The Terrace at Crystal LLC

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure a shared blood glucometer (device to test blood sugar levels) was cleaned and disinfected properly between resident use to prevent transmission of bloodborne pathogens for 2 of 2 residents (R33, R38,) and failed to properly disinfect a blood glucose monitor following use with R31 and prior to placing on shelf at nursing station for use with other residents reviewed for shared use of medical equipment. This practice resulted in an immediate jeopardy (IJ) situation for R38 due to the risk of potential transmission of blood borne pathogens from R33 to R38. [...]

Inspectors wroteBased on observation, interview, and document review, the facility failed to assess, monitor, follow up, and implement physician-ordered care for ongoing gastrointestinal symptoms, failed to obtain and track diagnostic testing results, failed to ensure ordered specialty referrals were completed, and failed to develop a care plan to address persistent diarrhea for 1 of 3 residents (R31) reviewed for quality of care. The deficient practice resulted in actual harm for R31 through delayed identification and treatment of Clostridioides difficile (C. difficile) infection, prolonged unresolved gastrointestinal symptoms, abdominal pain, impaired nutritional status, social isolation, and skin discomfort. In addition, the facility failed to ensure a physician's order was implemented for 1 of 1 residents (R37) reviewed for diagnostic testing.

Inspectors wroteBased on interview, observation, and record review, the facility failed to provide direction and oversight of the activity program by ensuring a qualified professional directed the development, implementation, and coordination of resident activities. The facility failed to maintain leadership of the activity department after the Activities Director position became vacant, failed to ensure staff assigned activity responsibilities were trained and competent to perform the duties of the position, and failed to maintain basic components of the activity program including development and distribution of monthly activity calendars. This deficient practice had the potential to affect all 58 residents residing in the facility.

Inspectors wroteBased on observation and interview, the facility failed to serve food in a sanitary manner by failing to ensure staff properly contained hair with a hairnet/beard net while serving food and preparing room trays. This had the potential to affect all residents residing on 2nd floor.

Inspectors wroteBased on interview and document review, the facility failed to ensure staff completed mandatory quality assurance and performance improvement (QAPI) training for 1 of 10 staff members, nursing assistant (NA)-J, who was reviewed for training requirements. This had the potential to affect all 58 residents residing in the facility.

Inspectors wroteBased on interview and document review, the facility failed to ensure staff completed mandatory compliance and ethics training for 1 of 10 staff members, nursing assistant (NA)-J, reviewed for training requirements. This had the potential to affect all 58 residents residing in the facility.

Inspectors wroteBased on observations, interviews, and document review, the facility failed to ensure 1 of 1 resident (R60) reviewed for wandering received adequate supervision per his plan of care to ensure safety and prevent elopement. Furthermore, the facility failed to check to ensure the correct sling size before transferring for 2 of 2 residents (R15, R23) using a mechanical lift and failed to ensure compatible lifts and slings were used for 1 of 2 residents (R54) who used a mechanical lift. The facility also failed to assess a bed in the high position for safety for 1 of 1 resident (R20) reviewed for bed height. [...]

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure a resident room was maintained in a clean, sanitary manner for 1 of 1 resident (R5) whose room was in a state of disrepair. In addition, the facility failed to ensure the memory care dining room floor was kept in a clean and sanitary condition, which had the potential to affect all 10 residents residing on the memory care unit.

Inspectors wroteBased on observation, interview and document review the facility failed to ensure dignity was maintained for 1 of 1 resident (R6) reviewed for catheters. R6's quarterly Minimum Data Set (MDS) dated [DATE], identified moderately impaired cognition, rejection of care one to three days, and was dependent on staff assistance with dressing, bed mobility and toileting. R6 was always incontinent of bowel and bladder and had intermittent catheterization. Diagnoses included infective bursitis of the left elbow. R6's care plan dated 4/27/26, identified R6 had a catheter for neurogenic bladder. An intervention dated 5/12/26, identified to position catheter bag and tubing below the level of the bladder and away from entrance room door. During an observation on 6/1/26 at 12:52 p.m., R6 was in the commons area near the elevator and hallways. [...]

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure a call light was within reach for a resident who had a history of seizure and fall and relied on staff assistance for 1 of 1 resident (R20) reviewed whose call light was not within reach.

Inspectors wroteBased on observation, interview and document review the facility failed to assess for potential side effects of antipsychotic medication for 1 of 5 residents reviewed (R6) who was reviewed for unnecessary medications.

Inspectors wroteBased on interview and document review, the facility failed to ensure an adequate discharge planning process was maintained to ensure resident preference for discharge was met for 1 of 1 residents (R7) reviewed for discharge planning.

Inspectors wroteBased on interview and document review, the facility failed to ensure a written transfer notice (including information such as the ombudsman information and the resident's appeal rights) and a written bed hold notice (including information such as the duration of the state bed-hold policy, the reserve bed payment policy, and the nursing facility's policies regarding bed-hold periods) was given as soon as practicable for 2 of 2 residents (R17, R63) reviewed for hospitalization.

Inspectors wroteBased on interviews and document review, the facility failed to provide the opportunity to attend and participate in a care conference for 1 of 1 residents (R10) reviewed for care conferences.

Inspectors wroteBased on observation, interview, and document review, the facility failed to implement interventions for 1 of 1 residents (R60) who required alternate means of communication due to hearing loss and being non-English speaking.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure routine personal hygiene (i.e., shaving) were completed for 1 of 1 resident (R51) reviewed for activities of daily living (ADLs) and who were dependent on staff for their care.

Inspectors wroteBased on interview, observation, and record review, the facility failed to provide an ongoing program of activities designed to meet the interests and well-being of a resident(s) and failed to ensure residents were informed of available activities for 2 of 2 resident (R3 and R37) reviewed who identified group activities and participation in favorite activities as important (R3, R37).

Inspectors wroteBased on interview and document review, the facility failed to ensure physician-ordered vision services were arranged and provided by failing to schedule and follow through with a routine referral to a retinal specialist for 1 of 1 resident (R31) reviewed for vision services. This failure had the potential for more than minimal harm by delaying evaluation and treatment of reported vision symptoms and potential diabetes-related eye conditions.

Inspectors wroteBased on observation, interview and document review the facility failed to ensure a catheter drainage bag (CDB) remained below the level of the bladder for 1 of 2 residents (R6) reviewed for catheter care.

Inspectors wroteBased on interview and document review, the facility failed to ensure a resident's physician completed the initial comprehensive 30-day visit for 1 of 3 (R50) newly admitted residents reviewed.

Inspectors wroteBased on observation, interview and document review, the facility failed to follow up on two pharmacy recommendations for 1 of 5 residents (R6) reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure patient care equipment was maintained in safe operating condition for 1 of 1 resident (R15) who used a Hoyer lift for transfers.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure residents had a fitted sheet on their bed for 2 of 2 residents (R15, R53) with bariatric beds.

Inspectors wroteBased on observation and interview, the facility failed to ensure required nurse staffing information was posted to reflect accurate total number and actual hours worked per shift for licensed and registered staff for each shift on a daily basis. This had potential to affect all 58 residents, staff, and visitors who could want to review this information.

Inspectors wroteBased on interview and document review the facility failed to obtain an order for restraint and perform an assessment following the restraint of 1 of 1 resident (R1) reviewed for physical restraint.

Inspectors wroteBased on interview and document review the facility failed to perform an appropriate discharge for 1 of 1 resident (R1) when R1 was discharged without a reassessment of the facility's ability to meet R1's needs when R1 returned from jail, and failed to identify the specific needs the facility could not meet nor the facility's efforts to meet those needs.

Inspectors wroteBased on interview and record review the facility failed to ensure appropriate discharge documentation was in the medical record for 1 of 1 resident (R1). reviewed for discharge.

Inspectors wroteBased on interview and record review the facility failed to administer long-acting insulin at consistent times according to the manufacturer's instructions for 2 of 3 residents (R2, R3) who were prescribed long-acting insulin.:

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident with known cognitive impairment was comprehensively evaluated and had individualized interventions implemented to ensure safety when leaving the facility independently for 1 of 3 residents (R3) reviewed for safety.

Inspectors wroteBased on interview and document review, the facility failed to maintain a complete and accurately documented medical record in accordance with accepted professional standards and practices for 1 of 1 resident (R3) reviewed for accidentsFindings includeR3's diagnoses list dated 3/5/26 included stroke, hypertension (high blood pressure), repeated falls, and cognitive communication deficit. R3's provider order dated 1/15/26 instructed clonidine (a medication that lowers blood pressure) oral tablet 0.3 milligrams (MG). Give one tablet by mouth three times a day for hypertensive urgency. Hold if heart rate is less than 60 beats per minute or if systolic blood pressure is less than 100 millimeters of mercury (mmHg). R3's nursing notes dated 3/1/26 identified on 2/28/26 around 7:30 pm, R3 had told the receptionist she was leaving the facility. [...]

Inspectors wroteBased on interview and document review, the facility failed to comprehensively assess pain and failed to offer or attempt non-pharmacological pain interventions prior to the administration of as-needed (PRN) pain medications for 2 of 3 residents (R1, R3) reviewed for pain

Inspectors wroteBased on interview and document review, the facility failed to accurately document a weekly bath and a current head to toe skin assessment for 2 of 3 residents (R1 and R3) reviewed when R1 had several bruises and scratches upon discharge from the facility. The facility only documented one weekly skin assessment form during his three-week stay, along with R3 who had two skin assessments completed from 11/1/25 through 1/21/26.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure 4 of 4 residents (R22, R53, R66 and R36) who exited the facility out of the front door after-hours had the ability to safely and timely reenter the building. This resulted in an immediate jeopardy situation for R22, R53, R66 and R36 who had to wait for an extended period of time in severe cold temperatures in order to get back into the building. This failure created a risk of serious harm, injury, impairment or death for any resident who may attempt to reenter the building after hours. The IJ began on 10/17/25 when the administrator had the after-hours door code to enter the facility changed without informing the residents it may affect and then did not provide the code or a consistently working system they could use to alert staff they needed reentry. [...]

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure contact precautions were followed 1 of 1 resident (R1, R12 ) reviewed for contact precautions. In addition, the facility failed to ensure infection prevention practices were followed for medications and food storage. This had the potential to affect all 31 residents on the 3rd floor.

Inspectors wroteBased on observations, interview, and document review, the facility failed to ensure written Physician's Orders for Life Sustaining Treatment (i.e., POLST) were accurately entered, transcribed and reflected in the medical record to ensure current resuscitation measures (i.e., DNR - Do Not Resuscitate or CPR - Cardiopulmonary Resuscitation) would be performed in accordance with resident wishes for 1 of 2 residents (R1) reviewed for advanced directives. These findings constituted an immediate jeopardy (IJ) situation for R1 who would have received CPR against her declared wishes documented on a POLST dated [DATE]. The IJ began on [DATE], when R1's POLST, indicating R1's wishes for DNR comfort focused treatment (allow natural death) was signed and it wasn't changed within the facility' electronic Medical Record (EMR) system (i.e., banner) to reflect R1's wishes. [...]

Inspectors wroteBased on observation and interview, the facility failed to provide a dignified dining experience for all 68 of 68 residents who were served meals using plastic silverware, Styrofoam cups and Styrofoam to-go containers. The facility further failed to ensure cares were provided in a dignified and respectful manner.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure resident mail was delivered on Saturdays for 2 of 2 residents (R8, R17) who voiced concerns with mail delivery. This deficient practice had the potential to affect all 68 residents residing in the facility.

Inspectors wroteBased on observation, interview, and document review, the facility failed to provide sufficient staffing and or oversight of non-licensed nursing staff to ensure the residents received care and assistance as needed and in a timely manner. This deficient practice had the potential to affect all 68 residents who reside in the facility.

Inspectors wroteBased on interview and document review, the facility failed to complete annual performance evaluations for 3 of 3 nursing assistants (NA-M, NA-N, NA-O) who had been employed by the facility for over one year.

Inspectors wroteBased on interview and document review, the facility failed to have evidence of a goal, an action plan, and analysis of data to identify Performance Improvement Projects (PIP). This had the potential to affect all 68 residents of the facility.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure residents' call light system was functioning throughout the building. This had the potential to affect all 70 residents in the facility.

Inspectors wroteBased on interview and document review, the facility failed to ensure staff completed mandatory communication training for 3 of 10 staff (the director of nursing (DON), registered nurse (RN)-B, nursing assistant (NA)-I) reviewed for training requirements. This had the potential to affect all 68 residents residing in the facility.

Inspectors wroteBased on interview and document review, the facility failed to ensure staff completed mandatory resident rights training for 2 of 10 staff members (the director of nursing (DON), nursing assistant (NA)-J) reviewed for training requirements. This had the potential to affect all 68 residents residing in the facility.

Inspectors wroteBased on interview and document review, the facility failed to ensure staff completed mandatory quality assurance and performance improvement training for 1 of 10 staff members (the director of nursing (DON)), reviewed for training requirements. This had the potential to affect all 68 residents residing in the facility.

Inspectors wroteBased on interview and document review, the facility failed to ensure staff completed mandatory compliance and ethics training for 1 of 10 staff members (the director of nursing (DON), reviewed for training requirements. This had the potential to affect all 68 residents residing in the facility.

Inspectors wroteBased on interview and document review, the facility failed to ensure staff completed mandatory behavioral health training for 5 of 10 staff members (the director of nursing (DON), registered nurse (RN)-B, nursing assistant (NA)-I, NA-J, NA-K) reviewed for training requirements. This had the potential to affect all 68 residents residing in the facility.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure routine personal hygiene (i.e., showers and toileting) were completed for 6 of 8 residents (R12, R30, R31, R37, R52, and R54) reviewed for activities of daily living (ADLs) and who were dependent on staff for their care.

Inspectors wroteDuring observation and interview, the facility failed to ensure food was served at a preferable temperature to residents. This had the potential to affect all 68 residents of the facility who received meals from the facility.

Inspectors wroteBased on observation, interview and document review, the facility failed to provide a safe, sanitary, comfortable environment for residents. This had the potential to affect all 70 residents, staff, and visitors.

Inspectors wroteBased on interview and document review the facility failed to provide a written notice of bed hold for one of 1 resident (R70) reviewed for hospitalization.

Inspectors wroteBased on observation, interview and document review the faciality failed to ensure a resident's comprehensive care plan was appropriately implemented for 1 of 2 resident (R30) who had interventions for specialized boots and cares is pairs that were not implemented.

Inspectors wroteBased on interview, and document review, the facility failed to provide the opportunity for 2 of 2 residents (R1, R31) reviewed to participate in care planning and care conferences.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure effective collaboration between the facility and a contracted hospice organization that affected 1 of 1 residents (R1) reviewed for hospice services.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure nursing staff were appropriately trained and competent in the use of a cough assist machine for 1 of 1 resident (R78) reviewed for the use of a cough assist machine.

Inspectors wroteBased on observation, interview and document review the facility failed to ensure 1 of 1 resident (R30) who had chronic pain received adequate pain control to include non-pharmacological pain interventions and appropriate communication and coordination with an outside pain provider.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure nursing staff were appropriately trained and competent in the use of a cough assist machine for 1 of 1 resident (R78) reviewed for the use of a cough assist machine.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure 1 of 1 resident (R31) reviewed received appropriate behavior health management to address continued rejection of care and behaviors of urinating and defecating in inappropriate places.

Inspectors wroteBased on observation, interview, and document review, the facility failed to monitor for potential side effects for 1 of 3 residents (R3) reviewed who received an anticoagulant (blood thinner) medication.

Inspectors wroteDuring observation, interview, and record review the facility failed to identify, implement, monitor and modify interventions to provide timely treatment and services to heal and to prevent further worsening of wounds. This failure resulted in harm for R254 when his bilateral heel pressure ulcers were not identified and addressed by facility until they progressed to stage three.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure opened dairy products (i.e., milk) for resident' consumption was either consumed or discarded in a timely manner to reduce the risk of foodborne illness; and failed to ensure 1 of 2 unit refrigerators were adequately monitored for temperature and food quality to reduce the risk of complication or illness. In addition, the facility failed to ensure staff covered their hair during food preparation and service; failed to ensure dry baking and frozen foods were stored in a manner to reduce the risk of cross-contamination; failed to ensure food items were properly stored, labeled, dated, and discarded properly; failed to ensure metal pans were completely dry before stacking to prevent bacterial growth; failed to These findings had potential to affect all 51 residents within the care center.

Inspectors wroteDuring observation, interview and record review the facility failed to ensure facility was kept sanitary and maintained in good repair which had the potential to affect all 51 residents, staff, and visitors of the facility. In addition, the facility failed to ensure the dish machine in the main kitchen was kept in a clean and sanitary manner and free of debris.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure adequate pest control measures were in place to eliminate small black flies from the building. This had the potential to affect all 51 residents of the facility.

Inspectors wroteBased on observation, interview, and document review, the facility failed to provide a dignified dining experience for 1 of 1 resident (R25) who was referred to as a feeder.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure meals were served in a warm, palatable manner to promote quality of life and nutritional intake for 3 of 3 residents (R12, R8, R153) who complained about cold food at meals. This had potential to affect a total of 25 residents identified to reside on the unit where the meals were served and sample tray tested.

Inspectors wroteBased on observation, interview, and document review, the facility failed to provide the ordered diet texture for 1 of 2 residents (R35) reviewed for dietary texture.

Inspectors wroteBased on interview and document review, the facility failed to obtain and document an informed consent, including with explanation of risk and benefits, before giving psychotropic medications for 2 of 5 residents (R24, R25) reviewed for unnecessary medication use.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure there was reasonable access to private phone use for 1 of 1 residents (R153) reviewed who utilized the facility phone.

Inspectors wroteBased on interview and document review, the facility failed to promptly notify the provider consistently of high blood sugars for 1 of 1 residents (R36) of reviewed for notification of change.

Inspectors wroteBased on observation, interview and document review the facility failed to appropriately follow up on continued and repeated voiced grievances of provided food for a diabetic diet for 1 of 2 residents (R31) reviewed for grievances who gained 35% of their weight since being admitted to the care facility.

Inspectors wroteBased on interview and document review, the facility failed to ensure appropriate side effect monitoring for potential orthostatic hypotension (sudden drop in blood pressure what occurs when a person stands up after sitting or lying down) was completed for 1 of 5 residents (R7) reviewed for unnecessary medication use and who consumed antipsychotic medication.

Inspectors wroteBased on interview and document review, the facility failed to ensure the comprehensive Minimum Data Set (MDS) was completed in a thorough manner to ensure all areas of resident performance and activities preference were evaluated for 1 of 4 residents (R24) reviewed for MDS accuracy and completion.

Inspectors wroteBased on interview and document review, the facility failed to ensure the quarterly Minimum Data Set (MDS) was completed in a thorough manner to ensure areas of cognition and potential depressive symptoms were fully evaluated for 2 of 4 residents (R22, R23) reviewed for MDS accuracy and completion.

Inspectors wroteBased on interview and record review the facility failed to ensure the Minimum Data Set (MDS) was accurately coded to reflect discharge status for 1 of 1 residents (R50) reviewed for hospitalization.

Inspectors wroteBased on interview and document review, the facility failed to ensure a comprehensive care plan was developed for 1 of 2 residents (R37) reviewed for diet preferences/allergies.

Inspectors wroteBased on interview and document review, the facility failed to provide routine care conferences to allow for resident participation and interdisciplinary review, and update, if necessary, of the care plan for 1 of 2 residents (R41) reviewed for care conferences.

Inspectors wroteBased on observation, interview, and document review, the facility failed to provide assistance to complete personal hygiene cares for 1 of 1 resident (R23) reviewed who needed assistance with fingernail care.

Inspectors wroteBased on observation, interview, and document review, the facility failed to comprehensively assess and, if needed or able, develop or implement activities programming to promote quality of life for 1 of 2 residents (R24) reviewed for activities.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure proper wheelchair positioning for eating was maintained to promote comfort for 1 of 1 resident (R22); and failed to ensure medical devices for edema management were consistently applied to reduce peripheral swelling for 1 of 2 residents (R258) reviewed for edema care.

Inspectors wroteBased on observation, interview and document review, the facility failed to provide services to maintain and/or prevent loss of range of motion and contracture care for 1 of 1 resident (R23) reviewed for limited range of motion (ROM).

Inspectors wroteBased on interview and document review, the facility failed to comprehensively assess and develop interventions as needed to reduce the risk of accidents or injury for 2 of 2 residents (R41, R38) reviewed with a history of substance abuse and suspected current use. In addition, the facility failed to implement interventions for 1 of 1 resident (R35) reviewed for falls.

Inspectors wroteBased on observation, interview and document review the facility failed to recognize and respond to a resident's weight gain in the facility to ensure they maintained acceptable parameters of nutritional status, such as desirable body weight, for 1 of 2 residents (R31) reviewed for nutritional status who gained 35% of their weight since admittance to the care facility.

Inspectors wroteBased on observation, interview and document review the facility failed to ensure a resident's pain was adequately controlled and failed to implement non-pharmacological pain interventions (i.e. heat, ice, massage, aromatherapy) if needed for adequate pain control for 1 of 2 residents (R41) reviewed for pain.

Inspectors wroteBased on interview and document review, the facility failed to identify triggers or attempt to identify triggers to avoid potential re-traumatization, and failed to develop a care plan to include individualized trauma-informed approaches for 1 of 1 residents (R36) who had a history of trauma.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure physician-ordered medications were re-ordered timely to prevent delay in administration and reduce the risk of complications for 1 of 5 residents (R10) reviewed for unnecessary medications.

Inspectors wroteBased on interview and document review, the facility failed to ensure a resident was free from unnecessary medication by failing to attempt to decrease a resident's nicotine patch (a known psychotropic medication) despite the consulting pharmacist's and Centers for Disease Control and Prevention's recommendations for 1 of 5 residents (R7), and failed to monitor, assess, and clarify an antibiotic without an end date for 1 of 5 residents (R25) reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from significant medication errors when a narcotic pain medication was not administered as ordered for 1 of 5 (R10) residents reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure prescribed inhaled medications were stored in their correct packaging to prevent potential administration error for 1 of 5 residents (R3); and failed to ensure prescribed oral medications were labeled with minimum identifiers to ensure correct administration (i.e., right patient, right medication) for 1 of 5 residents (R3) observed to received medication during the survey.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure food allergens and/or preferences were followed for 3 of 4 residents (R258, R35, and R37) reviewed for food allergens/preferences.

Inspectors wroteBased on interview and document review, the facility failed to ensure a therapeutic diet was ordered upon return to facility per orders on hospital discharge for 1 of 1 residents (R36) reviewed for therapeutic diets.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure current infection control standards of practice were followed when performing resident personal care for 1 of 4 residents (R153) observed for personal care.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure the most recent State agency (SA) were posted in a prominent location and readily accessible at all times of the inspection reports within the campus. This had the potential to affect all 51 residents and any visitors who wanted to review this informationFindings include: The CMS CASPER Report 0003D, dated 6/24/25, identified the completed recertification surveys for the previous three years, with the most recently completed recertification survey having exited on 2/13/25. On 7/1/25 at 11:30 a.m., an informal resident council meeting was held with R8, R13, and R1. The residents were asked, as part of the meeting, if the most recent survey results were readily posted within the facility for them to review at leisure. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to complete a comprehensive assessment for self-administration of medication for 1 of 1 resident (R2) reviewed for self-administration of medications.

Inspectors wroteBased on interview and record review the facility failed to sufficiently prepare, orientate, and understanding of discharge 1 of 3 residents (R1) reviewed for discharge. R1 was sent home without ordered home care services, which led to worsening of his wounds and an admission to the hospital.

Inspectors wroteBased on interview and record review the facility failed to ensure appropriate discharge documentation was in the medical record for 3 of 3 residents (R1, R2, & R3). R1, R2 and R3's medical records were missing discharge summaries, a recapitulation of their stay, a final summary of their status and reconciliation of all pre-discharge and post-discharge medication (both prescribed and over the counter medications).

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish an effective system of reconciliation and disposition to properly dispose of medications that were discontinued for 20 of 29 residents (R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, R24, R25, R26, R27, R28, and R29) reviewed. During observations, there were two trash bags full of approximately 153 medication cards of non-narcotic medications that were discontinued. This deficient practice had the ability to affect all sixty residents.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure side rails were comprehensively assessed to determine if they were appropriate and safe, discuss the risks and benefits, and obtain informed consent prior to use of bed rails for 1 of 3 residents (R1) who was observed to have side rails raised on their bed.

Inspectors wroteBased on interview and document review the facility failed to ensure admission orders on 1/8/25 for a diuretic (medicine that increases urine production and help lower blood pressure and fluid retention) were clarified and followed up for R1. As a result, R1 did not receive diuretic for sixteen days. This resulted in a significant medication error and actual harm when R1 was hospitalized for congestive heart failure (CHF) exacerbation.

Inspectors wroteBased on interview and document review, the facility failed to ensure a registered nurse (RN) was scheduled for a minimum of eight consecutive hours a day. This had the potential to affect all 62 residents who resided at the facility. Findings Include: Review of Payroll Based Journal (PBJ) Staffing Data Report, submitted for the fourth quarter of 2024 (July 1- September 30), identified no RN hours for the following dates: 7/7/24, 7/21/24, 8/18/24, 9/1/24, and 9/15/24. Review of the facility staffing schedules for the following dates 8/18/24, 9/1/24, and 9/15/24 were identified as Sundays and no RN was scheduled. Staffing schedules for 7/7/24 and 7/21/24 were not provided and were also identified as Sundays. [...]

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure meals were served in a warm, palatable manner to promote quality of life and nutritional intake for 2 of 2 residents (R18, R15) reviewed. This had potential to affect a total 33 of 33 residents identified to reside on the unit where the meals were served and sample tray tested.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure food was served at the proper temperature to 3 of 3 residents (R1, R7, and R9) reviewed for residents during breakfast and lunch on the third floor of the building. This had the potential to affect all 37 residents who resided on the third floor. Findings Include: R1's quarterly Minimum Data Set (MDS) dated [DATE] indicated R1 had a Brief Inventory of Mental Status (BIMS) of 15 indicating R1 was cognitively intact. R1 required set-up and clean-up assistance with activities of daily living. R1's pertinent diagnoses were cardiac failure, renal insufficiency, morbid obesity, and borderline personality (a mental disorder characterized by unstable moods. R1 required a therapeutic diet. R7's quarterly MDS dated [DATE] indicated R7's cognitions status was not completed. R7 used a wheelchair for mobility. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure that 1 of 2 residents (R6) reviewed received services in a dignified manner to promote quality of life when staff failed to respond timely to call light and provide assistance per residents needs resulting in R6 missing time with family.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement care plans for 3 of 3 residents (R2, R3, and R4) reviewed when the residents did not receive care according to the comprehensive assessment. The residents were not turned and/or repositioned every two to three hours as indicated on the care plan.

Inspectors wroteBased on interview and record review the facility failed to provide a systematic approach to assess and evaluate residents' fluid status to monitor the effectiveness of interventions for 2 of 2 residents (R1 and R8) reviewed. R1 and R8 were on a daily fluid restriction. The facility partially documented the fluid intake; however, the facility did not have a system in place to evaluate the total daily fluid intake to determine adequacy or if the provider required notification.

Inspectors wroteBased on observation, interview, and record review the facility failed to accommodate foods for resident allergies and/or intolerances for 1 of 3 residents (R1) reviewed. R1 had an allergy to gluten and was given gluten meals so often at the facility that R1 was buying her own food and stocking-up on foods from the facility kitchen to have when she was served a gluten meal.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide the prescribed diet to 2 of 3 residents (R6 and R8) reviewed for therapeutic diets. R6 and R8 were both prescribed a low sodium diet, and the facility was unable to demonstrate how they provided the specialized diet.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure proper handwashing/hand hygiene, personal protective equipment, and enhanced barrier precautions (EBP) were implemented for 2 of 2 residents (R1, R2) observed during wound care, an intravenous (IV) flush, and catheter care.

Inspectors wroteBased on interview and document review, the facility failed to develop a comprehensive care plan for skin integrity for 1 of 3 (R2) residents reviewed for wound care.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure structural issues and items in disrepair throughout the facility were addressed and fixed in order to help promote a functional, sanitary and safe environment. This had the potential to affect all 53 residents residing within the facility.

Inspectors wroteBased on interview and document review, the facility failed to ensure new, person-centered fall interventions were implemented to prevent further falls and potential injury for 1 of 1 residents (R28) reviewed for repeat falls. In addition, the facility failed to accurately and comprehensively assess for smoking practices for 1 of 1 residents (28) reviewed for smoking. In addition, the facility failed to ensure an overiszed and unsecured mattress was assessed for correct fit to a resident's bed for (R44) who was reviewed saftey hazards.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure toileting needs were comprehensively evaluated and appropriate to meet the resident' needs and prevent complication (i.e., skin damage, soiled clothing) for 1 of 2 residents (R27) reviewed who was dependent on staff for care.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure vision needs were comprehensively assessed or tracked and, if needed, referred to an appropriate service for 1 of 2 residents (R7) reviewed who complained about worsening vision.

Inspectors wroteBased on observation, interview and document review, the facility failed to deliver pressure ulcer care consistent with professional standards of care to prevent a facility acquired pressure ulcer for one of one resident (R8) reviewed for pressure ulcers.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure dental needs were assessed, offered and, if needed, referred to appropriate dental services in a timely manner for 2 of 3 residents (R7, R28) reviewed for dental care.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure enhanced barrier precautions (EBP) were implemented or followed for 2 of 2 residents (R6 and R8) reviewed for EBP.

Inspectors wroteBased on interview and document review, the facility failed to provide adequate supervision while out of the facility at an appointment for 1 of 3 residents (R1). This deficient practice resulted in an immediate jeopardy (IJ) for R1 when R1 went to an appointment without supervision and the facility did not know his whereabouts until 20 hours after he left. The immediate jeopardy began on 7/24/24 when the facility sent R1 to an appointment without supervision, R1 did not come back to the facility, and the facility did not know his whereabouts until 20 hours after he left. The director of nursing (DON) and administrator were notified of the immediate jeopardy at 12:15 p.m. on 8/2/24. The IJ was removed on 8/6/24, but noncompliance remained at the lower scope and severity level of D - isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy.

Inspectors wroteBased on interview and document review, the facility failed to ensure safe transfers with a full body mechanical lift resulting in a left femur fracture for 1 of 3 residents (R1) reviewed for accidents. The facility failed to complete a comprehensive sling assessment and use appropriate slings for the mechanical lifts per manufacture instructions. The immediate jeopardy (IJ) began on 4/2/24 when two nursing assistants used a Lumex brand full body sling with a Joerns Hoyer brand mechanical lift resulting in a fall with fracture for R1. The administrator and director of nursing (DON) were notified of the IJ on 4/9/24 at 5:00 p.m. The IJ was removed on 4/12/24 at 1:00 p.m. but noncompliance remained at the lower scope and severity of a level D isolated, which indicated no actual harm with potential for more than minimal harm that was not immediate jeopardy. [...]

Inspectors wroteBased on interview and document review, the facility failed to thoroughly investigate a fall from a mechanical lift that resulted in a broken femur for 1 of 3 residents (R1) reviewed for accidents. A report submitted to State Agency (SA) dated 4/4/24 at 7:45 p.m. indicated R1 had a fall on 4/2/24 during a transfer with a Hoyer (mechanical) lift that resulted in a left femur fracture. R1's diagnoses list included metabolic encephalopathy (a change in brain function that may cause confusion, memory loss, and/or sleepiness) and Alzheimer's Disease. R1's quarterly MDS dated [DATE] indicated R1 rarely/never understands or is understood, and was dependent on staff for all transfers. R1's care plan dated 2/27/24 indicated she required total assist of two staff using the Hoyer lift for all transfers. The care plan lacked indication of what size sling was to be used. On 4/2/24 at 9:30 a.m. [...]

Inspectors wroteBased on interview and document review, the facility failed to have a written transfer agreement with a hospital approved for participation under Medicare or Medicaid programs, which reasonably ensured that residents would be transferred to the hospital and ensured timely admission. This had the potential to affect all 55 residents in the facility who could require hospitalization on an emergent basis.

Inspectors wroteBased on interview and document review, the facility failed to ensure a potential allegation of neglect was recognized and reported to the State agency (SA) in a timely manner for 1 of 1 resident (R1) reviewed who reported a burn to staff during therapy treatment.

Inspectors wroteBased on observation, interview and document review, the facility failed to comprehensively reassess and develop interventions to provide safety for 1 of 4 residents (R1) who sustained a burn from a heat pad machine in the therapy department and 1 of 2 residents (R2) who was documented to have a cigarette burn.

Inspectors wroteBased on interview and document review, the facility failed to ensure 2 of 5 nursing assistants (NA-O, NA-R) received and demonstrated required competency skills for resident cares. This had the potential to affect all 61 residents who resided in the facility. Findings Include: Review of NA-O and NA-R's employee files indicated no skills competencies were completed within the last year. During interview on 3/27/24 at 10:01 a.m., human resource director (HRD)-J indicated NA-O, and NA-R had not completed the annual NA competencies, but the new administration was planning on completing a facility wide review of all employee files for competency completion. During interview on 3/27/24 at 2:18 p.m., the administrator stated the employee files lacked documentation for annual competencies however, with the new administration there was a plan underway for a facility wide skills fair. [...]

Inspectors wroteR109's quarterly Minimum Data Set, dated [DATE], indicated R109 had mild cognitive impairment, required substantial/maximal assistance with most activities of daily living (ADLs), and had diagnoses of traumatic brain injury (TBI), seizure disorder, and aphasia (loss of ability or difficulty expressing speech). R109's care plan (CP) revised 3/1/24, indicated R109 had a communication problem and was at risk for falls. The CP instructed staff to ensure call light was in reach. R109's care plan revised 3/1/24, included R109 had a communication problem, was at risk for falls and directed staff to ensure call light near him in case he should want to use it. During observation and interview on 3/24/24 at 4:43 p.m. R109 was in bed with bed perpendicular to the wall and away from the wall. [...]

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure they were free of a medication error rate of five percent or greater. The facility had a medication error rate of 63.64% with 21 errors out of 33 opportunities involving 8 of 8 residents (R10, R15, R20, R22, R25, R33, R46, R53) who were observed during medication administration.

Inspectors wroteBased on observation interview and record review, the facility failed to provide meals at a palatable temperature for any resident who choose to eat in their rooms. This had the potential to affect 61 residents in the facility who could eat meals in their rooms. On 3/26/23 at 12:13 p.m., Dietary Aide (DA)-B started assembling room tray. Lunch was tacos, beans, rice, and a slice of watermelon. Food Service Director (FSD) assisted with the tray preparations for 11 residents on the 3rd floor. The watermelon and drinks were not covered. On 3/26/23 at 12:28 p.m., the first room tray was delivered. At 12:36 p.m., the last room tray was delivered, a test tray was reviewed. The rice and beans were 102 degrees Fahrenheit (F), and the meat on the taco did not reach 100 degrees F. The FSD indicated the food should be 130 degrees and the temperature were not acceptable. [...]

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure residents' call lights were functioning for 2 of 2 residents (R15, R36) reviewed for call lights.

Inspectors wroteBased on observation, interview and document review, the facility failed to maintain a dignified dining experience for 1 of 6 resident (R109) reviewed for dignity.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure appropriate therapeutic diets were consistently provided for 1 of 5 residents (R109) reviewed for nutrition.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide necessary respiratory care consistent with professional standards of practice for 1 of 2 residents (R46) reviewed for oxygen use. Furthermore, the facility failed to ensure 1 of 1 resident (R46), who used intermittent oxygen via nasal cannula, had current physician orders.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure menu items were prepared and served as written to the resident population for (R1, R210, R109) and failed to ensure foods were provided according to preferences for 1 of 1 resident (R210)

Inspectors wroteBased on interview and document review, the facility failed to ensure an allegation of sexual abuse was reported to the State Agency (SA) immediately, within 2 hours as required, for 1 of 3 residents (R1) reviewed who alleged sexual abuse by a staff member.

Inspectors wroteBased on interview and document review, the facility failed to thoroughly investigate an allegation of sexual abuse for 1 of 3 residents (R1) reviewed.

Inspectors wroteBased on interview, observation, and document review, the facility failed to ensure the care plan was updated to ensure smoking interventions were re-evaluated and implemented for 1 of 1 resident (R1) reviewed for smoking.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure oral cares and shaving were offered or provided for 1 of 3 residents (R2) who was dependent upon staff for assistance with activities of daily living (ADLs).

Inspectors wroteBased on observation, interview, and document review, the facility failed to develop and implement smoking policies to include smoking marijuana to ensure 1 or 1 residents (R1) reviewed for smoking was assessed for the safe use of a marijuana pipe, and failed to address the risks of smoking marijuana in resident rooms.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure resident's safety, by assessing each resident for the risk of substance abuse, and develop a care plan with interventions for each resident, who had been identified as at risk, with efforts to prevent overdose (OD), which would include increased monitoring and supervision, resulting in risk of potential serious harm, injury, impairment, or death to 2 of 3 residents (R1, R2) who were reviewed. The immediate jeopardy began on 8/19/23, when R2 overdosed, was hospitalized and the facility failed to assess, develop and implement care planning interventions to prevent overdose for R2. The administrator and interim director of nursing (DON) were notified of the immediate jeopardy on 10/27/23. [...]

Inspectors wroteBased on interview and document review, the facility failed to identify specific care or practices necessary to meet identified care needs regarding substance abuse disorders. This had the potential to affect all residents currently residing in the facility with a diagnosis or history of substance use disorders.

Inspectors wroteBased on interview and document review, the facility failed to have a discharge planning process to ensure discharge goals were achieved for 2 of 3 residents (R1, R2) who were reviewed.

Inspectors wroteBased on interview and document review the facility failed to develop a comprehensive care plan with appropriate services, treatments, and prevention interventions for substance use disorders for 2 of 3 residents (R1, R2) reviewed. In addition, the facility failed to follow physician orders for referral to behavioral health services 1 of 3 residents (R1) and failed to follow behavioral health specialist's recommendations regarding managing continued substance abuse for 1 of 3 residents (R2) reviewed for behavioral health services.

Inspectors wroteBased on interview and document review, the facility failed to address a diagnosis of post-traumatic stress disorder (PTSD) by obtaining a history of trauma, and develop a person-centered care plan to avoid triggers related to past trauma for 1 of 3 residents (R1) reviewed for mental disorders.

Inspectors wroteBased on observation, interview, and document review, the facility failed to perform timely comprehensive skin assessments, follow provider orders for therapy to assess for necessary equipment, provide interventions, monitoring, and care for pressure ulcer prevention, management and treatment who was admitted to the facility without pressure ulcers for 1 of 3 residents (R3) reviewed for pressure ulcers R3 was harmed when the facility failed to develop and implement interventions to promote healing and prevention resulting in R3 developing an unstageable pressure ulcer.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure the call light system was set-up in a functional manner to allow residents to call for staff assistance through a communication system which relays the calls directly to the staff member or a centralized work area. This had the potential to affect all 72 residents who resided within the facility.

Inspectors wroteBased on observation, interview and document review the facility failed to provide sufficient staffing to ensure resident care needs were provided for 4 of 4 residents (R1, R3, R4, R5 and R6) who expressed concerns of not being toileted timely and concerns with dependent residents not assisted with activities of daily living (ADL's) timely.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure the call light system was set-up in a functional manner to allow residents to call for staff assistance through a communication system which relays the calls directly to the staff member or a centralized work area. This had the potential to affect all 72 residents who resided within the facility.

Inspectors wroteBased on interview and document review the facility failed to notify the ombudsmen for long term care regarding facility discharges tor 4 of 4 residents (R1, R5, R6, R7) reviewed for discharge.

Inspectors wroteBased on interview and document review the facility failed to document required health information for 4 of 4 residents (R1, R5, R6, R7) reviewed for discharge summary.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure sufficient staffing was available to provide timely assistance with personal cares according to the residents' assessed need and as directed by the care plan for 4 of 4 residents (R2, R4, R8, and R9) reviewed for staffing needs.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure the facility offered a comfortable homelike environment for 2 of 2 residents (R2 and R8) when R2 and R8's room was not kept free of odors, and R2 was laying on soiled linens and R8 was found without proper linens on his bed.