The Rowland

Inspectors wroteBased on interview and record review, the facility failed to ensure two of two sampled residents' (Residents 12 and 116) Minimum Data Set (MDS - a federally mandated resident assessment tool) assessments were accurately documented to reflect: a. Resident 12's fall on 3/11/2026. b. Resident 116's discharge location/destination on 3/3/2026. These failures had the potential to negatively affect Resident 12 and 116's plan of care and delivery of necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement specific, comprehensive, and individualized person-centered care plan (CP) to meet the residents' needs for two of two sampled residents (Residents 53 and 76) by failing to: a. Develop an individualized CP to address Resident 53's diagnosis of dementia (a decline in mental abilities severe enough to interfere with daily life). b. Develop an individualized CP to address Resident 76's fall that occurred on 6/16/2026. These failures resulted in Residents 53 and 76 not receiving individualized care to maintain the residents' highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of two sampled residents (Resident 123 and 74) received care in accordance with professional standards of practice to attain or maintain the highest practicable physical, mental, and psychosocial well-being, when the facility failed to: a. Ensure staff followed the physician's (MD) order to call/notify the physician if Resident 123's oxygen saturation (measure of how much oxygen the blood is carrying as a percentage of the maximum it could carry) level was below 91%. b. Ensure a change of condition (COC) documentation was completed and Resident 76's physician and family were notified after Resident 76 was found on the floor on [DATE] with a skin tear on the right forearm. These deficient practices had the potential for Residents 123 and 76 not receiving necessary care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe food storage practices in one of one facility kitchen (Kitchen 1), by failing to:Discard a bag containing three (3) bagels that was not dated. Discard a tray containing 3 bags of ham dated 6/26/26. Discard one a tray containing 5 strawberries and 2 orange ice cream cups dated 6/27/26. These deficient practices had the potential to result in food-borne illnesses (illness caused by ingesting contaminated food or beverages) for the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe food storage practices for two of two of the residents' refrigerators, by failing to:a. Discard a container of ultra pasteurized milk with a used by date of 6/29/26.b. Discard a gallon of whole milk with no open date. These deficient practices had the potential to result in food-borne illnesses (illness caused by ingesting contaminated food or beverages) for the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly cover two of three large trash bins as indicated in the facility's Policy and Procedure (P&P) on garbage disposal. This deficient practice had the potential to attract vermin (animals that are harmful and carry diseases) and pests (any living thing that has a negative effect on humans) that could potentially enter the facility, affect the resident care areas, and expose the residents and staff to diseases.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain complete and accurate medical records for three of three sampled residents (Residents 9, 12 and 123) by failing to document:a. Wound treatments for Resident 9.b. A physician's transfer order for Resident 12. c. Accurate oxygen saturation reading of Resident 123 on [DATE] at 6:46 AM. These failures had the potential to negatively impact evaluation of Resident 9's wound progression or regression, affect Resident 9's and 12's care and delivery of services and resulted in an inaccurate assessment of Resident 123's respiratory status after the resident expired.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection prevention and control practices by failing to:a. Ensure Licensed Vocational Nurse 2 (LVN 2) sanitized the medication tray before giving medications to two of four sampled residents (Residents 63 and 87).b. Label and properly store personal care items that were found inside shared bathrooms for two of three sampled residents (Residents 51 and 118) when:b.1. Resident 51's three unlabeled razors were left on top of the bathroom sink inside a shared bathroom.b.2. Resident 118's unlabeled toothbrush was left on top of the bathroom sink inside a shared bathroom. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 12) was called by the resident's legal (official name recognized by government on documents), proper and preferred name. This failure had the potential for Resident 12 to lose dignity and individuality.

Inspectors wroteBased on interview and record review the facility failed to ensure the advance directive (AD-a legal document explaining a resident's health care wishes if he or she cannot speak for themselves) for one of two sampled residents (Resident 3) was accessible to facility staff as indicated in the facility's policy and procedure (P&P) titled, Advance Directives when Resident 3's AD was stored in the medical records office. This failure had the potential to result in conflict regarding Resident 3's choices regarding health care decisions.

Inspectors wroteBased on interview and record review, the facility failed to ensure there was a m/b (manifestation by- refers to the specific, observable signs, symptoms, or behaviors that show a resident needs the antidepressant. It provides concrete, measurable clinical proof [e.g., crying spells, insomnia, weight loss] that justifies the medication and ensures it meets regulatory standards for residents) behavior documented for Sertraline (an antidepressant medication) ordered for one (1) of one (1) sampled resident (Resident 53). This deficient practice had the potential to result in serious health complications for Resident 53.

Inspectors wroteBased on interview and record review, the facility failed to accurately complete a Preadmission Screening and Resident Review Level I screening (PASRR I-the prescreening process which determines if a resident has a serious mental illness [SMI-diagnosable mental, behavioral, or emotional disorder that significantly impairs a person's ability to function in major life activities], intellectual disability [ID], developmental disabilities [DD], or related condition [RC]) for one of two sampled residents (Resident 3) when Resident 3's PASRR I indicated Resident 3, who was diagnosed with schizophrenia (a mental illness characterized by disturbances in thought), did not have a SMI.This failure resulted in Resident 3 not receiving the PASRR level 2 screening (PASRR II-a required federal assessment that ensures individuals with a SMI or ID are placed in appropriate facilities) and had the [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to revise a care plan for one of one sampled resident (Resident 12), who sustained a fall on 3/11/2026. This failure had the potential to place Resident 12 at risk for recurrent falls.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the nasal cannula oxygen tubing (a flexible tube that administers oxygen through the nose) for one of two sampled residents (Resident 1) was labeled with date and time in accordance with the facility's policy on oxygen administration. This deficient practice had the potential to result in respiratory complications for Resident 1 associated with oxygen therapy.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents (Resident 110) received dialysis (a treatment involving the removal of extra fluid and waste products from the blood when the kidneys are unable to function properly) care consistent with professional standards of practice, when the facility failed to take Resident 110's vital signs (measurements of the body's most basic functions such as heart rate and blood pressure) upon arrival to the facility after receiving dialysis on 6/30/2026. This deficient practice had the potential to result in adverse (harmful) consequences on Resident 110.

Inspectors wroteBased on interview and record review the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for four resident of four sampled residents (Resident 1, 3, 4 and 5) by: 1. Not ensuring Resident 1 and 3 had floor mats at bedside. 2. Not ensuring Resident 1, 4, and 5 had a fall risk assessment (a comprehensive, non-invasive evaluation conducted to determine an individual's likelihood of falling, typically focusing on older adults or high-risk patients) after experiencing a fall. These deficient practices placed Residents 1, 3, 4 and 5 for recurring falls and increased the risk for the residents to sustain injuries after a fall from their beds.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide safe oxygen administration practices ([oxygen therapy], is the medical practice of delivering oxygen at a concentration greater than ambient air) for three of four sampled residents (Residents 1, 3, 4) by: 1. Not ensuring Resident 1's nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) was dated with an open date and did not ensure nasal cannula was not touching the floor. 2. Not ensuring Resident 3 had a bag at the bedside for oxygen equipment and did not ensure nasal cannula was not touching the floor. 3. Not ensuring Resident 4 received oxygen administration when using motorized wheelchair and did not ensure the nasal cannula was not touching the floor and placed over the restroom doorknob. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure dietary staff followed the dietary menus for two of two meals: 1. Facility did not ensure residents received meals according to dietary menu (a structured, planned selection of food items tailored to meet specific nutritional, health, lifestyle, or cultural needs) on 4/21/2026 and 4/22/2026. 2. Facility did not ensure the Dietary Services Supervisor (DSS) checked food before food left the kitchen. 3. Facility did not notify residents there was a change in food that was served on 4/21/2026 and 4/22/2026. These deficient practices had the potential to impact on resident's nutritional status and placed all (112) residents at risk for unintentional weight loss.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide the correct food texture-modified diet (alters the consistency of food and liquids to make swallowing safer and easier for people with chewing or swallowing difficulties) for two of four sampled residents (Residents 1 and 2) when: 1. The facility did not ensure Resident 1 and Resident 2 received the correct food texture. 2. The facility did not ensure Dietary Supervisor checked for food texture for Resident 1 and Resident 2 before the food leaving the kitchen. These deficient practices had the potential for Residents 1 and 2 to have problems chewing and swallowing and increased the risk of choking for Residents 1 and 2 while eating.

Inspectors wroteBased on observation and interview, the facility did not provide a working call light to one of four sampled residents (Resident 2). This deficient practice had the potential to cause a delay or the inability in obtaining necessary care and services for Resident 2.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow professional standards of practice of infusion therapy for peripheral intravenous catheter (PIV - small flexible tube placed into a vein to administer fluids and/or medications) and total parenteral nutrition (TPN- a medication used to manage and treat malnourishment) care for two of two sampled residents (Resident 55 and 307) by failing to: a. Ensure Resident 55's PIV site was labeled with a date and initials upon insertion. b. Ensure Resident 307's total parenteral nutrition (TPN- a medication used to manage and treat malnourishment) administration set was labeled with a date and time when hung. These failures had the potential to result in infection at Resident 55's IV site, and contamination of Resident 307's TPN and/or TPN tubing that could have led to further infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary care and services for residents receiving oxygen therapy (treatment that provides supplemental, or extra oxygen) in accordance with professional standards of practice for four of four sampled residents (Residents 16, 73, 206, and 256) by failing to: a. Ensure Resident 16 received oxygen therapy as ordered by the physician and ensure that the nebulizer face mask (a soft pliable mask that covers the nose and mouth used to deliver liquid medication in the form of a mist directly into the lungs) was stored in a sanitary condition when not in use. b. Ensure a sign Oxygen No Smoking, No Open Flames, was posted outside Resident 206's room in accordance with the facility's policy and procedure. c. Ensure Resident 73's oxygen and nebulizer tubings were not on the floor. d. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement its Policy and Procedure (P&P) on the use of bedrails/siderails (adjustable metal or rigid plastic bars attached to the bed) for two of three sampled residents (Residents 56 and 75). These failures placed Residents 56 and 75 at risk for entrapment (an event in which resident was caught, trapped, or entangled in the tight spaces around the bed), and injury from the use of bedrails/siderails.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were administered in a timely manner and as prescribed to meet the therapeutic (treatment, therapy, or drug) needs of the resident for one of one sampled resident (Resident 62). This failure had the potential to increase the risk of adverse drug reactions and potential medical complications for Resident 62.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure the medication error (any preventable event that may cause or lead to inappropriate medication use or patient harm) rate was five (5) percent (%) or lower during medication administration on 5/15/2025 for one of four sampled residents (Resident 62). This failure resulted in five medications errors out of twenty-eight (28) opportunities for errors, which resulted in medication administration error rate of seventeen and eighty-six hundredths (17.86) %.

Inspectors wroteBased on observation and interview, the facility failed to ensure medications were kept secure with limited access by failing to: 1. Ensure to lock the medication cart (Med Cart) that contained residents' medications on North Station when not attended and outside of view. 2. Ensure the Wixela Inhub Inhalation Aerosol Powder Breath (used to control and prevent symptoms (wheezing and shortness of breath) caused by asthma or ongoing lung disease) was in Resident 34's possession. These deficient practices had the potential to result in residents' medications to be accessible to others not authorized to have access to drugs (medications) and biologicals (drugs derived from natural sources) and increased the risk for loss of control, safety, and security of all medications necessary to meet the health care needs of residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain safe food handling practices by failing to ensure: a. Two of four red sanitization buckets with chemical that used in the kitchen to sanitize kitchen surfaces was maintained at the correct chemical concentration to maintain effectiveness of the disinfectant. b. One of one plastic container of expired red tomato salsa, with an open date of 5/4/25, and one plastic container of green salsa, with an open date of 5/2/25, were inside the walk-in refrigerator. c. One of one bag of open penne pasta noodles and one bag of open spaghetti pasta noodles was in dry storage area and was not labeled with an open date and use by date. These deficient practices had the potential to result in food surfaces not being properly sanitized and foodborne illness (illness caused by contaminated food) due to expired food.

Inspectors wroteb. During a review of Resident 16's AR, the AR indicated Resident 16 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included malignant neoplasm (cancerous tumor) of the lung, pneumonia (an infection/inflammation in the lungs) and chronic kidney disease (gradual loss of kidney function). During a review of Resident 16's MDS, dated [DATE], the MDS indicated Resident 16 had moderately impaired cognition (ability to understand and process information). The MDS indicated Resident 16 required substantial/maximal assistance (helper did more than half the effort) with eating, upper and lower body dressing and dependent (helper did all the effort, resident did none of the effort to complete the activity) with oral hygiene, toileting, shower and personal hygiene. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff promoted dignity while assisting one of one sampled resident (Resident 64) during meals by feeding the resident at eye level to maintain face-to-face contact with the resident. This deficient practice had the potential to affect Resident 64's self-worth, dignity, and safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 47) call light was within reach. This failure had the potential to result in Resident 47 not receiving the necessary care or delayed services.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident's Advance Directive (AD, a legal document indicating a resident's preference for end-of-life treatment decisions) and AD Acknowledgement Form was in the resident's medical record for one of three sampled residents (Resident 16). This failure had the potential to result in the staff providing care and services against the will of Resident 16.

Inspectors wroteBased on interview and record review, the facility failed to screen one of two randomly selected employees (Certified Nurse Assistant 2 [CNA 2]) with the Office of Inspector General (OIG - investigates alleged violations of criminal and civil laws) data base prior to hire in accordance with the facility's Policy and Procedure (P&P) titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program. This deficient practice had the potential for employees with a history of abuse get hired, which could lead to possible harm and abuse of the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary care and services for a resident with Foley catheter (FC, a medical device that helps drain urine from the bladder) in accordance with the facility's Policy and Procedure (P&P) on catheter care for one of one sampled resident (Resident 257). This failure had the potential to result in catheter-related complications for Resident 257.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 307), who had a biliary drain (biliary drain- allows bile to flow out from a blocked bile duct from the liver into a collection bag outside the body) did not have biliary drainage on the resident's floor. This failure had the potential to result in the transmission of infection from bodily fluids.

Inspectors wroteBased on interview and record review, the facility failed to act upon the pharmacist's medication regimen review (MRR, a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences associated with medication) recommendation for one of five sampled residents (Resident 72). This failure had the potential for Resident 72 to receive unnecessary medications and result in undesirable or non-therapeutic effect of the medication to the resident.

Inspectors wroteBased on interview and record review, the facility failed to implement their policy on the use of an antibiotic and a change in condition for one of five sampled residents (Resident 84) for a urinary tract infection (UTI- an infection in the bladder/urinary tract). This failure resulted in Resident 84 receiving antibiotics without meeting facility criteria and had the potential to result in Resident 84 developing antibiotic resistance.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement their Policy and Procedure (P&P) titled, Handwashing and Hand Hygiene for one of eight sampled residents (Resident 3), when Certified Nursing Assistant 1 (CNA 1) did not wash CNA 1's hands after touching the overbed table and bed linens of a resident who tested positive for clostridium difficile (C. diff; bacteria that can cause diarrhea, enterocolitis [inflammation of the small and large intestines], and other intestinal conditions) infection. This failure had the potential to spread infection to other residents, staff, and visitors in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents had an environment free of accident hazards (risks) for two of four residents (Residents 8 and 36) who were smokers (tobacco users) by failing to: 1. Implement the facility's smoking policy titled, Smoking Policy-Residents, for Residents 8 and 36 who did not have smoking privileges to smoke with staff supervision, and for staff to keep Residents 8 and 36's smoking articles including cigarettes and cigarette lighters for Residents 8 and 36. 2. Implement the facility's smoking policy titled, Smoking Policy-Residents, to evaluate Resident 8's ability to smoke safely with the consultation from the facility's Director of Nursing (DON) and Resident 8's Attending Physician when safety restriction for smoking was needed in accordance with facility's Safe Smoking Evaluation Form. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain safe food handling practices by failing to: A.1. Store one of one ice scoop in a sanitary condition. The ice scoop was stored in the ice scooper container that had approximately 100 milliliters (ml-unit of measurement) of brown liquid substance. The ice scoop was touching the brown liquid substance. Certified Nursing Assistant 1 (CNA 1) and CNA 3 used the contaminated ice scooper to fill up two ice chests (containers) with ice and distributed the ice chests to the North and South Nursing Stations. [...]

Inspectors wroteBased on interview and record review, the facility failed to transmit assessments within 14 days of completion for 23 of 23 sampled residents (Residents 1, 4, 17, 21, 22, 26, 28, 29, 31, 33, 35, 41, 49, 52, 56, 61, 62, 70, 71, 72, 78, 79, and 80). This failure had the potential to result in inaccurate facility information submitted to the Centers for Medicare and Medicaid Services (CMS, federal agency that works with the health care community to improve quality, equity, and outcomes in the health care system) and would affect the quality of care to the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary care and services for gastrostomy tube (GT, a tube inserted through the abdomen that delivers nutrition directly to the stomach) tubing and site as ordered by the physician and as indicated in the plan of care for two of three sampled residents (Residents 193 and 195). These failures had the potential for infection and adverse consequences related to tube feedings for Residents 193 and 195.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary care and services for residents on oxygen therapy (a treatment that provides with extra oxygen to breathe in) as ordered by the physician, as indicated in the residents' plan of care and in accordance with the facility's Policy and Procedure (P&P) on Oxygen Administration for four of seven sampled residents (Residents 2, 31, 64 and 189). These failures had the potential to result in respiratory complications and infection for Residents 2, 31, 64 and 189.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dialysis emergency kit was readily available for staff use in case of bleeding in resident's dialysis (a type of treatment that helps the body remove extra fluid and waste products from the blood when the kidneys are not able to) access site for two of two sampled residents on dialysis (Residents 44 and 85). This deficient practice placed Residents 44 and 85 at risk for excessive bleeding from dialysis access site.

Inspectors wroteBased on observation, interview, and record review, the facility failed to post accurate nurse staffing information of actual hours worked by the licensed and unlicensed nursing staff directly responsible for resident care per shift daily. The staffing information was not posted in a prominent location for two of four days during the recertification survey. This deficient practice had the potential to mislead the residents and visitors of the actual hours worked by licensed and unlicensed nursing staff directly providing resident care and had the potential to affect the quality of nursing care provided to the residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure five of five sampled residents (Residents 13, 25, 41, 47 and 77) on psychotropic drugs (any drug capable of affecting the mood, emotions, and behavior) were free from unnecessary medication by failing to: A. Attempt a Gradual Dose Reduction (GDR- tapering of a dose) for Residents 25 and 47 B. Ensure PRN (as needed) orders for psychotropic medications were limited to 14 days use for Residents 13, 41, and Resident 77. These deficient practices had the potential for the facility to use psychotropic drugs inappropriately and had the potential to affect residents' physical, emotional and psychosocial wellbeing.

Inspectors wroteBased on interview and record review the facility failed to provide a safe and sanitary environment to help prevent the development and transmission of disease and infection by failing to: a. Establish facility wide systems and water safety management based on national standards of practice and the facility assessment for the prevention, identification, investigation, and control to prevent the growth of Legionella (bacteria that causes Legionnaires [severe form of pneumonia [lung infection caused by bacteria] and other opportunistic waterborne pathogens [any organisms or agent that can cause disease]) in the building water systems. b. [...]

Inspectors wroteBased on interview and record review the facility failed to follow the facility's policy on Advance Directives (AD, a legal document that informs healthcare providers what kind of care a person would want to receive if the individual was unable to speak for self) to ensure a current copy of a resident's AD was in the medical chart for one of three sampled resident (Resident 288). This failure had the potential for Resident 288's AD to not be followed by the facility staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide privacy during a bed bath to one of one sampled resident (Resident 28.) This deficient practice had the potential to cause embarrassment and lowered self-esteem for Resident 28.

Inspectors wroteBased on observation, interview, and record review, the facility failed implement its policy and procedure (P&P) on Translation and Interpretation services to ensure needs and questions from the resident with limited English proficiency (LEP) were addressed by staff for one of one sampled resident (Resident 289). This failure had the potential to not meet Resident 289's needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to answer the call light and provide assistance to a resident in a timely manner in accordance with the resident's care plan (CP) and the facility's Policy and Procedure (P&P) on answering call lights, for one of one sampled resident (Resident 289). This failure had the potential to result in fall or injury to Resident 289 who had a history of falling.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure interventions were developed and implemented to address the resident's positioning preference for one of one sampled resident (Resident 16.) Resident 16 had a non-healing wound to the left lateral (side) ankle and left medial (middle) ankle and Resident 16 preferred to lie on the left side. This deficient practice had the potential to delay wound healing for Resident 16.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure care and services was provided to prevent pressure ulcer (lesion/wound caused by unrelieved pressure that results in damage of underlying tissue) for one of five sampled residents (Resident 16.) Resident 16 developed redness at the base of the left lateral toe and redness at the base of the right big toe. This deficient practice had the potential for the development of pressure ulcer. Cross Reference:

Inspectors wroteBased on interview and record review, the facility failed to follow its policy and procedure (P&P) on Restorative Services (care designed to improve or maintain the functional ability of residents) to provide restorative services in accordance with Medical Doctor's (MD-physician) order for one of four sampled residents (Resident 2). This failure had the potential to result in a decrease in range of motion (ROM, full movement potential of a joint [where two bones meet]) in Resident 2's bilateral (both) legs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary care and services for a resident with foley catheter (FC, thin, sterile tube inserted into the bladder to drain urine into a bag outside the body) as indicated in the resident's plan of care for one of two sampled residents (Resident 189). This failure had the potential to result in catheter-related complications for Resident 189.

Inspectors wroteBased on observation, interview and record review, the facility failed to accurately monitor the resident's fluid intake (measurement of the fluids that enter the body) for one of one sampled resident (Resident 30) as ordered by the physician. This failure had the potential for complications related to electrolyte imbalance for Resident 30.

Inspectors wroteBased on observation, interview, and record review, Licensed Vocational Nurse 2 (LVN 2) failed to ensure enteric coated (barrier to prevent gastric acids in the stomach from dissolving or degrading medications after being swallowed) Aspirin (medication to prevent blood clot) was not crushed for one of four sampled residents (Resident 7) during medication administration. This deficient practice had the potential to affect Resident 7's medication efficacy and placed the resident at risk for adverse complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policy and procedure (P&P) on Storage of Medications to ensure drugs and biologicals (class of medicines which were grown and purified) were stored in the Medication Refrigerator (MR) at required temperature for one of one sampled Medication Storage room [ROOM NUMBER] (MSR 1). This failure had the potential to result in medications to become unstable and ineffective.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a safe and sanitary environment to prevent the spread of infection during a Coronavirus (COVID-19 an illness caused by a virus that can spread from person to person) outbreak (a sudden increase in occurrences of a disease when cases are in excess of normal expectancy for the location or season), as evidenced by failing to: a. Ensure the Activities Director (AD) performed hand hygiene after contact with objects in the immediate vicinity of two of two residents (Residents 4 and 5). b. Ensure Certified Nursing Assistant 1 (CNA 1) changed gloves and performed hand hygiene before and after providing care to two of two residents (Residents 6 and 7). c. [...]