The Meadows on Sunset Post Acute

Inspectors wroteBased on interview and record review, the facility failed to ensure prompt attempts were made to process and resolve the grievances for one of three sampled residents (Resident 1) when the facility failed to investigate the concern reported by Resident 1. This deficient practice had the potential to violate Resident 1's rights.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care in a manner that maintained a resident's respect and dignity for six (6) of eight (8) sampled residents (Resident 3, 21, 51, 84, 106, 123) when: 1. Certified Nurse Assistant (CNA) 1 and CNA 4 failed to maintain privacy for Residents 21 and 84 while providing Activities of Daily Activities (ADL - basic tasks that must be accomplished every day for an individual to thrive) care. 2. CNA 8 and CNA 3 were standing over Resident 51 and 106 while assisting the residents during mealtime. 3. The staff failed to cover urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) bags with dignity bags (device used to cover the contents of a urinary catheter bag) for Residents 3 and 123. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the call light (an alerting device for nurses or other nursing personnel to assist a patient when in need) was within reach of five of nine sampled residents (Resident 45, 15, 103, 102, 96) reviewed under environment task. The deficient practice had the potential to place the resident at risk for delayed assistance, potentially affecting safety and timely care.

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 71, 102, and 106) reviewed for physical restraints by failing to ensure: 1. Resident 71`s use of a bed placed against the wall was assessed on a quarterly basis. The most recent assessment was completed on 10/2/2025. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to update a resident's comprehensive care plan (a document outlining a detailed approach to care customized to an individual resident's need) for one of five sampled residents (Resident 91) reviewed under the urinary catheter (also known as Foley catheter, is a hollow flexible tube inserted in the bladder through the urethra to drain urine) or UTI (urinary tract infection - an infection in the bladder/urinary tract) care area to include notifying Resident 91's physician when the indwelling urinary catheter becomes dislodged or removed, place a urinary catheter securement device, and follow Resident 91's physician order to change Resident 91's indwelling urinary catheter every 30 days. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment was free of accident hazards for four of eight sampled residents (Residents 13, 109, 138, and 106) reviewed for accidents by failing to ensure residents did not have a furniture or equipment on top of the floor mat (specially designed mats provide cushioning and support to patients who are at risk of falling, helping to prevent serious injuries) and bilateral padded siderails were in place as ordered by the physician. These deficient practices increased the risk of accidents such as falls with injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents with a urinary catheter (also known as Foley catheter - a hollow tube inserted into the bladder to drain or collect urine) received appropriate care and services to prevent urinary tract infections (UTI, an infection in the bladder/urinary tract) for seven of seven sampled residents (Resident 91, 135, 137, 51, 123, 3, and 61) reviewed for urinary catheter or UTI by failing to: 1a. Follow the physician order to insert indwelling urinary catheter 16 French (Fr - outer diameter of the catheter size) size when Resident 91 was observed with a gauge 18 Fr size indwelling urinary catheter. 1b. Label with a date when the indwelling urinary catheter was inserted for Resident 91. 1c. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents' bed rails (metal or plastic bars or guards attached to the sides of a bed to act as a barrier or support) prior to installation for three of three sampled residents (Residents 96, 85, and 5) reviewed for bed rails by failing to ensure: 1. Resident 96's use of bilateral half (1/2) side/bed rail (or half-length rail) is a safety device for hospital-style beds that covers only a portion of the bed's side, usually the top half near the headboard) had a/an: -Physician's order -Current consent, the resident was readmitted to the facility on [DATE], the consent on the electronic healthcare record was from 9/13/2025 -Correct care plan, the care plan on the electronic healthcare record was for bilateral 1/4 side rail. 2. [...]

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 (Resident 8 and 2) 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 subcutaneous (sq, beneath the skin) insulin administration sites. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Label and date fresh foods held in the kitchen walk-in refrigerator. 2. Discard leftover food held in the kitchen walk-in refrigerator beyond seven days. 3. Record open dates on personal food items held in the resident refrigerator. These deficient practices had the potential to result in harmful bacterial growth that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or toxins) in 125 of 132 medically compromised residents receiving meals from the kitchen and those who had food stored in the patient refrigerator.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections by, failing to ensure: 1. Three of three sampled linen carts (linen carts 10, 11, and 12) were kept in good condition that were free of holes, tears, and rips. 2. Linens were free of contamination. This deficient practice had the potential to result in contaminated linens, sheets, towels, and gowns being provided to the residents. 3. Employee COVID-19 (an infectious disease caused by the SARS-CoV-2 virus) Vaccination Policy was updated and matched facility's practice. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure visitation restrictions were addressed for one (1) of three (3) sampled residents (Resident 41) when the facility was not aware of Resident 41's responsible party's (RP) request for no visitors without the RP's presence. This deficient practice had the potential for Resident 41 to have unwanted visitors that could cause anxiety or distress to the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that mail is being delivered to three (3) out of ten (10) sampled residents (Resident 17, Resident 88, and Resident 130) on Saturdays. This deficiency had the potential for residents to feel isolated and worry that their mail might get lost.

Inspectors wroteBased on interview and record review, the facility failed to inform and provide written information to all adult residents concerning the right to accept and refuse medical and surgical treatment and, at the resident's option, to formulate an advance directive (a legal document indicating resident preference on end-of-life treatment decisions) for two (2) of four (4) sampled residents (Resident 12 and 71) with the Social Services Director (SSD) by failing to ensure the Advanced Healthcare Directive Acknowledgement Form was completed. This deficient practice violated the resident's rights and/or representative's right to be fully informed of the option to formulate their advanced directives.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a homelike environment for one of one sampled resident (Resident 54) by not maintaining functional closet drawers. This deficient practice violated Resident 54's rights to a safe, clean, sanitary, and homelike environment.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents are screened using the Preadmission Screening and Resident Review (PASRR - a federal requirement to help ensure that individuals are not appropriately placed in nursing homes for long-term care) for a mental disorder (MD - a health condition that significantly affects a person's thinking, emotional regulation, mood, or behavior, making it difficult to cope with daily life) or intellectual disability (ID - a condition that limits intelligence and disrupts abilities necessary for living independently) prior to admission and that individuals identified with serious mental illness (SMI - a health condition that significantly affects how a person thinks, feels, behaves, or interacts with others) and/or ID/developmental disability (DD - a group of conditions due to an impairment in physical, learning, language, or [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a tool that ensures residents receive personalized, comprehensive, and goal-oriented care in a nursing home setting) for one (1) of 1 sampled resident (Resident 106) reviewed under Preadmission Screening and Resident Review (PASRR - a federal requirement to help ensure that individuals are not appropriately placed in nursing homes for long-term care) care area addressing the resident's diagnoses of schizophrenia (a mental illness that is characterized by disturbances in thought). These deficient practices had the potential for a delay in the delivery of the necessary care and services the resident needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure effective communication for one of one sampled resident (Resident 61) with hearing impairment, when the facility did not provide communication board (a device that displays symbols, photos, or illustrations to help individuals with limited hearing or language skills to communicate) or other alternative communication tools. This deficient practice had the potential to result in Resident 61's unmet needs, misunderstanding of care and instructions, decreased participation in care, and increased risk for harm due to inability to effectively communicate.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary Activities of Daily Living (ADL - activities such as bathing, dressing and toileting a person performs daily) care, specifically grooming, including nail care, for one of one sampled resident (Resident 43). This failure had the potential to result in poor hygiene, increased risk of infection, skin injury from scratching for Resident 43.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents with pressure ulcers/injury (a skin and tissue injury caused by prolonged pressure on the skin, often over bony areas) received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for one of four sampled residents (Resident 85) reviewed under pressure ulcer/injury by failing to ensure the low air loss mattress (LALM, a specialized bed mattress that helps prevent and treat pressure ulcers by using a continuous flow of air to regulate temperature and moisture on the skin) of Resident 85 was set according to the resident's weight. The deficient practices had the potential for worsening of Resident 85`s pressure injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff providing care and services to the resident who had a feeding tube (are soft plastic tubes through which liquid nutrition travels through the gastrointestinal tract [the series of organs that food and liquids pass through as they are digested, absorbed, and leave the body as feces]) were aware of, competent in, and utilized facility protocols regarding feeding tube nutrition and care for one of twenty-two sampled residents (Resident 136) observed during initial screening of the residents by failing to label the water flush bag for enteral fluid hydration (is the process of delivering water and essential fluids directly into the stomach or small intestine to keep the body hydrated, typically using a feeding tube) with the rate of infusion. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure parenteral fluids (are liquids that are administered intravenously or by injection to bypass the digestive system) were administered consistent with professional standards of practice for one (1) of one (1) sampled resident (Resident 28) reviewed during a random observation by failing to ensure Resident 28's midline catheter (a long, thin, flexible tube that is inserted into a large vein in the upper arm) indicated the date of the last dressing change. This deficient practice had the potential to place Resident 28 at risk for developing complications such as inflammation of the vein and infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respiratory care provided to residents was consistent with professional standards of practice for two of two sampled residents (Residents 71 and 78) reviewed for respiratory care by failing to ensure: 1. Resident 71's oxygen tubing (a small, soft plastic tube used to give someone extra oxygen) was kept off the floor. The deficient practice had the potential for residents to develop complications such as shortness of breath and desaturation (low levels of oxygen in the blood) and respiratory infections. 2. Resident 78`s oxygen tubing was not touching the floor, trash can, and under the bedside table. This deficient practice had the potential to result in placing Resident 78 at risk for infection.

Inspectors wroteBased on observation, interview, and record review, Licensed Vocational Nurse (LVN) 2 failed to accurately identify the resident and assess the resident's pain level (also known as the pain scale, a 0-10 numerical scale to help healthcare providers assess pain severity and manage treatment that ranges from 0 [no pain] to 10 [worst imaginable pain], with 1-3 being mild, 4-6 moderate, and 7-10 severe) prior to administrating pain medication for one (1) of 1 sampled resident (Resident 117). This deficient practice has the potential to result in medication error and effective pain management, which may negatively impact Resident 117's comfort, safety, and overall well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident's (Resident 61) hearing assessment was accurately documented to reflect Resident 61's impaired hearing. This deficient practice resulted in inaccurate clinical documentation and had the potential to impact Resident 61's care planning and communication interventions.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the hospice (compassionate care for people who are near the end of life) provides services to the resident in a way that meets his/her needs in a timely manner including review of the resident's record for pertinent documentation regarding the delivery of hospice care for one of one sampled resident (Resident 5) reviewed for hospice and end of life by failing to ensure hospice care services were provided according to Hospice Orders/Visit Frequency List. The deficient practice had the potential to result in a delay or lack of coordination in delivery of hospice care and services to residents.

Inspectors wroteBased on interview and record review, the facility failed to implement its antibiotic (ATB - a medicine that fights bacterial infections by killing bacteria or stopping them from multiplying) stewardship program (a coherent set of actions which promote using antimicrobials responsibly) that includes antibiotic use protocols and a system to monitor antibiotic use for (1) of three (3) sampled residents (Resident 28) reviewed for antibiotic use by failing to ensure the physician indicated a reason for the continued use of antibiotics when the resident did not meet the criteria. This deficient practice placed Resident 28 at risk for development of resistance to antibiotics which may lead to multidrug resistant organisms (MDRO - organisms primarily bacteria that have developed resistance to multiple classes of antibiotics making infections difficult to treat).

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain mechanical, electrical, and resident care equipment in safe operating condition for one (1) of nine (9) sampled residents (Resident 129) reviewed under the environment task by: 1. Failing to ensure Resident 129's bed controller (device used to change the height and angle of the bed) cord did not have exposed wires and was covered with black plastic tape. 2. Failing to ensure Resident 129's bed control's touch pad cover was not peeling off and properly functioning. These deficient practices had the potential to place Resident 129 at risk of incurring injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that call light (an alerting device for nurses or other nursing personnel to assist a resident when in need) was functioning in the bathroom located in resident's room for three of three sampled residents (Resident 1, 2, and 3). This deficient practice had the potential to delay assistance and increase the risk of falls for Residents 1, 2, and 3.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a person-centered care plan (a plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs) for one of three sampled residents (Resident 1) to address Resident 1's left upper chest port catheter (a long-term vascular access device placed in chest pain for easy access to vein for renal dialyses [a life-sustaining treatment for kidney failure that uses an external machine and a specialized filter to remove waste products and excess fluid from the blood]). This failure had the potential to delay care and negatively affect Resident 1's well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement their policy and procedure on ensuring the medications in the facility were checked and maintained by failing to:a. Ensure one of 15 locked e-kit (e-kit - a pre-packed set of medications used in emergency situations) medication boxes did not contain expired medications. The intramuscular (IM - medication administered into a muscle) e-kit medication box located at station 2 had an expired medication in it for 75 days. b. Ensure the licensed nurses checked 15 out of 15 e-kits in the facility every shift. c. Ensure licensed nurses disposed of the medications of one of four sampled residents (Resident 4) within 90 days after discharge. Resident 4's medications were in the facility for 179 days after the resident was discharged from the facility.d. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) receive treatment and care in accordance with professional standards of practice to meet the resident's physical, mental, and psychosocial (relating to the interrelation of social factors and individual thoughts and behavior), by failing to: 1. Initiate Change of Condition (COC -major decline or improvement in a resident's status that will not resolve without intervention) form, notify the physician, and complete a post-fall assessment of Resident 1, when on 6/29/2025, at approximately 9:50 p.m., Resident 1 sustained a fall in the bathroom, in Room A (Resident 1's room). 2. Obtain orders from the physician for Resident 1's right wrist and distal forearm splint (a strip of rigid material used for supporting and immobilizing a broken bone when it has been set) care. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure prompt attempts were made to resolve the grievances for one of three sampled residents (Resident 1) when the facility failed to investigate the concerns reported by Resident 1. This deficient practice had the potential to violate Resident 1's rights.

Inspectors wroteBased on interview and record review, the facility failed to follow its Policy and Procedures (P&P) titled, Discharge Planning Process, for one of three sampled residents (Resident 1) by failing to: 1. Initiate a Care Plan (a plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs) for Resident 1's discharge plan upon admission. 2. Provie the Discharge Transition Plan to Resident 1 prior to discharge on [DATE]. 3. Provide the Notice of Transfer or Discharge (a mandatory legal document formally informing the resident about the transfer or discharge, stating the reason for discharge or transfer, and their rights to appeal the decision) form to Resident 1 prior to discharge on [DATE]. This deficient practice had the potential to violate Resident 1's rights. Cross Reference with F842.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a person-centered care (CP, a plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs) for one of three sampled residents (Resident 1), by failing to: 1. Develop a care plan to address Resident 1's discharge planning. 2. Develop a care plan to address Resident 1's right wrist and distal forearm splint (a strip of rigid material used for supporting and immobilizing a broken bone when it has been set). These failures had the potential to delay care and negatively affect Resident 1's well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure the medical records for one of three sampled residents (Resident 1) were maintained in accordance with accepted professional standards and practice, complete, and accurately documented, by failing to: 1. Ensure facility staff did not sign Resident 1's Notice of Transfer or Discharge (a mandatory legal document formally informing the resident about the transfer or discharge, stating the reason for discharge or transfer, and their rights to appeal the decision) form to show that Resident 1 had received the Notice of Transfer or Discharge form prior to Resident 1's discharge on [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two of five sampled residents (Resident 1 and Resident 2) were free from significant medication errors by failing to ensure the physician orders were followed. The facility failed to ensure Resident 1 and 2's calcium carbonate oral tablet (a medication, taken by mouth, used for calcium supplement, relieve heartburn, indigestion, and upset stomachs) 600 milligrams (mg - unit of measurement) was administered on multiple dates. This deficient practice had the potential to cause Resident 1 and Resident 2's discomfort.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of seven sampled residents (Resident 4, Resident 5, and Resident 6) were free of any significant medication error when Licensed Vocational Nurse (LVN) 2, failed to administer medication as ordered and there was a delay in administration of four hours to six hours and 30 minutes. These deficient practices had the potential to negatively affect Resident 4, Resident 5, and Resident 6.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its activities program for one of seven sampled residents (Resident 2) when on 11/18/2025 at 2 p.m. the resident activity room was observed closed with no activities being held, when the facility activities calendar indicated on 11/18/2025 at 2 p.m., Crossword Club, would be held. This deficient practice had the potential to negatively affect Resident 2.

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 two of seven sampled resident (Resident 1 and Resident 3) by falling to complete post dialysis assessment after the residents' return to the facility 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 your entire body] and venous [blood vessels located throughout your body that collect oxygen-poor blood and return it to your heart] side of heart). 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that one of three sampled residents (Resident 1), who had moderately impaired cognition (a noticeable decline in thinking, memory, and judgment that is more significant than normal aging but does not prevent the resident from performing most daily tasks), bed-bound (unable to leave the bed due to illness or weakness), dependent on staff for activities of daily living (ADLs - activities such as bathing, dressing, and toileting a person performs daily), and was receiving Porcine Heparin injection (a powerful anticoagulant [blood thinner] medication used to prevent and treat blood clots that increases the risk of bleeding), was provided the necessary care and services in accordance with professional standards of practice when on 9/26/2025 at 4:47 a.m., Resident 1 had a change in condition (CIC - a major decline in a [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free from significant medication errors by failing to ensure the physician orders were followed. The facility failed to ensure Resident 1's metoprolol oral tablet (a medication, taken by mouth, used to treat high blood pressure) 25 milligrams (mg - unit of measurement) was not administered for systolic blood pressure (SBP - the pressure in the arteries when the heart beats) of less than 110 or heart rate (HR) of less than 60 beats per minute (bpm) on multiple dates. This deficient practice placed Resident 1 at risk for inadequate blood pressure management which can cause hypotension (low blood pressure) and irregular heartbeat.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive person-centered care plan (a written or electronic record containing all the information the resident needs to effectively manage their own health) for one out of three sampled residents (Resident 1) by failing to ensure Resident 1's care plan was updated and revised after Resident 1 refused a blood draw for complete blood count (CBC- a routine blood test that gives doctors a snapshot of your overall health by measuring the types and quantities of cells circulating in your bloodstream) test. This deficient practice had the potential to result in lack of delivery of care and services to Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure services provided or arranged by the facility as outlined by the comprehensive care plan met professional standards of quality for two out of three sampled residents (Resident 4 and Resident 6) when Resident 4 and Resident 6 were not monitored as indicated in the residents' care plans. These deficient practices could lead to the residents' condition to decline and could delay providing care to residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the facility staff were wearing proper personal protective equipment (PPE - equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) when changing resident who were in Enhance Barrier Precautions (EBP - infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs - germs that have become so tough they shrug off most common medicines (antibiotics) designed to kill them, making infections much harder to treat) for one of eight sample residents (Resident 2). This deficient practice had the potential to spread infections and illnesses among residents and staff.

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: 1. Ensure licensed nurses communicated with the transport services the correct dialysis (process of removing waste products and excess fluid from the body when the kidneys stop working properly) center for Resident 1. 2. Ensure licensed nurses communicated Resident 1 ' s late transport to the dialysis center. 3. Ensure that Resident 1's decreased dialysis treatment time was communicated among licensed nurses. 3. Ensure the Attending Physician (MD) was notified of Resident 1 ' s decreased dialysis treatment duration. This deficient practice resulted to Resident 1 being transported to the wrong dialysis center. On 6/2/2025 Resident 1 was brought to the wrong dialysis center. [...]

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 6) 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 6's blood sugar and may have other adverse side effects.

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote care for residents in a manner and an environment to maintain or enhance each resident ' s dignity in full recognition of his or her individuality when 151 of 158 sampled residents received their meals in a plastic container and utensils. This failure had the potential to result in psychosocial distress, a lack of self esteem and frustration for 151 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare food by methods that conserved temperature, flavor and appearance. The residents' food was served in plastic food containers and staff distributed this food via the stairs as the elevator was in disrepair. This deficient practice placed 151 of 158 facility residents on regular, therapeutic diets (a meal plan that controls the intake of certain food and nutrients) and puree diets (food with soft pudding like consistency) 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 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 failing to: -Maintain infection control by storing Certified Nursing Assistant (CNA) 1 personal cup inside the clean linen cart and drinking in the hallways. -Implement Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDRO, microorganisms, mainly bacteria, that are resistant to one or more classes of antibiotics] that uses targeted gown and glove use during high contact resident care activities) when CNA 7 was observed not wearing a gown after showering one of 10 sampled residents (Resident 10). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the meal ticket and ensure residents receive their dietary preferences for one of three sampled residents (Resident 7). Resident 7's meal tray was observed in his room with onions but Resident 7 did not like onions. This deficient practice had the potential to result in decreased food and nutrient intake which may result in unintended (not planned) weight loss for the resident.

Inspectors wroteBased on interview and record review, the facility failed to ensure a licensed staff administered medication for one of three sampled residents (Resident 1). This deficient practice had the potential to result in a medication error.

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) for one of three sampled residents (Resident 1) by failing to ensure a licensed staff administer medication for one of three sampled residents (Resident 1). This deficient practice had the potential to result in a medication error.

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

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 for one of four sampled residents (Resident 1) by failing to: 1. Implement Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDRO, microorganisms, mainly bacteria, that are resistant to one or more classes of antibiotics] that uses targeted gown and glove use during high contact resident care activities) when Certified Nursing Assistant 1 (CNA 1) did not don (put on) a gown while providing care to Resident 1. 2. Perform hand washing after CNA 1 remove his gloves. [...]

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, equipment, or material that is attached or adjacent to the resident's body, cannot be removed easily by the resident, and restricts the resident's freedom of movement or normal access to his/her body) for six of seven sampled residents (Resident 137, 61, 132, 123, and 42) investigated during review of the physical restraints care area when the facility failed to obtain a physician's order, informed consent, and conduct a restraint assessment on the use of bed placement against the wall. [...]

Inspectors wroteBased on interview and record review, the facility's licensed nursing staff failed to provide care in accordance with professional standards to four out of 4 sampled residents (Residents 29, 42, 402, and 134) investigated under insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) and heparin (an anticoagulant [blood thinner] that stops the blood from forming blood clots or making them bigger) by failing to: 1. Rotate (a method to ensure repeated injections are not administered in the same area) Residents 29 and 402's (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) insulin and heparin administration sites. 2. Rotate Resident 42 and 134's insulin subcutaneous administration sites. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment was free of accident hazards for six of 6 sampled residents (Residents 495, 61, 402, 11, 52, and 137) investigated under accidents by failing to ensure: 1. [...]

Inspectors wroteBased on interview and record review the facility failed to include the verifying signatures of either the Director of Nursing (DON) or a Registered Nurse (RN) along with Licensed Vocational Nurse (LVN) on the Antibiotic or Controlled Drug Record accountability logs for two (2) of two (2) sampled records awaiting disposal (removal, destroying) in DON's office. As a result, control and accountability of Controlled Substances ([CS] - also known as Controlled Drug and Controlled Medications [CD, CM]- medications which have a potential for abuse and may also lead to physical or psychological dependence) did not follow state and federal regulations and facility policy and procedures. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five (5) percent (%). Four (4) medication errors out of 27 total opportunities contributed to an overall medication error rate of 14.81% affecting two (2) of seven (7) residents observed for medication administration (Resident 71 and 88.) The medication errors were as follows: 1. Resident 71 did not receive psyllium husk powder (a medication used to form a bulky stook to pass easily) as ordered by Resident 71's physician and received a dose of oyster shell calcium (a medication used as a dietary supplement to provide support to bones) that was different than the one ordered by Resident 71's physician. 2. [...]

Inspectors wrotec). During a review of Resident 63's admission Record, dated 12/31/24, the admission Record indicated Resident 63 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnosis including DM2. During a review of Resident 63's Order Summary Report, dated 12/31/24, the report indicated Resident 63 was prescribed Lantus to inject 7 un SQ at bedtime for DM, starting 11/20/24. During a review of Resident 63's Medication Administration Record ([MAR] - a document of the medications administered to a resident that is part of the resident's permanent medical record], for December 2024, the MAR indicated Resident 63 was prescribed insulin Lantus 7 units SQ at bedtime for DM, at 9 PM, and that Resident 63 received 10 doses of expired insulin Lantus from the following nurses at 9 p.m. on the following dates: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Remove and discard from use two (2) open, expired insulin (a medication used to control high blood sugar levels) Lantus (brand name insulin for glargine, a long-acting insulin) pens stored at room temperature for Resident 63 and 71 in accordance with manufacturer's requirements and facility policy and procedures, in one (1) of two (2) observed medications carts (Medication cart 4.) 2. Remove and discard from use one (1) open, expired insulin Humulin 70/30 (brand name combination insulin for isophane human and regular human; an intermediate-acting insulin combined with rapid onset regular insulin) pen stored at room temperature for Resident 141 in accordance with manufacturer's requirements and facility policy and procedures, in one (1) of two (2) observed medications carts (Medication cart 4.) 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose garbage and refuse properly when the garbage dumpsters located in the facility parking lot were overflowing with garbage. This deficient practice had the potential to attract pests and possibly spread infection to 138 out of 138 facility residents.

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 failing to: 1. Ensure the Housekeeping Supervisor (HSKS) did not place two pillows from the ground on top of clean linens, observed during the Infection Control task. 2. Ensure the resident's right floor mat did not have any damage on the top exposing the foam for one (1) of 1 sampled resident (Resident 402). These failures had the potential to spread infections and illnesses among residents and staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to honor the resident's right to a dignified existence for one of one sampled resident (Resident 23), investigated under dignity, by failing to ensure the staff kept the curtains drawn to a confused resident that kept on removing her hospital gown while only being covered with a thin white sheet in her room. The deficient practice violated the resident's right to a dignified existence.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, comfortable, and homelike environment for one of two sampled residents (Resident 402) investigated under Environmental Task by failing to ensure Resident 402's floor mat did not have a tear on the top cover with the foam exposed. This deficient practice has the potential to negatively affect the resident's quality of life.

Inspectors wroteBased on interview and record review, the facility failed to accurately code one (1) of two (2) sampled residents (Resident 103) 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) when the PASARR prior to admission did not indicate Resident 103 had major depressive disorder (a major disorder that causes persistent feeling of sadness and loss of interest). This deficient practice had the potential to result in the resident's medical and nursing care needs not being met.

Inspectors wroteBased on interview and record review the facility failed to develop a baseline care plan (initial written guide that organizes information about the resident's care) addressing the use of oxygen for one (1) out of 1 sampled resident (Resident 129) reviewed for respiratory care. This deficient practice had the potential for Resident 129 not to receive the appropriate care and treatment specific to the resident's needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan (CP, a document outlining a detailed approach to care customized to an individual resident's need) for one of six sampled residents (Resident 137) investigated under the accident hazards care area, one of seven sampled residents (Resident 137) investigated under the physical restraints (any manual method, physical or mechanical device, equipment, or material that is attached or adjacent to the resident's body, cannot be removed easily by the resident, and restricts the resident's freedom of movement or normal access to his/her body) care area, and one of five sampled residents (Resident 128) investigated under infection control task, when: 1. The facility failed to implement Resident 137's care plan for storing the resident's smoking material. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents with a urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) received appropriate care and services to prevent urinary tract infections (UTI, an infection in the bladder/urinary tract) for one (1) of 1 sampled resident (Residents 129) investigated under the urinary catheter or UTI care area by failing to: 1. Ensure Resident 129's urinary catheter tubing did not have a loop while hanging on the side the bed. 2. Apply a catheter securement device on Resident 129's urinary catheter. This deficient practice had the potential to result in the resident's urine not to flow freely which may lead to development of recurrent UTI.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents receiving enteral feeding (EF - also known as tube feeding, a method of supplying nutrients directly into the stomach) received appropriate care and services to prevent complications of enteral feeding for two (2) of two (2) sampled residents (Residents 52 and 104) investigated under the tube feeding care area by failing to: 1. Ensure the EF formula bag indicated the administration rate prescribed by the physician for Resident 52. 2. Ensure the EF formula bag and water flush bag dated 12/31/2024 at 2 p.m. was primed (refers to prepared for immediate use) and hung as observed on 12/31/2024 at 9:46 a.m. for Resident 52 3. Cover the feeding tube tip with a cap when the feeding tube was disconnected from Resident 104. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure parenteral fluids (are liquids that are administered intravenously or by injection to bypass the digestive system) were administered consistent with professional standards of practice for one of 1 sampled resident (Resident 132) investigated under peripheral intravenous catheter (PIVC, a thin, flexible tube that is inserted into a vein through the skin to administer fluids, medications, or blood products) by failing to: 1. Clarify with the primary physician if the PIVC was still needed in the facility. 2. Change the dressing of the PIVC of the resident, dated 12/18/2024 on the day of observation. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to evaluate and assess Registered Nurse (RN) 1 for specific clinical competency and skills with specialized training to care for residents with indwelling urinary catheters (also called foley catheter [FC] - a hollow tube inserted into the bladder to drain or collect urine) reviewed under the Sufficient and Competent Nurse Staffing task. This failure had the potential to result in missed opportunities to address identified staff's performance issues that could impact resident safety and satisfaction.

Inspectors wroteBased on interview and record review, the facility failed to arrange provisions of hospice services (a program designed to provide a caring environment for meeting the physical and emotional needs of the terminally ill) in a consistent manner for one of one sampled resident (Resident 11) investigated during review of hospice services by failing to: 1. Ensure the hospice staff including the registered nurse (RN), licensed vocational nurse (LVN), and hospice aide (HA), provided nursing and visitation notes to the facility. 2. Ensure the calendar of visits from 9/23/2024 to the most current visits was provided by Hospice Provider 1 (HP 1). These deficient practices had the potential to negatively affect the residents' physical comfort and psychosocial well-being and had the potential to result in the delay or lack of necessary hospice care and services.

Inspectors wroteBased on interview and record review the facility failed to ensure the 2024/2025 COVID-19 (a highly contagious viral infection that can trigger respiratory tract infection) booster vaccine (a supplemental dose of medication that is administered annually and used to prevent complications from COVID-19) was administered and the vaccination status of residents was known and documented in the resident's clinical record for one of five sampled residents (Resident 77) reviewed during the Infection Control task. This failure had the potential to result in increased risk of residents developing complications from COVID-19 including acute respiratory failure (a serious condition that occurs suddenly when the lungs cannot get enough oxygen).

Inspectors wroteBased on interview and record review the facility failed to ensure an accurate assessment was conducted by failing to ensure the Minimum Data Set (MDS - resident assessment tool) was coded correctly to indicate a resident was discharged to a skilled nursing facility for one of one sampled resident (Resident 143) reviewed during the Hospitalization Closed Record Review care area. This failure had the potential to result in negatively affecting Resident 143's delivery of care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 3) was treated with dignity and care in a manner that promotes maintenance or enhancement of their quality of life by failing to ensure Resident 3's urinary drainage bag (a device that collects urine from a urinary catheter [a hollow tube inserted into the bladder to drain or collect urine] that is inserted into the bladder) had a dignity bag (a special pouch or cover that discreetly hides the drainage bag from view, allowing someone using a catheter to maintain privacy). This deficient practice had the potential to negatively affect Resident 3 psychosocially (involving mental, emotional, social, and spiritual aspects of a person's life).

Inspectors wroteBased on interview and record review, the facility failed to ensure that one of three sampled residents (Resident 3) who was a quadriplegic (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury) and was dependent (helper does all the effort) on care received the necessary services to maintain grooming, and personal hygiene when on 10/28/2024 Certified Nursing Assistant 1 (CNA 1) described Resident 3's fingernails as long and curving in and toenails as long and needed to be cut. This deficient practice had the potential to cause Resident 3 to scratch or harm self.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 3) had a call light (a device that patients use to request assistance from nursing staff in a healthcare facility) that was within Resident 3's reach. This deficient practice had the potential to result in a delay in meeting Resident 3's need for assistance.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide one of five sampled residents (Resident 1) a safe, clean, comfortable, and homelike environment when on 9/6/2024 at 1:39 p.m. the Maintenance Supervisor (MS) measured the temperature of Resident 1 room with a laser thermometer (measures the temperature of an object from a distance by using a laser to target the object and measuring the infrared radiation [a type of energy that is invisible to the human eye but can be felt as heat] it emits) measuring 88 degrees Fahrenheit (°F- a scale for measuring temperature, in which water freezes at 32 degrees and boils at 212 degrees). This deficient practice resulted in Resident 1 being uncomfortable with the temperature of his room.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (is a form that summarizes a person ' s health conditions and current treatments for their care)for one of six sampled residents (Resident 3), who was dependent (helper does all the effort or the assistance of 2 or more helpers is required for the resident to complete the activity) on staff on personal hygiene and diagnosed with muscle weakness (generalized), morbid (severe) obesity (abnormal or excessive fat accumulation that presents a risk to health) and paraplegia (the inability to voluntarily move the lower parts of the body), by failing to: 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of six residents (Resident 3), who was dependent (helper does all the effort or the assistance of 2 or more helpers is required for the resident to complete the activity) on staff on personal hygiene with diagnosis of muscle weakness (generalized), morbid (severe) obesity (abnormal or excessive fat accumulation that presents a risk to health) and paraplegia (the inability to voluntarily move the lower parts of the body), was free from accidents, by failing to: 1. Provide Resident 3 with the needed two-person assistance when Certified Nursing Assistant 1 (CNA 1), with no assistance from another staff, was giving nursing care to Resident 3 on 8/4/2024. 2. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a homelike environment for two of three sampled residents (Resident 1 and Resident 2) by failing to ensure the walls in the resident ' s room was in good condition and free from peeling paint and plaster debris. This deficient practice had the potential to cause injuries and altered comfort level.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident received care consistent with professional standards of practice to prevent pressure ulcer (a localized injury to the skin and or underlying tissue usually over a bone prominence as a result of pressure or pressure in combination with shear [occur between the internal body structures and skin tissues typically moving in opposite directions and may lead to deep tissue injury]) for one of three sampled residents (Resident 1) by: 1. Failing to ensure the low air loss mattress (LALM- a mattress, composed of inflatable air cushions that is used to relieve pressure on the body parts) was turned on. 2. Failing to ensure only one sheet of linen was placed over the LALM mattress top cover as indicated in the manufacturer's guidelines. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to respond to a functioning call light for one of two sampled residents (Resident 1). This deficient practice had the potential to result in a delay in meeting Resident 1's needs for assistance, pain management and could cause frustrations to Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents had the right to receive mail for three of 10 sampled residents (Resident 35, 82, and 86). Resident 35, Resident 82, and Resident 86 stated they do not receive mail on Saturdays. This deficient practice violated the residents' right to receive mail on Saturdays and had the potential to negatively affect the resident's psychosocial well-being.

Inspectors wroteBased on interview and record review the facility failed to develop and implement a person-centered care plan for four out of 27 sampled residents (Residents 33, 36, 54, and 87) by failing to: 1. Ensure Resident 33 had a care plan addressing the use of insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood). 2. Ensure Resident 36 had a care plan addressing the use of antidepressants, Lexapro (a type of medicine used to treat clinical depression d [mood disorder that causes a persistent feeling of sadness and loss of interest]) and Buspirone (a type of medicine used to treat anxiety disorders [persistent and excessive worry that interferes with daily activities]). 3. Ensure Resident 54 had a care plan addressing the use of Sertraline (a medication used to treat depression and panic attacks). 4. [...]

Inspectors wroteBased on interview and record review, the facility's licensed nursing staff failed to provide care in accordance with professional standards to three out of sixteen sampled residents (Residents 87, 33, and 23) by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) insulin (a hormone that lowers the level of sugar in the blood) and Lovenox (enoxaparin sodium, an anticoagulant medication that prevent blood clots) administration sites. The deficient practice had the potential for adverse effects (unwanted, unintended result) of same site subcutaneous administration of insulin and Lovenox such as lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (a rare disease that occurs when a protein called amyloid builds up in organs).

Inspectors wroteBased on observation, interview and record review the facility's nursing staff failed to ensure that a resident received a medication as prescribed by his physician for two out of 22 sample residents (Resident 14 and 57) by: a. Resident 14 received his insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) two hours and 30 minutes later than ordered by his physician on 12/23/2023 at 9:28 a.m. and 12/23/2023 at 9:29 a.m. [NAME] b. Resident 57 did not receive his medication supplement ordered for Osteoporosis (a condition in which bones become weak and brittle). The facility failed to notify the physician when a medication supplement ordered for Osteoporosis was unavailable and the facility continued to document the administration of the medication for Resident 57 on the resident's Medication Administration Record (MAR) between 12/13/2023 through 12/27/2023. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from unnecessary drugs for two of four sampled residents (Residents 7 and Resident 40) by failing to: a. Monitor and document Resident 7's adverse effects and behavior manifestations when taking Trazadone (antidepressant for treating major depressive disorders). b. Monitor and document Resident 40's postural/orthostatic hypotension- (a drop in blood pressure [hypotension] due to a change in body position when a person moves to a more vertical position: from sitting to standing or from lying down to sitting or standing postural/orthostatic hypotension and can lead to falls and injuries of the residents) readings while taking Seroquel (an antipsychotic medication-used to treat disordered thinking associated with severe mental illness) per physician's order. [...]

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 four sampled resident (Resident 6) investigated under the dignity investigative care area, by failing to ensure Resident 6's preference for use of hot water during peri-care was honored and respected. 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 keep the call light (an alerting device for nurses or other nursing personnel to assist a resident when in need) within reach of the resident for one out of eleven 11 sampled residents (Resident 87). These deficient practices had the potential to result in the resident not being able to call for facility staff assistance and delay in the provision of necessary care and services that can negatively affect the resident's comfort and well-being.

Inspectors wroteBased on interview and record review, the facility failed to complete and provide a notice of bed-hold policy and return form (reserving a resident's bed while the resident is absent from the facility) when the resident was transferred to the general acute care hospital 1 (GACH 1) for one of sixteen sampled residents (Resident 82). This deficient practice had a potential to result in the resident's responsible party being unaware of the bed hold policy and can lead to a transfer of the resident to another skilled nursing facility not of the resident's or responsible party's preference.

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 (injury to skin and underlying tissue resulting from prolonged pressure on the skin) to one out of sixteen sampled residents (Resident 99) by: 1. Failing to ensure Resident 99's Low air-loss mattress (LALM, an air mattress designed to distribute the resident's body weight over a broad surface area and help prevent skin breakdown) was set according to the residents' weight. 2. Failing to turn and reposition Resident 99 every two (2) hours for pressure ulcer management and treatment. These deficient practices had the potential for the development and worsening of pressure ulcers to the resident.

Inspectors wroteBased on interview and record review the facility failed to provide a Restorative Nurse Aide (RNA - responsible for following a resident care plan in helping residents with range of motion [ROM - extent of movement of a joint) program for ROM for one of three sampled residents (Resident 46) when Physical Therapist 1 (PT 1, healthcare provider who improve quality of life through prescribed exercise, hands-on care, and patient education) failed to communicate to the nursing department the recommendation for ROM. This deficient practice had the potential for development of contractures (abnormal shortening of muscle tissue) and complications of immobility.

Inspectors wroteBased on observation and interview the facility failed to ensure an opened box of Blood Glucose (BG) test strips had an open date. The deficient practice of failing to label BG test strips per the manufacturers' requirements increased the risk that residents with Diabetes (a serious condition where blood glucose [sugar] level is too high) could have received medication based on inaccurate BG levels which could result in health complications or hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide meals that accommodated their food preferences to one out of 16 sampled residents (Resident 277). This deficient practice had the potential to result in decreased meal intake and can lead to weight loss and malnutrition (a serious condition that happens when your diet does not contain the right amount of nutrients).

Inspectors wroteBased on observation, interview, and record review the facility failed to implement and maintain an infection control program to one out of 16 sampled residents (Resident 121) by failing to label the urinal bottle (a container used to collect urine) of the resident to prevent cross contamination (the physical movement or transfer of harmful bacteria from one person, object, or place to another). The deficient practice had the potential to spread infection among residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to post daily staffing information that included the actual hours worked by registered nurses (RN), licensed vocational nurses (LVN), and certified nursing assistants (CNA) for all three shifts (7:00 a.m. to 3:00 p.m., 3:00 p.m. to 11:00 p.m., and 11:00 p.m. to 7:00 a.m.) on three of three sampled days (12/26/2023, 12/27/2023, and 12/28/2023). This deficient practice resulted in residents, visitors, and facility staff not knowing how many staff were available to provide care to the residents.

Inspectors wroteBased on interview, and record review, facility failed to accurately code in the Minimum Data Set (MDS, a standardized assessment and care screening tool) the discharge destination of a resident who was discharged to home on [DATE] for to one out of sixteen sampled residents (Resident 124). 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 interview and record review, the facility failed to obtain a doctor's order for the use of oxygen for one of three sampled residents (Resident 2). This deficient practice had the potential to cause complications associated with oxygen therapy.