The Hills Post Acute

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the nutritional needs were addressed for one of five sampled residents (Resident 2). * Resident 2 was observed with Nepro (specialized, calorie-dense nutritional shake) and Ensure (nutritional supplement) at his bedside table without a physician's order. This failure placed the resident at risk to receive nutritional supplements unnecessarily.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary pharmaceutical services for one of five sampled residents (Resident 5). * The facility failed to administer the potassium chloride (medication used to treat and prevent hypokalemia-low potassium level) medications according to the pharmacy-related directions for Resident 5. This failure had the potential to put the resident at risk for adverse consequences related to the medication use.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the appropriate infection control practices were followed for one of five sampled residents (Resident 4). * LVN 1 failed to perform hand hygiene after the removal of gloves post cleaning of a glucometer (a machine to measure blood sugar level) and a medication tray. This failure posed the risk of spreading infectious organism to the residents in the facility.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of one final sampled resident (Resident 7) and two nonsampled residents (Residents 31 and 175) reviewed for respiratory care were provided the appropriate respiratory care. * The facility failed to ensure Resident 7 nasal canula tubing was dated and labeled and had an oxygen storage bag as per the facility's P&P. * The facility failed to ensure Resident 31's nasal cannula tubing was dated and labeled as per the facility's P&P. * The facility failed to ensure Resident 175 nasal canula tubing was dated and labeled and had an oxygen storage bag as per the facility's P&P. These failures had the potential for the residents to not receive the appropriate care and may negatively impact the residents' medical conditions.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the dialysis care and services were provided for three of three final sampled residents (Residents 2, 12, and 81) reviewed for dialysis care. * The facility failed to ensure the Dialysis Communication Forms for Resident 2 were completed and accurate on multiple dates. * The facility failed to ensure Resident 12's hemodialysis communication records were complete and failed to ensure accurate documentation of the monitoring of Resident 12's fluid restriction as ordered by the physician. * The facility failed to ensure Resident 81's hemodialysis communication records and fluid intake monitoring were completed accurately. These failures had the potential of not identifying negative outcomes for Residents 2, 12, and 81.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to store the drugs and biologicals in a safe manner for two of three medication carts (Medication Carts A and B); and two of 32 final sampled residents (Residents 132 and 164). * The facility failed to ensure safe medication labeling practices was in accordance with the accepted professional standards when the opened inhaler mouthpieces and nasal spray bottles were not properly labeled with sufficient information to clearly identify the specific resident for Resident 192 in Medication Cart A, and Residents 67, 117, and 158 in Medication Cart B. These failures had to potential to cause medication errors and preventable infections from cross-contamination from other residents if accidently mixed up with other residents' similar or same drugs. [...]

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the menu and recipes were followed for 26 of 153 residents (Resident 94, 18 of 18 residents who received pureed food and seven of seven residents on a renal diet) eating from the kitchen. * The facility failed to ensure the puree recipe for IDDSI Level 4 Pureed Starch (Rice, Pasta, Polenta, Potatoes, etc.) was followed. * The facility failed to follow the renal diet menu. * The facility failed to inform the residents of menu changes. * The facility failed to offer Resident 94 appropriate food substitutions when he refused both breakfast and lunch. These failures had the potential to result in residents on special diets not receiving adequate nutritional and caloric intake as recommended.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure food safety and sanitary requirements were met in the kitchen. * The facility failed to ensure food preparation equipment was in good, cleanable and sanitary condition. * The facility failed to ensure temperature was monitored in the dry storage room. * The facility failed to ensure food items were labeled and discarded by the best by or use by date. These failures had the potential to cause foodborne illnesses in the medically vulnerable residents population who consumed food prepared in the kitchen.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to implement its Infection Prevention and Control Program in accordance with the facility's P&P. * The facility failed to implement its infection control surveillance program for April 2025 through February 2026. The facility conducted surveillance only for the residents prescribed antimicrobial medications. The facility failed to determine whether the residents who exhibited signs and/or symptoms of infection but not prescribed antimicrobial medications met McGeer's criteria for infection. The facility failed to include these residents in the facility's infection control surveillance program. * The facility failed to ensure the clean laundry sorting table remained free of staff personal items. A laundry staff member's cell phone was observed on the clean laundry sorting table. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the staff provided care and promoted dignity and respect for one nonsampled resident (Resident 77). * The facility failed to ensure Resident 77's call light was answered in a timely manner. This failure had a potential for the resident's need to not be met as the call light was not answered timely and negatively affected the resident's well-being.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide a reasonable accommodation to meet the needs of one of 32 final sampled residents (Resident 54) and one nonsampled resident (Resident 147). * The facility failed to ensure Resident 54 and 147's call light was within the resident's reach. This failure had the potential to negatively impact the residents' psychosocial well-being and cause delays in receiving the needed care.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to maintain a safe, clean, and homelike environment for two of 32 final sampled residents (Residents 26 and 48) and one nonsampled resident (Resident 117). * Resident 26 resided in Room D. The wall behind Resident 26's bed was observed in disrepair with black streak marks on the wall and chipped paint on the wall and wall trimmings. In addition, Resident 26's ceiling was observed with chipped and peeling paint. * Resident 48 resided in Room E. The wall behind Resident 48's head of bed was observed in disrepair with chipped paint and cracked wall trims. * The walls and bathroom door in Resident 117's room were observed in disrepair. These failures had the potential to negatively impact on the residents' quality of life.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide a copy of the notification of the transfer/discharge to the Office of the State Long-Term Care Ombudsman for one of the two residents (Resident 7) who were transferred to the acute care hospital. * The facility failed to ensure copy of the transfer discharge notification was sent to the Ombudsman when Resident 7 was transferred to the acute care hospital on 2/24/26. This failure had the potential for the resident to not receive additional protection when the residents was being inappropriately transferred or discharged .

Inspectors wroteBased on interview, medical record review, and document review, the facility failed to ensure the PASRR Level 1 screening was accurate for one of four final sampled residents (Resident 94) reviewed for PASRR. * Resident 94 had diagnosis of psychosis, however, the PASRR Level 1 screening showed Resident 94 had no diagnosis of serious mental illness and had no psychotropic medication. This failure had the potential risk for Resident 94 not to receive the necessary care and services due to inaccurate assessment.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the comprehensive, person-centered care plan was developed and implemented for four of 32 final sampled residents (Residents 1, 12, 13, and 94). * The facility failed to develop a comprehensive, person- focused care plan addressing Resident 1's noncompliance with the prescribed dietary regimen. * The facility failed to develop the comprehensive, person-centered care plan to address Resident 12's hemodialysis treatments, fluid restrictions, hemodialysis access monitoring, and nutrition status. * The facility failed to develop a care plan to address Resident 13's use of a low air loss mattress (LAL). * The failed to develop a care plan to address and support Resident 94's care needs related the resident's diagnosis of dementia. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the comprehensive plans of care for two of 32 final sampled residents (Residents 53 and 98) was revised to reflect the resident's current care needs and interventions. * Resident 53's care plan was not updated to reflect the resident's care needs and interventions. * Resident 98's plan of care was not revised to reflect resident's care needs and interventions. These failures posed the risk of not providing Residents 53 and 98 with individualized and person-centered care.

Inspectors wroteBased on observation, interview, medical record review, and the facility P&P review, the facility failed to ensure the appropriate services needed to maintain the acceptable parameters of nutritional status were provided for one of five final sampled residents (Resident 53) reviewed for nutrition. * The facility failed to ensure the RD and IDT analyzed and implemented the necessary interventions and the physician and resident and/or their representative were notified when Resident 53's had unplanned significant weight loss of 16 lbs. (8.04%) between 4/4 and 5/2/26. In addition, Resident 53's resident-centered care plan was not revised to address Resident 53's severe weight loss of 16 lbs. These failures had the potential for Residents 53 to not receive the necessary intervention to prevent further weight loss.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary GT care and services for one of three final sampled residents (Resident 164) reviewed for enteral feeding care. * The facility failed to ensure Residents 164 was administered the total amount of the enteral feeding as ordered by the physician. This failure posed the risk of developing complications related to the enteral feeding.

Inspectors wroteBased on observation, interview, medical record review and facility P&P review, the facility failed to provide the necessary care and services to maintain the IV access for one of one final sampled resident (Resident 107) reviewed for IV therapy, consistent with the professional standards of practice. * The facility failed to ensure Resident 107's IV tubing was correctly labeled. In addition, the facility failed to develop a care plan for the use of an IV antibiotic therapy cefepime (medication used to treat serious bacterial infection including urinary tract infection). These failures posed the risk for the resident to develop complications related to the IV therapy.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure safe and effective pharmaceutical services was provided for one of four residents (Resident 85) observed for medication pass and the proper accounting procedures of controlled substances was provided for two residents (Residents 90 and 193) reviewed for controlled substances reconciliation. * The facility failed to ensure medication for Resident 85 was administered in accordance with the prescriber's orders. This failure resulted in a medication error and had the potential to negatively affect the resident's health conditions. * The facility failed to ensure the RX Number was documented on the Controlled Substances Log for the bottles of morphine sulfate liquid solutions for Residents 90 and 193 which were stored in Medication Cart B. [...]

Inspectors wroteBased on interview, medical record review and facility document review, the facility failed to ensure the Pharmacy Consultant's recommendation was acted upon for one of five residents (Resident 3) reviewed for unnecessary meds. * The facility failed to ensure Resident 3's continued use of the trazodone(antidepressant) and escitalopram (antidepressant) medications had a clinical rationale as per the Pharmacy Consultant recommendation. This failure had the potential to put Resident 3 at risk for adverse consequences related to the medications.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of five sampled residents (Resident 7) reviewed for unnecessary medication was free from the unnecessary medications. * The facility failed to ensure Resident 7's heart rate was monitored for the use of the amiodarone (medication to treat irregular or fast heartbeats) as ordered by the physician. This failure had the potential for the resident to receive unnecessary medication and put the resident at risk for adverse side effects.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure food prepared in the facility kitchen was appealing and palatable when three of 153 residents (Residents 6, 12, and 94) expressed dissatisfaction with the taste of the food served. * The facility failed to ensure the potatoes served on the test tray was palatability. This failure posed the risk of the residents not receiving palatable and appetizing meals from the facility kitchen.

Inspectors wroteBased on observation, interview, facility documents review, and facility P&P review, the facility failed to ensure two nonsampled residents (Resident 175 and 194) out of 153 residents receiving a lunch tray were provided meals in accordance with the residents documented food preferences. * The facility failed to ensure Resident 175 did not receive vegetables on her lunch tray, as per the resident's documented preference. * The facility failed to ensure Resident 194 did not receive apple juice on her lunch tray, as per the resident's documented preference. These failures had the potential to affect the residents not receiving meals consistent with their preferences.

Inspectors wroteBased on observation, interview, document review, and facility P&P review, the facility failed to ensure the staff followed the facility's P&P on Foods Brought by Family or Visitor and failed to ensure staff were educated on safe food handling of outside food. * The facility failed to ensure food items in the residents' refrigerator were labeled with the resident name, location, and date as per the facility's P&P. * The facility failed to ensure the staff who receive the food from the residents' family and/or visitors were educated on the safe and proper food handling of outside food. These failures had the potential to cause foodborne illnesses in the medically vulnerable resident population who consumed food brought from outside sources.

Inspectors wroteBased on observation, interview, medical record, facility record review, and facility P&P review, the facility failed to ensure the medical records were accurate and complete for two of 32 final sampled residents (Residents 48 and 129). * The facility failed to ensure Resident 129's Hospice Visit Communication completed forms had the resident identifier for 6/1/25 to 5/5/26. In addition, the facility failed to ensure Resident 129's Hospice Team Visit Calendar was accurately initialed. * The facility failed to ensure the elopement re-evaluation and documentation for Resident 48's exit-seeking behavior was documented in the medical records. These failures had the potential for the residents' care needs to not be met as their medical information was inaccurate and incomplete.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary care and services for one of three final sampled residents (Resident 52) reviewed for hospice services. * The facility failed to ensure Resident 52's medical record contained the visit notes by the Chaplain and Certified Home Health Aide (CHHA), failed to ensure the monthly hospice visitation calendar for May 2026 was available in the resident's medical record, and failed to show the day Resident 52 would be visited by the Skilled Nurse for the week of 4/26/26. These failures posed the risk of delayed communication and uncoordinated medical care between the facility and the hospice provider, which could negatively affect Residents 52's care.

Inspectors wroteBased on interview, medical record review, and facility document review, the facility failed to complete and transmit the MDS assessment timely for three of three nonsampled residents (Residents 19, 24, and 101) reviewed for resident assessments. * The facility failed to transmit Resident 19, 24, and 101's Discharge MDS assessment within the required time. This failure caused a delay in providing resident specific information for the payment and quality measure purposes to CMS.

Inspectors wroteBased on observation, interviews, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to maintain the IV access for five of six final sampled residents (Residents 24, 125, 139, 145, and 816) reviewed for the IV care. * The facility failed to ensure the dressing change was completed weekly, the arm circumference and external catheter length of the PICC line were measured, and the care plan was developed timely for Resident 24's PICC line use . * The facility failed to ensure the dressing change was completed weekly, the arm circumference and external catheter length for midline were measured, and the care plan was developed for Resident 125's midline IV catheter use. * The facility failed to obtain a physician's order for the care and maintenance of the IV line and developed a plan of care for Resident 139's IV use. [...]

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen as evidenced by: * The facility failed to ensure the sanitary condition of the hood over the stove was maintained. * The facility failed to ensure the kitchen utensils had a smooth cleanable surface and in good condition. * The facility failed to ensure the kitchenware and kitchen utensils were clean and free of food particle or residue. * The facility failed to ensure the cutting boards were kept in a sanitary condition and with cleanable surface. * The facility failed to ensure the chest freezer had a thermometer to monitor the temperature of the freezer. * The facility failed to ensure the cold beverage were maintained within the acceptable temperature range. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain the comfortable and homelike environment for one of 33 final sampled residents (Resident 70) and four nonsampled residents (Residents 6, 40, 48, and 56) as evidenced by: * The facility failed to provide the environment with comfortable sound levels for Residents 6, 40, 48, and 56 . * The wall adjacent to Resident 70's bed was observed in disrepair, with scratches and chipped paint. These failures had the potential to result in negatively impact the residents' quality of life.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the comprehensive care plan was revised for two of 33 final sampled residents (Residents 15 and 70). * The facility failed to ensure Resident 15's comprehensive care plan was revised to reflect a physician's order for the prescribed amount of fluid to be provided to Resident 15 with meals. The care plan showed to provide Resident 15 with 240 ml of fluid with meals; however, the physician had ordered Resident 15 to receive 360 ml of fluid with meals. * The facility failed to ensure Resident 70's comprehensive care plan was revised when there was a change of the behavior manifestation for Resident 70's use of Seroquel (antipsychotic) medication. These failures placed the residents at risk for not being provided with the appropriate, consistent, and individualized care.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 12 final sampled residents (Resident 2) reviewed for ADL care received the adequate personal hygiene care. * The facility failed to provide the nail care for Resident 2 which caused self-inflicted scratches. This failure had the potential to not meet the personal care needs of the dependent residents in the facility.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to provide the prescribed amount of fluids with meals, for one of 33 final sampled residents (Resident 15). * Resident 15's physician had ordered for Resident 15 to receive 360 ml of fluids with meals (breakfast, lunch, and dinner). However, Resident 15 only received 240 ml of fluids with meals. This failure had the potential to compromise Resident 15's hydration status and posed the risk for negative health outcomes.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the respiratory services in a safe and sanitary manner in accordance with the facility's P&P for three of three residents (final sampled resident, Residents 123 and 614; and nonsampled resident, Resident 815) reviewed for the respiratory care. * Resident 123 received oxygen therapy without a physician's order and Resident 123's oxygen tubing and nasal cannula were not maintained in a sanitary manner. * The facility failed to ensure the oxygen tubing was labeled and stored in sanitary manner for Resident 815. * The facility failed to ensure Resident 614's oxygen tubing and humidifier bottle were labeled with the date when they were last changed, in accordance with the facility's P&P. [...]

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to provide the necessary care and services to attain and maintain the highest practicable physical, well-being for two of 33 final sampled residents (Residents 162 and 816). * Resident 162 had scheduled dialysis treatments three times per week at a dialysis center. On the days Resident 162 was scheduled at dialysis, the resident's blood pressure medications were not held as ordered by the physician. This failure posed the risk for Resident 162 not being provided with appropriate care and treatment and possible medical complications. * The facility failed to ensure Resident 816's dialysis access site was assessed and monitored appropriately and consistently. [...]

Inspectors wroteBased on observation, interview, facility record review, and facility P&P review, the facility failed to ensure proper accounting and safeguarding of the controlled medications to prevent loss, diversion, or accidental exposure; and failed to ensure proper administration of eye drop medication for one nonsampled resident (Resident 71). * The facility failed to ensure the incoming and outgoing licensed nurses assigned to Medication Carts 2 and Cart 3 consistently signed the narcotic binder titled Controlled Substance Log. This failure posed the risk for loss or diversion of controlled medications in the facility. * The facility failed to ensure the eye drop medication was administered properly to Resident 71. This failure posed the risk of not receiving the eye drop as ordered to maintain the resident's well being.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure proper storage, labeling, and disposal of the medications. * One vial of Lidocaine (anasthetic, numbing medication) 1% removed from Medication room [ROOM NUMBER]'s IV e-kit was not documented in the Emergency Kit Usage Log. This failure has the potential for the medication in the emergency kit to be lost and/or not be replaced. * The facility failed to ensure the expired Santyl ointments were removed from Treatment Cart 2. This failure had to potential for using of the expired medications.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the special eating equipment was provided during the mealtime for one of 33 final sampled residents (Resident 27). This failure posed the risk for Resident 27 not maintaining or improving his independence in self-feeding skills when consuming meals and snacks.

Inspectors wroteBased on interview, medical record review, facility document review, and the facility P&P review, the facility failed to ensure the medical records were complete and accurately maintained for three of 33 final sampled residents (Residents 15, 20, and 123). * Resident 123's MAR failed to show the Protonix (treats conditions that cause too much stomach acid) and humalog insulin (antidiabetic) per sliding scale were administered on 3/3/25 at 0630 hours. The MAR failed to show the tuberculin test was completed on 3/18/25. In addition, the MAR failed to show the hours of sleep monitoring, non-pharmacological interventions, monitoring of side effects of hypnotics, monitoring of signs and symptoms of bleeding related to anticoagulant use, and monitoring of pain level were completed on 3/2/25 for night shift. [...]

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the appropriate infection control practices designed to provide a safe and sanitary environment and help prevent the development and transmission of infections were implemented. * Resident 139's urinal was placed next to a water pitcher and two cups of juice on the bedside table. * The facility failed to ensure a hand hygiene was performed before touching the GT. * The facility failed to ensure the staff practiced EBP when rendering GT care for one of 33 sampled residents (Resident 24). These failures posed the risk for transmission of disease-causing microorganisms.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the comprehensive care plan was developed for one of 33 final sampled residents (Resident 123). * The facility failed to develop a comprehensive care plan to address the use of oxygen for Resident 123. This failure placed the resident at risk of not being provided the appropriate, consistent, and individualized care.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the food preference was honored for one of 33 final sampled residents (Resident 34). This failure had the potential for poor meal intake and negatively impact Resident 34's psychosocial well-being.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the appropriate dietary texture was provided for one of four sampled residents (Resident 1) as ordered by the physician. * The facility failed to ensure Resident 1 was provided with the appropriate food texture as per the physician's diet orders. This failure had put Resident 1 at risk for choking.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary pharmacy services to safeguard the controlled medications for nine of 11 sampled residents (Residents 3, 4, 5, 6, 7, 8, 9, 10, and 11) as evidenced by: * 116 tablets of tramadol (a controlled pain medication used to treat moderate to severe pain) 50 mg for Resident 3 were missing from the medication cart's locked narcotic drawer. * 39 tablets of hydrocodone-acetaminophen (a controlled pain medication made up of an opioid and a mild analgesic) 5 mg/325 mg for Resident 4 were missing from the medication cart's locked narcotic drawer. * 60 tablets of tramadol 50 mg for Resident 5 were missing from the medication cart's locked narcotic drawer. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of three sampled residents (Resident 3) received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. * Resident 3 had an unwitnessed fall with injury to his head. There were no details of skin documentation after Resident 3's fall. This failure had the potential to negatively affect the resident's health and well-being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the medical records for three of eight sampled residents (Residents 2, 3, and 8) were complete and accurate. * The facility failed to ensure the licensed nurse documented the blood sugar levels and medications administered to Resident 2 in the MAR. * The facility failed to ensure the licensed nurse documented the blood sugar levelsand insulin medication administered to Resident 3 in the MAR. * The facility failed to ensure the licensed nurse documented the initials in the MAR when Resident 8's medications were administered. These failures had the potential for the residents' care needs not being met as their medical information were inaccurate and incomplete.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary pharmacy services for one of four sampledresidents (Resident 1). * The facility failed to ensure Resident 1's oxycodone medications (narcotic/pain medications) were stored properly that resulted in the missing medications. * The facility failed to ensure Resident 1's Controlled Drug record and the MAR documentation for oxycodone matched. * The facility failed to ensure the proper inventory of all narcotics during the incoming and outgoing shift changes for the licensed nurses assigned to Medication Carts 1, 2, 3, and 5. These failures had the potential for diversion of the controlled medications and possible health complications due to not administering the medications as prescribed.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the staff implemented the proper storage, labeling, and disposal of medications in a safe manner as evidenced by: * The facility failed to ensure Resident 12's opened stool softener and fish oil were properly labeled and dated in Medication Cart 5. * The facility failed to dispose of the Ozempic pen after 28 days of the open date for Resident 12 in Medication Cart 4. * The facility failed to dispose the single use opened wound care treatments and expired wound care treatments in Medication Cart 4. * The facility failed to ensure a working thermometer was in place inside the refrigerator containing medications for Medication room [ROOM NUMBER]. * The facility failed to dispose expired COVID-19 testing kit in Medication Cart 3. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the proper infection control as evidenced by: * The facility failed to perform infection surveillance for 23 of 23 residents (Resident 7, 13, 14, 20, 21, 24, 31, 42, 46, 59, 78, 90, 92, 97, 110, 132, 134, 135, 136, 762, 763, 1012, and 1013) during their COVID-19 outbreak. * The facility failed to ensure the infection control practices were maintained in the facility's laundry room area when Laundry Aide 1 was observed picking linen from the floor and then putting it in a clean laundry bin with other clean laundry. Additionally, the soiled linen carts were kept in the clean linen area touching the cover of a clean linen cart and the clean laundry bin was not covered. * Rooms A, B, and C had posted signage outside of the rooms for contact/droplet/respiratory precaution. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the antibiotic stewardship for the residents as evidenced by: * The facility failed to monitor antibiotic use for 33 of 33 residents who were ordered antibiotics in January 2024. * The facility failed to identify Residents 20 and 100's antibiotic use did not meet McGeer's criteria to notify the physician to evaluation of the prescribed antibiotics. These failures had the potential to expose the residents to the adverse effects of unnecessary antibiotic use.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure four of 33 final sampled residents (Residents 49, 61, 107, and 122) were informed in advance regarding their proposed treatments. * The facility failed to ensure the informed consent was obtained from Resident 107 before administering lorazepam (antianxiety medication) to Resident 107. * The facility failed to ensure the informed consent was obtained from Resident 49 before administering sertraline (antidepressant medication) to Resident 49. * The facility failed to ensure Resident 122's informed consent for mirtazapine (antidepressant medication) was obtained. * The facility failed to ensure Resident 61's informed consent for nortriptyline (antidepressant medication) was obtained prior to medication administration. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 33 final sampled residents (Resident 24) was assessed to safely self-administer the medications prior to performing the self-administration of medications. This failure had the potential to negatively impact the resident's physiological well-being and could administer the medications inaccurately.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to provide privacy to six of 33 final sampled residents (Residents 1, 12, 61, 128, 131, and 133) and one nonsampled resident (Resident 963). * The facility failed to provide privacy by closing the curtains while applying the topical medication patch to Resident 12's right hip. * The facility failed to provide privacy by closing the curtains while administering the medications via GT for Resident 61. * The facility failed to provide privacy when providing wound care to Resident 128. * The facility failed to ensure Residents 1, 131, and 133 were provided a dignity bag for their indwelling urinary catheter drainage bag as per the facility's P&P. * The facility failed to ensure Resident 963's laboratory results were safeguarded to protect the resident's confidential health information. [...]

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to maintain a clean, sanitary, and homelike environment for five of 33 final sampled residents (Residents 19, 61, 116, 122, and 128) and one nonsampled resident (Resident 74). * Resident 61's window was missing four blind slats and had three broken blind slats * Resident 122's room was observed with cracks and paint peeling on the ceiling * The facility failed to assess Resident 128's living condition for sanitary and homelike environment, as the bathtub and showerhead were observed with presence of rusty stain and calcium deposits. * The facility failed to ensure there were adequate washcloths to be used for Resident 19 in the facility during care. [...]

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the information on how to file a grievance was provided to one of 33 final sampled residents (Resident 116) and one nonsampled residents (Resident 153). This failure posed the risk for the residents grievances not being addressed and resolved timely.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the residents or the residents' representative were provided written or verbal notice of the facility's bed hold (holding or reserving a resident's bed while the resident in the acute care hospital) policy upon transfer to the acute care hospital for one of 33 final sampled residents (Resident 29) and one closed record sample resident (Resident 152). This failure had the potential for the residents and the residents' representative to be unaware of their rights to return to the facility following a hospitalization.

Inspectors wroteBased on interview and medical record review, and facility P&P review, the facility failed to ensure the recommendations from the Preadmission Screening and Resident Review (PASARR - a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) level II determination was followed up and incorporated into the resident care for one of 33 final sampled residents (Resident 99). This failure had the potential for Resident 99 not receiving the adequate care that was recommended by PASARR level II determination and evaluation report assessed by a appropriate state-designated authority.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the baseline care plan for one of 33 final sampled residents (Resident 133) were initiated upon admission. * The facility failed to ensure Resident 133's baseline care plan included the necessary information to properly care for the resident with the history of fluctuating weights, necessary nutritional interventions to maintain or prevent further weight loss, and individualized activity care plan to appropriate for the resident. This failure had the potential for Resident 133 not receiving necessary resident-centered care.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the care plans for two of 33 final sampled residents (Residents 133 and 812) were developed to address the residents' activities. * The facility failed to ensure Resident 133 and 812's care plans included the individualized activity care plans to provide the appropriate activities for the residents. This failure posed the risk for Residents 133 and 812 not receiving the necessary resident-centered care.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the services to attain or maintain the highest practicable well-being for five of 33 final sampled residents (Residents 12, 31, 107, 105, and 1012) and one nonsampled resident (Resident 39). * The facility failed to ensure the systolic blood pressure and heart rate for Resident 107 were monitored before administering carvedilol (anihypertensive medication) medication as per the physician's order. * The facility failed to ensure the systolic blood pressure and heart rate for Resident 105 were monitored before administering amlodipine (antihypertensive medication) hydralazine (antihypertensive medication) medications as per the physician's order. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review the facility failed to provide the necessary care and services related to pressure injury for two of 33 final sampled residents (Residents 61 and 94). * The facility failed to ensure the bilateral heel protectors were provided as ordered by the physician for Residents 61 and 94. This failure posed the risk for skin breakdown for these residents.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to ensure the adequate assistance and supervision were provided for two of 33 sampled residents (Residents 49 and 122). * The facility failed to ensure a portable space heater was not plugged in Resident 49's room at bedside. This failure provide an accident hazard for the resident and the facility in case of malfunction, and fire. * The facility failed to ensure Resident 122's tab alarm was attached to the resident. Furthermore, the facility failed to obtain directions for the use of the tab alarm. These failures had the potential to negatively impact the residents' well-being and increase the risk of the residents for more accidents which may result in further injuries. 1. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 33 final sampled residents (Resident 12)'s hydration needs were met. * The facility failed to monitor Resident 12's intake and output as per the physician's order. This failure had the potiential to negatively affect the resident's health and well-being.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary enteral feeding (a way of delivering nutrition directly to the stomach or small intestine) care and services were provided to two of 33 final sampled residents (Residents 29 and 110). * The facility failed to ensure Resident 29's enteral syringe was labeled and dated. * The facility failed to ensure Resident 110's enteral syringe was changed daily as per the facility's policy. These failures posed the risk for complications related to the use of the enteral feeding for Residents 29 and 110.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to maintain the intravenous accesses for one of 33 final sampled residents (Resident 105) and one nonsampled resident (Resident 814). * The facility failed to ensure Resident 105's midline catheter was assessed upon admission and weekly. In addition, Resident 105's midline catheter dressing was unlabeled and undated. * The facility failed to follow the physician's orders for flushing of the intravenous catheter before medication administration for Resident 814. These failures had the potential to delay identification of catheter related complications for the residents, an increased risk of potential drug incompatibility and lacking assessment of IV line patency prior to medication administration.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary respiratory care services for six of 33 final sampled residents (Residents 19, 29, 61, 107, 110, and 128) and six nonsampled residents (100, 134, 156, 162, 662, and 762). This failure posed the risk for residents' safety and respiratory related complications including infection. * The facility failed to obtain the physician's order for oxygen therapy for Residents 107 and 128. * The facility failed to ensure Resident 19's BiPap was stored properly and not hanging on the wall. * The facility failed to provide oxygen therapy as per the physician's order for Resident 662. * The faclity failed to ensure the nebulizer machine was not on the floor for Resident 134. [...]

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to offer or provide adequate and appropriate pain management for one of 33 final sampled residents (Resident 34). * The facility failed to administer pain medication for Resident 34 after a fall on 1/26/24. This failure had the potential to cause the resident unnecessary pain and complications from worsened pain.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary care and services to attain the highest physical wellbeing for four of 33 final sampled residents (Residents 42, 107, 128, and 812) who required dialysis. * The facility failed to ensure Residents 812's pre dialysis assessment (access site, vital signs, time of last meal, blood sugar, lung sound assessment, LOC, Covid-19 signs, and symptoms), dialysis center assessment and post dialysis assessment (dressing in place, bleeding on site, SOB, assessment of dialysis site, signs and symptoms of infection to access site, vital signs, and Covid-19 signs and symptoms) were completed. * The facility failed to perform the post dialysis treatment assessment and ensure the dialysis communication forms for Resident 128 were completed. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services for two of 33 final sampled residents (Residents 12 and 89). * The facility failed to obtain the consent for 1/2 side rails for Resident 12 as per the physician's order. In addition, the facility failed to ensure the bed assessment was correct to reflect Resident 12's bariatric bed. These failures had the potential to put the residents at risk for serious injuries from side rail use.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the pharmaceutical services to meet the residents' needs for two of 33 final sampled residents (Residents 24 and 42) and two nonsampled residents (Residents 162 and 814). In addition, the facility failed to ensure the controlled medication was accurately reconciled. * The facility failed to ensure Residents 24 and 42's scheduled medications were administered within 60 minutes of scheduled time per the facility's P&P. * The facility failed to ensure accurate documentation of the controlled medications to one nonsampled resident (Resident 162) for hydrocodone-acetaminophen 5-325 mg (narcotic pain medication). * The facility failed to ensure the prefilled normal saline syringe for Resident 814 was not left unattended on the medication cart. [...]

Inspectors wroteBased on interview, medical record review, and facility document review, the facility failed to ensure the Pharmacy Consultant's recommendations were acted upon for two of 33 final sampled residents (Residents 19 and 107). * The facility failed to follow-up on the Pharmacy Consultant recommendation to place hold parameters for minoxidil (a vasodilator used to treat high blood pressure) medication for Resident 107. * The facility failed to follow-up on the Pharmacy Consultant recommendation to place blood glucose hold parameters for glargine (a synthetic version of human insulin) medication for Resident 19. These failures had the potential to put the residents at risk for adverse consequences related to the medications.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure one of 33 final sampled residents (Resident 12) was free from the unnecessary drugs. * Resident 12 was administered midodrine (medication to treat low blood pressure) when Resident 12's blood pressure was above the parameter prescribed by the physicians. This failure had the potential for Resident 12 to develop significant side effects such as hypertension (high blood pressure).

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure three of 33 final sampled residents (Residents 21, 34, and 49) were free from the unnecessary psychotropic drugs (any drug that affects brain activity associated with mental processes and behavior) as evidenced by: * The facility failed to ensure the PRN orders for lorazepam (antianxiety) and temazepam (hypnotic) medications were limited to 14 days. There was no documented evidence explaining why the PRN orders were extended beyond the 14 days. This failure had the potential for the resident to have adverse complications from the medications. * The facility failed to ensure the physician's order for Lexapro (antidepressant medication) included a specific behavior manifestation for Resident 34. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 12.82%. Three licensed nurses (LVNs 8, 12, and 17) were found to have made errors during the medication administration for two of 33 final sampled residents (Residents 12 and 61) and one nonsampled resident (Resident 62). * LVN 8 failed to administer the Cholecalciferol Tablet and multivitamin with minerals for Resident 61. * LVN 17 failed to properly administer omeprazole (a medication used to treat gastroesophageal reflux disease (GERD) to suppress stomach acid secretions) for Resident 12. * LVN 12 failed to properly administer the eye drops for Resident 62. These failures had the potential to negatively affect the residents' health conditions.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure six of 149 residents who received meals in the facility were provided the correct amount of gravy as directed by the Cook's Spreadsheet. This failure had the potential to provide the residents who received meals in the facility with incorrect nutrients.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to provide the food preference for two of 33 final sampled Residents (Residents 3 and 26). This failure had the potential for inadequate nutrition.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure proper sanitation was maintained for food prepared by the kitchen when: * The Assistant Director of Dietary Services/Cook 2 (Assistant DDS/Cook 2) failed to perform hand hygiene while preparing pureed food from the kitchen. * The facility failed to ensure Resident 762's dessert was stored and prepared under sanitary conditions when their pumpkin dessert was not covered or wrapped on the resident's meal tray while being transported by the staff to the resident's room. * The facility failed to ensure Resident 1's two bags of chips, five bottles of coke and disposable drinking cups were properly stored. These failures had the potential to cause foodborne illnesses and spread of infection.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure accurate and complete medical records for two sampled residents (Residents 61 and 94) and one closed record sample resident (Resident 152). * Resident 61's physician's order was not consistent with the resident's condition. * The facility failed to ensure the discharge documentation was completed for Resident 152. * The facility failed to ensure the TAR was completed to show the treatment was administered for Resident 94. These failures had the potential to result in medication error and delay of care administration; and potential for lack of follow up.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the coordination of hospice services for one of 33 final sampled residents (Resident 32). * The facility failed to ensure Resident 32 had hospice visitation calendar projection for each month showing the scheduled visits of the hospice's staff. There was no coordination regarding the care plan. This failure had the potential for not providing the timely, appropriate, and consistent care to Resident 32.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the residents' entrapment assessments were completed for two of 33 final sampled residents (Resident 12 and 34). This failure had the potential to negatively impact the residents resulting in possible entrapment, serious injury, and death.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 33 final sampled residents (Resident 812) was provided with the opportunity to participate in care plan meeting. * The facility failed to ensure Resident 812 was provided with the opportunity to be informed of the plan of care. This failure had the potential for Resident 812 to not be able to choose the treatment options and make the decisions in the care planning.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to develop the comprehensive plans of care to reflect the use of oxygen therapy for two of 33 final sampled residents (Resident 128) and one nonsampled resident (Resident 662). This failure had the potential for not providing appropriate, consistent, and individualized care to these residents.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the comprehensive plan of care for one of 33 final sampled residents (Resident 1) and one nonsampled resident (Resident 762) were revised to reflect the residents' current care needs and interventions. * Resident 762's care plan for obstructive sleep apnea (occurs when the upper airway becomes blocked, leading to brief pauses in breathing during sleep) was not revised to address the current CPAP (machine used to provide mild air pressure to keep breathing airways open during sleep) order. * The facility failed to ensure Resident 1's plan of care was revised to reflect the use of hydrocodone-acetaminophen (Norco is used to relieve moderate to severe pain). These failures posed the risk of not providing the residents with individualized and person-centered care.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure one nonsampled resident (Resident 69 ) was provided with the prescribed therapeutic diet. * Resident 69 was prescribed with a low fat low cholesterol diet food, fat free skim milk. The resident was not provided skim milk or alternative on the lunch tray. This failure had the potential for Resident 69 to not receive adequate nutrition which poses a risk of compromising the resident's nutritional and medical status.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the call lights for 10 of 29 sampled residents (Residents 2, 3, 4, 7, 8, 11, 12, 24, 25, and 26) were answered promptly. In addition, the facility failed to ensure Residents 2, 4, and 7 ' s call lights were within the resident ' s reach. These failures had the potential for the residents to not get their needs met timely.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to ensure eight of 29 sampled residents (Residents 1, 3, 6, 8, 9, 10, 13, and 22) and one nonsampled resident (Resident B) attained and maintained their highest practicable and physical well-being. * The facility failed to provide the appropriate and necessary nursing services to ensure Resident 13 received daily wound treatments for his diabetic foot ulcer (a wound complication of diabetes which can cause bone infection and amputations) as per the physician's orders. In addition, the facility failed to evaluate Resident 13's skin upon admission and failed to implement weekly skin assessments as per the facility P&P. The facility additionally failed to ensure Resident 13's admission assessments were completed upon his admission to the facility. [...]

Inspectors wroteBased on interview and facility document review, the facility failed to ensure adequate 24-hour staffing was maintained to meet the residents' care needs. This failure had the potential to result in the residents not being provided with care consistent with professional standards of practice and care as outlined in their person-centered plans of care. * The facility failed to have adequate licensed nurses to administer the scheduled medications at 2100 hours on 1/9/24, for Residents 8, 9,and 10. * The facility failed to have adequate licensed nurses to provide the wound care to Residents 13, 14, and 15. * The facility failed to have adequate staff to ensure the care was provided timely to the residents on 1/9/24. These failures placed the residents at risk for adverse outcomes.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure one of 29 sampled residents (Resident 3) was provided the right to self-determination and communication regarding the changes of Resident 3 ' s Social Security Income (provides monthly payments to people with disabilities and older adults who have little or no income or resources) collection. This failure had the potential to affect Resident 3 ' s quality of life.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the Physician Orders for Life Sustaining Treatment (POLST) and advance directives information were accurate for four of 29 sampled residents (Residents 1, 2, 3, and 22) and one nonsampled resident (Resident B). These failures had the potential for the facility to provide treatment and services against the resident's wishes.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to maintain the comfortable temperatures for six of 80 resident rooms (Rooms A, B, C, D, E, and F) housing 12 residents (Residents 2, 4, 17, 18, 23, 25, 27, E, F, G, H, and I). This failure had the potential for negatively affect the residents' health and well-being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the safe and appropriate discharge when one of 29 sampled residents (Resident 1) was discharged to another skilled nursing facility approximately 36.5 miles away. * The facility failed to ensure Resident 1 met the facility's criteria for discharge according to the facility's P&P. * The facility failed to document Resident 1's transfer information in the medical record. * The facility failed to ensure appropriate information was communicated to SNF 2 prior to the transfer of Resident 1. These failures had the potential of miscommunication of information, unsafe discharge, and not providing necessary care and services to the resident.

Inspectors wroteBased on interview and medical record review, the facility failed to notify one of 29 sampled residents (Resident 1) and their representative of their transfer/discharge and the reasons for the move in writing. In addition, the facility failed to send a copy of the transfer/discharge to the representative of the Office of the State Long-Term Care Ombudsman (a person who routinely visits the facility and advocated for the residents). These failures resulted in Resident 1 and the representative to be not aware of the discharge.

Inspectors wroteBased on interview and medical record review, the facility failed to provide and document sufficient orientation and preparation to ensure the safe and orderly discharge for one of 29 sampled residents (Resident 1) prior to Resident 1's discharge to another healthcare facility, SNF 2. This failure resulted in Resident 1 and his responsible party of not having the necessary information for a safe and orderly discharge.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the comprehensive plans of care for two of 29 sampled residents (Residents 1 and 17) were revised to reflect the resident's current care needs and interventions. * Resident 1's plan of care was not updated to include all the fall interventions recommended by the IDT. * Resident 17's plan of care failed to show a care plan problem addressing the use of Seroquel. These failures posed the risk of not providing the residents with individualized and person-centered care.

Inspectors wroteBased on interview and medical record review, the facility failed to develop the discharge plan for one of 29 sampled residents (Resident 1) when Resident 1 was discharged to another healthcare facility, SNF 2. Subsequently, Resident 1 was discharged to another skilled nursing facility approximately 36.5 miles away. This failure had the potential to negatively impact the resident's well-being.

Inspectors wroteBased on observation, interview, and medial record review, the facility failed to ensure the necessary care and services were provided to prevent the development and worsening of pressure injuries for three of 29 sampled residents (Residents 14, 15, and 24). * The facility failed to provide the appropriate and necessary nursing services to ensure Resident 14 received daily wound treatments for his Stage 4 pressure injury (a wound caused by pressure which results in tissue loss with exposed bone, tendon, or muscle) as per the physician's orders. * The facility failed to ensure Resident 15 received daily wound treatments for his Stage 4 pressure injury as per the physician's orders. * Resident 24 had a physician's order for a low air loss mattress (a special mattress designed to distribute the resident's body weight over a broad surface area and help prevent skin breakdown); [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure three of 29 sampled residents (Residents 19, 20, and 21) remained free from accident hazards. * The facility failed to update a care plan to address the fall sustained by Resident 20 on 1/6/24, and Resident 21 on 12/15/23. * The facility failed to ensure the IDT had met and discussed the factors that lead to the fall and the intervention on how to prevent further falls for Resident 19 who sustained a fall on 1/6/24, Resident 20 who sustained a fall on 1/6/24, and Resident 21 who sustained a fall on 12/15/23. These failures had the potential for the residents to sustain additional falls and possible injuries.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the proper indwelling urinary catheter care for one of 29 sampled residents (Resident 17). * Resident 17 was observed with an indwelling urinary catheter bag on the floor and/or attached to a trash can on multiple occasions. This failure put Resident 17 at risk for infection, such as UTI.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the appropriate pain management was provided to two of 29 sampled residents (Residents 10 and 23). * The licensed nurse failed to notify the physician regarding Resident 10's complaint of pain level more than 6 and the resident's prescribed PRN pain medications were only for the pain levels of 1-6. * The facility failed to ensure the pain medication was given as ordered by the physician. Resident 23 waited six hours to receive the next pain medication dose. These failures resulted in the residents not receiving effective pain management. 1. Medical record review for Resident 10 was initiated on 1/10/24. Resident 10 was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the pharmaceutical services to ensure the accurate administration, reconciliation, and disposition of all drugs to meet the needs of the residents. * The facility failed to ensure the physical inventory of controlled medications was conducted during shift change as per the facility's P&P, for one of the six medication carts (Medication Cart A). * The facility failed to ensure administration of the medications for Resident 9 and Resident D were accurately documented to ensure accurate reconciliation and prevent medication errors. These failures posed the risk for diversion and medication administration errors.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of 29 sampled residents' (Resident 17) medication regimen was managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being. * Resident 17 had a physician's order for the use of Seroquel (antipsychotic medication) for hallucinations; however, there was no monitoring of the behaviors and side effects in place. This failure had the potential for Resident 17 to receive the unnecessary psychotropic medication and/or the physician to not know the effects of the medication.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure two of 29 sampled residents (Residents 8 and 9) were free from the significant medication errors. The facility failed to administer Residents 8 and 9 their scheduled medications. This failure put the Residents 8 and 9 at risk for medical complications.

Inspectors wroteBased on observation and interview, the facility failed to ensure the garbage was stored in a sanitary manner. This posed a threat of pest contamination. According to the USDA Food Code 2017, 5-501.113, Covering Receptacles, receptacles and waste handling units for refuse .shall be kept covered (B) with tight-fitting lids or doors if kept outside the food establishment. On 1/17/24 at 1424 hours, an observation and concurrent interview with Maintenance Assistant was conducted. Two of two dumpsters were observed overflowing with garbage restricting the lid from closing. The Maintenance Assistant confirmed dumpsters should be closed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 10 sampled residents (Resident 3) who had limited mobility and ROM received the appropriate treatment and services to maintain or improve their ROM functions and prevent further decline in their ROM functions. * Resident 3 had orders for RNA services to both BUE and BLE;however, Resident 3 was not provided RNA services for the BLE since it was ordered by the OT on 5/2/23. In addition, Resident 3 had physician ' s orders for a hand surgeon consultation due to hand contracture ordered on 8/22/23; however, the order was not addressed until 12/7/23. This failure had the potential for Resident 3 to experience a decline his physical abilities.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the proper side effect monitoring of blood thinner medications for one of 10sampled residents (Resident 8) and one nonsampled resident (Resident GG); and hemodialysis monitoring for Resident GG while on hemodialysis as evidenced by: * The facility failed to monitor for bleeding or bruising for Resident 8 while on the blood thinner medications. * The facility failed to monitor Resident GG for bleeding or bruising while on a blood thinner medication and hemodialysis monitoring while on hemodialysis. These failures had the potential to cause negative outcomes for the residents.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the food safety requirements were met. * The frozen foods stored in the freezer were not maintained at a temperature to keep the frozen food solid. The freezer had no thermometer to monitor food temperatures and functioning of the freezer. * The foods stored in the freezer were not dated. * The freezer was not maintained in a clean and sanitary condition. These failures had the potential to cause foodborne illnesses in a medically vulnerable resident population.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the medical record for two of 10 sampled residents (Residents 1 and 2) were accurate and complete. * Residents 1 and 2 ' s medical recordshad inconsistent documentation on the MAR for checking the placement and functionality of their WanderGuards (a safety bracelet with a sensor which a resident will wear. When the resident approaches a monitored door, the system with alert with a loud noise. WanderGuards are typically utilized for residents who are at risk for wandering and elopement). This failure had the potential for the staff to not have accurate and complete medical information, which could contribute to accidents and hazards associated with malfunctioning of the WanderGuards.

Inspectors wroteBased on observation, interview and medical record review, and facility P&P review, the facility failed to maintain the infection control practiceswhen Resident 9 ' s family member was observed not wearing the PPE while inside a contact isolation room. This failure had the potential to spread the infection to the staff and residents.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the reasonable accommodations to meet the care needs for one of five sampled residents (Resident 1). * The facility failed to ensure Resident 1's call light was kept within sight and reach. This failure had the potential to negatively impact Resident 1's psychosocial well-being or result in a delay to provide care and services to the resident.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the medical record for one of five sampled residents (Resident 5) was accurate and complete. * The facility's licensed nurse failed to document a summarization of Resident 5's change of condition event, interventions provided after Resident 5 had experienced signs of unresponsiveness, and if the medical information of Resident 5 was reported to the receiving acute care hospital. This failure had the potential for medical information for Resident 5 to be inaccurate and incomplete.

Inspectors wroteBased on interview, medical record review, and facility document review, the facility failed to ensure the Long-Term Care Ombudsman (a person who routinely visits the facility and advocated for the residents) was notified of the discharge for four of 18 closed record sampled residents (Residents 15, 16, 17, and 18). This failure had the potential of not providing the residents with access to an advocate who could inform them of their options and rights related to discharge.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the resident or the resident's representative was provided written or verbal notice of the facility's bed hold policy upon transfer to the acute care hospital for one of 18 sampled residents (Resident 4). This failure had the potential for the resident or the resident's representative to not being aware of their rights to return to the facility following a hospitalization.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the medications were administered as ordered by the physician for three of 18 sampled residents (Residents1, 2, and 3). * Resident 1's nystatin external cream (antifungal cream) doses were missed and administered six hours later than scheduled. * Resident 2's gabapentin (a medication used to treat nerve pain) doses were not administered as prescribed. * Resident 3's insulin injection (a medication used lower the level of glucose (type of sugar in the blood) doses was not administered as prescribed. These failures had the potential to result in poor health outcomes to the residents.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to comply with the State law related to four employees (LVNs 5 and 6; and Housekeeping Staff 1 and 2) not wearing their name badges while on duty. This failure had the potential to place the residents at risk to be cared for by unidentified persons.

Inspectors wroteBased on interview and medical record review, the facility failed to provide the necessary respiratory care to meet the needs of one of four sampled residents (Resident 3). * The facility failed to ensure Resident 3 was assessed and monitored after Resident 3 had complained of difficulty breathing and shortness of breath (known medically as dyspnea, often described as an intense tightening in the chest, air hunger, difficulty breathing, breathlessness or a feeling of suffocation). * The facility failed to ensure Resident 3 was adequately oxygenated when she was hypoxemic (a low level of oxygen in the blood) and experienced symptoms of hypoxia (low levels of oxygen in the body tissues; symptoms may include confusion, restlessness, difficulty breathing, rapid heart rate, and bluish skin). [...]

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure one LVN (LVN 3) had the specific competencies and skill sets necessary to care for the residents' needs. The facility failed to ensure LVN 3 was competent in the administration of medications via inhalation. This failure had the potential to negatively impact the resident's well-being.

Inspectors wroteBased on interview and medical record review, the facility failed to provide the necessary care and services to ensure two of four sampled residents (Residents 1 and 2) maintained good grooming and personal hygiene. This failure had the potential for the residents to experience the physical discomfort, emotional distress, health complications, and a decreased quality of life.