) was not available on 12/10/2024, 12/11/2024 and 12/12/2024 for one of three sampled residents (Resident 214). This deficient practice resulted in delay of obtaining appropriate instructions from the physician for proper management and Resident 214 received an incomplete dose of the antibiotic.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe and homelike environment to one of one sampled resident (Resident 114) by failing to ensure the resident's wall clock was in working condition. The deficient practice had the potential to disrupt Resident 114's daily routine and other scheduled activities.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary services to maintain good grooming and personal hygiene for two of two sampled residents (Resident 33 and 39) by: 1. Failing to trim Resident 33's fingernails. 2. Failing to provide Resident 39 with a shower. These deficient practices had the potential to negatively affect the residents' psychosocial wellbeing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary treatment and services for two of four residents (Resident 14 and Resident 214) at risk for developing pressure ulcer (a localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure, or pressure in combination with shear) by failing to follow the manufacturer guideline for low air loss mattress (LAL- a mattress that uses air to help prevent and treat pressure wounds and maintain a comfortable temperature and moisture level for the patient). This deficient practice had the potential for Resident 14 and Resident 214 to develop a pressure ulcer or for the wounds to worsen.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide an environment free from accidents and hazards for two of two sampled residents (Resident 44 and 23) reviewed under the Accidents care area by: 1. Failing to ensure Resident 44, who was identified as a smoker requiring supervision, had staff supervising the resident while the resident was smoking. This deficient practice had the potential to result in harm to the resident leading to burns and injuries. 2. Failing to properly manage and secure all cords and cables by Resident 23's left side bed rail (a bar attached to the side of a hospital bed to help prevent patients from falling out). This deficient practice had the potential to result in harm to the resident leading to risk of electric shock or fire.

Inspectors wroteBased on interview and record review, the facility failed to provide a Registered Nurse (RN) for eight consecutive hours on 11/19/2023 for 57 of 58 residents. This deficient practice had the potential to delay necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident was free from any significant medication error for one of three sampled residents (Resident 214) by not following the physician's order. This deficient practice resulted in delay of antibiotic (medication used to treat infection) administration, incomplete antibiotic dose (a quantity of medicine prescribed by the physician) and had the potential to prolong Resident 214's pneumonia (PNA- lung infection).

Inspectors wroteBased on interview and record review, the facility failed to accurately code the Minimum Data Set (MDS-a resident assessment tool) for one of one sampled resident (Resident 61) reviewed under Hospitalization care area, by failing to ensure the resident's MDS discharge assessment was completed accurately when the resident's MDS was coded discharged to hospital instead of discharged to home. This deficient practice had the potential to negatively affect the resident's plan of care and delivery of necessary care and services upon discharge.

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet the requirement for no more than four resident per room for 1 out of 25 rooms (room [ROOM NUMBER]). This deficient practice had the potential to result in inadequate space to provide safe nursing care, privacy for the residents, and limit the residents' ability to maneuver personal care devices.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its infection control policy by failing to: 1. Implement its Enhanced Barrier Precautions (EBP- refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities, residents with wounds or indwelling medical devices) for three of seven sampled residents (Resident 4, Resident 6, and Resident 7). 2. [...]

Inspectors wroteBased on interview and record review the facility: 1. Failed to provide documented evidence staff were provided education regarding the benefits and potential risks associated with coronavirus disease 2019 (COVID-19, a highly contagious viral illness that can lead to mild respiratory issues to severe pneumonia [a lung infection causing symptoms like cough, fever, and difficulty breathing]) and or influenza (an infection of the nose, throat, and lungs, which are part of the respiratory system) vaccine for 6 out of 6 sampled staff investigated during record review. 2. Failed to provide documented evidence staff were offered the COVID-19 and or Flu vaccine for 6 out of 6 sampled staff investigated during record review. This deficient practice had the potential to result in an increase for transmission of COVID-19 and flu infections among residents and staff.

Inspectors wroteBased on interview and record review, the facility failed to follow the facility's policy and procedure on submitting the 5-day report to the State Survey Agency (SSA) within five working days of the incident for one of three sampled residents (Resident 1). The alleged family-resident financial abuse was reported to the SSA on 6/21/2024 and the 5-day report was submitted on 7/3/2024, eight days after the alleged incident. This deficient practice had the potential to result in unidentified abuse in the facility and failure to protect other residents from abuse.

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 3) 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 can possibly lead to unsafe drop in Resident 1's blood pressure and heart rate, and may have other adverse side effects.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain one of four means of egress (designated exit door) was free from obstructions. This deficient practice had the potential to prevent prompt evacuation of residents and staff due to obstruction of egress access in the event of an emergency.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services in accordance with professional standards of practice that will meet each resident's physical, mental, and psychosocial needs for one (Resident 107) of three sampled residents reviewed under the insulin care area by failing to obtain a physician's order for the use of a flash glucose monitoring system (a flash glucose monitor uses a sensor that is placed on the back of the upper arm and worn externally by the user, allowing glucose information to be monitored using a mobile application; the hand held reader is used to scan the glucose without the need to prick the fingers) provided by Resident 107's family member for the resident to use. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that licensed nursing staff have the specific competency (measurable pattern of knowledge, abilities, behaviors in order to perform occupational functions successfully) and skills set necessary to care for residents using a flash glucose monitoring system (a flash glucose monitor uses a sensor that is placed on the back of the upper arm and worn externally by the user, allowing glucose information to be monitored using a mobile application; the hand held reader is used to scan the glucose without the need to prick the fingers) for one of three sampled residents reviewed under the insulin care area. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the services of a registered nurse (RN) for at least eight consecutive hours a day as indicated in the facility's policy. This deficient practice had the potential to result in the provision of substandard quality of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe storage and handling of medications by failing to: 1. Ensure Licensed Vocational Nurse 3 (LVN 3) dispose of nine medications in an unusable form in one of two medication carts (Med Cart 1). LVN 3 disposed the nine medications in a trash can instead of the medication room incinerator (a container for burning waste materials). This deficient practice had the potential to result in loss, diversion, or accidental exposure to medications. 2. Ensure one of two medication room (Med room [ROOM NUMBER]) temperature logbook for the medication room and refrigerator had documented temperature readings for 12/3/2023 and 12/6/2023. This deficient practice had the potential to result in medications not being stored as manufactured guidelines recommended which can render the medications ineffective.

Inspectors wroteBased on interview and record review, the facility failed to implement their facility assessment (determines the resources necessary to care for residents competently during the day-to-day operations and emergencies) by: 1. Failing to create and update the facility assessment for the year 2022. 2. Failing to assess three of five sampled staff (Licensed Vocational Nurse 1 [ LVN 1], LVN 2 and Registered Nurse 1 [RN 1]) for annual competencies for the year 2022 and 2023 as per their facility assessment. These deficient practices had the potential to delay the necessary care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection prevention and control practices for one of one sampled medication rooms (Med room [ROOM NUMBER]) and for one of 18 sampled residents (Resident 108): 1. When the listed items were observed in Med room [ROOM NUMBER]: - Resident personal belongings (dentures). - Entraflo feeding bag (a feeding bag for residents that require gastrointestinal feeding) with expiration date of [DATE]. - Influenza (contagious respiratory illness) vaccine (protects against harmful disease) with expiration date of [DATE]. This deficient practice had the potential for cross-contamination (unintentional transfer of bacteria/germs or other contaminants from one surface to another) of the medication room. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care in a manner that promoted dignity and respect for one of one sampled resident (Resident 19) by failing to ensure Resident 19's indwelling urinary catheter bag (also known as Foley catheter, is a hollow flexible tube inserted in the bladder through the urethra to drain urine) was covered with a privacy bag. This deficient practice had the potential to affect resident's sense of self-worth and self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident's responsible party was informed in advance prior to the use of the bed side rails for one of one sampled resident (Resident 42). This deficient practice violated the resident's right to be informed of the risks and benefits of using side rails and the right to make decisions about the resident's treatment.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the call light was within reach for one of eight sampled residents (Resident 108). This deficient practice had the potential to result in the delay in or lack of necessary care and services that can negatively affect the resident's comfort and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote the resident rights to examine the results of the most recent survey (a survey to determine compliance with state and federal regulations) of the facility by failing to post the most recent survey results in a place that are prominent and accessible (a place where individuals wishing to examine survey results do not have to ask to see them) to residents, family members, and legal representatives of residents. This deficient practice resulted in the residents' and their representative not having access to examine the most recent survey results.

Inspectors wroteBased on observation, interview and record review facility failed to maintain privacy of confidential information when Licensed Vocational Nurse 2 (LVN 2) left an electronic health record (EHR- a digital version of a resident's paper chart) open, unattended, and out of view for one of one resident sampled (Resident 43). This deficient practice violated Resident 43's right to privacy and confidentiality of their medical records.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive care plan for one of three sampled residents (Resident 46) by: a. Failing to develop a care plan for Resident 46's use of antibiotic metronidazole (medication used to treat infection) on 9/6/2023. b. Failing to ensure the care plan addressing Resident 46's colostomy had specific instructions on how to provide colostomy care. These deficient practices had the potential to result in failure to deliver necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to update a resident's comprehensive care plan after the resident's nephrostomy (a procedure to drain urine from the kidney using a tube) tube was removed for one of one sampled resident (Resident 2) reviewed under the catheter care area. This deficient practice had the potential to result in inconsistent implementation of the care plan that may lead to a delay in or lack of delivery of care and services.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a discharge care plan for a resident who was discharged to another long term care facility for one of three residents (Resident 56) reviewed under closed records. This deficient practice placed the resident at risk for not receiving the necessary care and services related to the resident's discharge goals and needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide the appropriate treatment and services to a resident who has a suprapubic catheter (a type of catheter that is inserted through a hole in the abdomen and then directly into the bladder) for one (Resident 2) of one sampled resident reviewed under the catheter care area by failing to follow the physician's treatment order for care of the resident's suprapubic stoma site. This deficient practice placed Resident 2 at risk for skin breakdown around the stoma site and at risk for urinary tract infection (UTI, an infection in any part of the urinary system).

Inspectors wroteBased on interview and record review the facility failed to provide the appropriate treatment and services to a resident who has a colostomy (a surgical procedure that brings on end of the large intestine out through the abdominal wall) for one of one (Resident 46) by failing to clarify with the physician the treatment order for colostomy care to ensure the order had specific instructions consistent with professional standards of practice, the comprehensive-centered care plan, and the resident's goals and preferences. This deficient practice placed the resident at risk for complications related to colostomy such as bleeding and infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident who received dialysis (process of removing waste products and excess fluid from the body when the kidneys stop working properly) received treatment in accordance with standards of practice for one out of one sampled resident (Resident 26) by falling to complete post-dialysis assessment that included: 1. Failing to assess the dialysis access site (coronary arteriovenous [AV] shunt: an access made by joining coronary arteries [blood vessels that distribute oxygen-rich blood to the entire body] and venous [blood vessels located throughout the body that collect oxygen-poor blood and return it to the heart] side of heart). 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 12) was free from unnecessary medication when Licensed Vocational Nurse 3 (LVN 3) tried to administer docusate sodium (a stool softener) without verifying if the resident had loose stool per doctors' orders. This deficient practice had the potential for Resident 12 to have loose stools and had the potential of dehydrating (cause a person to lose a large amount of water) the resident.

Inspectors wroteBased on interview and record review, the facility failed to complete Surveillance Data Collection Forms for one of five residents (Resident 46) in the 9/2023 log. This deficient practice had the potential to increase antibiotic (medication used to treat infection) resistance (when bacteria change so antibiotic medicines can't kill them or stop their growth) and provide antibiotics without justification.

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet the requirement for no more than four residents per room for 1 out of 26 rooms (room [ROOM NUMBER]). This deficient practice had the potential to result in inadequate space to provide safe nursing care, privacy for the residents, and limit the residents' ability to maneuver personal care devices.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement infection control practices for five of seven sampled residents by: 1. Failing to conduct a complete screening of visitors on 10/5/2023 and 10/6/2023 for temperature and signs and symptoms of 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) before entering the facility. 2. Failing to ensure three visitors were screened for COVID-19 before entering Resident 4's room. 3. Failing to ensure Certified Nursing Assistant 1 (CNA 1) performed hand hygiene and don (put on) gown and gloves before entering Resident 5's room, who was on contact isolation. 4. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five residents sampled received the pneumococcal vaccine (a drug that helps the immune system develop immunity from pneumococcal pneumonia [an infectious bacterial lung disease]). This deficient practice place resident at risk for respiratory infection including pneumonia.

Inspectors wroteBased on interview and record review, the facility failed to implement their COVID-19 (a disease caused by a virus named SARS-CoV-2 than can be contagious and spreads quickly) vaccination policy for two (Residents 1 and 2) out of five sampled residents by failing to provide documentation that Resident 1 and Resident 2 or their representative either accepted and received the vaccine or did not receive the vaccine due to refusal, prior vaccination or contraindication to having the COVID-19 vaccine. This deficient practice placed Residents 1 and 2 at risk for developing serious illnesses when infected with COVID-19 virus.

Inspectors wroteBased on interview and record review, the facility failed to conduct skin scraping on one of four sampled resident (Resident 1) when on 9/1/2023 Resident 1 was identified with a rash on their back, chest, and abdomen, on 9/4/2023 Resident 1 was placed on contact isolation precautions, and on 9/7/2023 the Dermatologist 1 (MD 1) diagnosed Resident 1 with unspecified dermatitis and was considering it as scabies. This deficient practice had the likelihood to spread scabies infestation to other residents and staff.

Inspectors wroteBased on interview and record review, the facility failed to implement their policy and procedure by failing to ensure the Responsible Party (RP) was informed for one of four sampled residents (Resident 1) when Resident 1 was diagnosed with unspecified dermatitis (inflammation of the skin). This deficient practice violated the resident's rights to be informed of and participate in the resident's treatment.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) was free of unnecessary medication when Resident 1 was given ivermectin (an anti-parasitic drug approved in humans for treatment of certain tropical diseases) and permethrin (an insecticide [chemicals used to control insects by killing them or preventing them from engaging in undesirable or destructive behaviors]) for unspecified dermatitis (inflammation of the skin). This deficient practice resulted in Resident 1 receiving unnecessary medications and had the potential to not receive the necessary care and services that will address the underlying problem.