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Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident safety during transportation for 2 of 3 residents reviewed for dementia care. Locked memory care unit residents with a history of falls and/or behaviors were transported to outside appointments without being signed out and without adequate supervision. (Resident B, Resident C)

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement the plan of care for a cognitively impaired resident at high risk of falling for 1 of 1 residents reviewed for falls. Fall care plan interventions were not in place. (Resident 14)

Inspectors wroteBased on interview and record review, the facility failed to ensure medications were given as ordered and a discharged resident was sent home with the correct medication for 1 of 3 closed records reviewed. A blood thinner was not given as ordered, and a resident was sent home with another resident's medications at discharge. (Resident B)On 1/30/26 at 4:00 P.M., the Administrator provided an incident form that indicated on 9/19/25 when Resident B was discharged from the facility, medications belonging to another resident had been sent home with them. The form indicated the facility attempted to contact Resident B's representative several times daily until 9/25/25 when contact was made and the medication was brought back to the facility the same day. On 1/29/26 at 11:32 A.M., Resident B's clinical record was reviewed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a sanitary environment to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents observed for incontinence care. Hand hygiene was not done, gloves were not changed between clean and dirty tasks, and the soiled incontinence pad was laid on the bedsheet. (Resident 45)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were stored safely or under proper temperature controls for 2 of 15 residents sampled for medications on the floor, and 2 of 2 medication storage rooms. (Resident D, Resident M, 100 Hall Medication Storage Room, 300/400 Hall Medication Storage Room)

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure food was stored and prepared safely in accordance with professional standards for food service for 1 of 2 kitchen observations. Foods were not labeled correctly, food was stored uncovered, and the facility failed to dispose of outdated food.

Inspectors wroteBased on interview and record review, the facility failed to ensure staff thoroughly and completely assessed a resident after a fall with head injury, failed to ensure the fall was effectively documented with specific fall details to ensure interventions were immediately implemented to prevent further falls, failed to effectively monitor the neurological status of the resident after a subdural hematoma was identified for 1 of 3 residents reviewed for falls. (Resident D) This deficient practice resulted in the resident experiencing right-sided shaking, slurred speech, altered mental status, and an active brain bleed that required a craniotomy to repair.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident safety during transportation for 1 of 3 residents reviewed for accidents. A resident was improperly loaded onto a transportation vehicle lift causing the resident to fall backwards from a wheelchair onto the lift platform. (Activity Assistant 3, Resident B)

Inspectors wroteBased on interview, and record review, the facility failed to ensure the plan of care was implemented for 1 of 3 residents reviewed for ADL (activities of daily living) care provided. A resident was not assisted by two staff members during a transfer during incontinence care per the resident's plan of care. (Resident D, Resident C)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nursing care and services consistent with professional standards of practice were provided to a resident that required ostomy care. Staff did not appropriately change a resident's newly placed ostomy appliance, resulting in pain, psychological trauma and a fear of getting out of bed for 1 of 1 residents reviewed for ostomy care. (Resident 219)

Inspectors wroteBased on observation, interview and record review, the facility failed to develop resident specific care plans and implement interventions for 4 of 4 residents reviewed for care plans. A resident's care plan indicated to encourage fluids when the resident was NPO (nothing by mouth). Two residents had orders that did not match care plans for dental services. A resident with falls did not have interventions in place. (Resident 6, Resident 49, Resident 51, Resident 62)

Inspectors wroteBased on observation and interview, the facility failed to ensure the resident's right of dignity was promoted and protected for 2 of 3 residents reviewed for dignity. A visibly soiled resident was not stopped by staff on his way to the dining room and a resident receiving incontinence care was told the staff was going to change his diaper. (Resident 35, Resident 40)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents that were self-administering medications were assessed for capability to self administer medications for 1 of 2 residents reviewed for accidents and 1 of 5 residents reviewed for medication administration. Resident clinical records lacked a self administration of medication assessment. (Resident 6, Resident 65)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure assessments were conducted and completed following an emergency room visit where all insulin medications were discontinued for a diabetic resident for 1 of 3 residents reviewed for change of condition. (Resident 31)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were administered free of error for 1 of 5 residents reviewed for medication administration. A resident was administered the wrong dose of (2) medications, resulting in an error rate of 8%. (Resident 65)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure posted nurse staffing sheets contained the correct information daily for 5 of 6 days during the survey.

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate submission of all direct care staffing data into the Payroll-Based Journal (PBJ) system for the reported period of January 1, 2023 through March 31, 2023. One entry, March 11, 2023, was triggered in error for low weekend staffing due to inaccurate staffing information submitted.