Valley Grande Manor

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote and facilitate resident self-determination through support of resident choice, for 1 of 3 residents (Resident #1) reviewed for resident rights. The facility failed to promote Resident #1's self-determination by not allowing him to choose when he wanted to go to bed. This failure could place residents at risk for their needs and preferences not being met.

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services to meet the needs of each resident by failing to ensure the timely acquisition and administration of prescribed medications for 1 (Resident #3's) of 3 residents reviewed for pharmacy services. The facility failed to timely acquire and administer an ordered central nervous system (CNS) stimulant medication, Ritalin 20 mg twice daily for Attention-Deficit/Hyperactivity Disorder (ADHD), resulting in an unapproved treatment delay. This failure has the potential to leave residents without critical prescribed therapies to manage their clinical and behavioral symptoms. Record review of Resident #3's admission record, dated 06/30/2026, reflected a [AGE] year-old male admitted on [DATE]. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to follow their policy regarding storage of foods brought to the residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption of the food and beverages for 1 of 1 Residents (Resident #1) reviewed for personal food storage. The facility did not have completed documentation of temperature checks for Resident #1's personal refrigerator from November 2025 through June 2026. This failure could place residents with personal refrigerators at risk of food borne illness.

Inspectors wroteBased on interviews and record reviews the facility failed to ensure the residents right to be informed of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers, for 1 of 5 residents (Resident #3) reviewed for consent for antipsychotic medications in that: Resident #3 was prescribed and administered Risperidone (an antipsychotic) without prior consent based on information of the benefits, risks, and options available. This failure could affect the right to self-determination of all facility residents who receive medication by allowing them to receive medication without their prior knowledge or consent, or that of their responsible party or emergency contacts.

Inspectors wroteBased on interviews, and record review, the facility failed to develop a baseline care plan within 48 hours of a resident's admission that included the instructions needed to provide effective and person-centered care of 1 (Resident #3) of 3 residents reviewed for baseline care plan completion. The facility failed to complete a baseline care plan for Resident #3 within 48 hours of his admission. This failure could place newly admitted residents at risk of not receiving effective, person-centered care.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents who needed respiratory care were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of (Resident #1) of 5 residents reviewed for respiratory care. The facility failed to ensure Resident #1's oxygen was administered at the correct setting of 2 liters per minute on 06/30/2026 and at 4 liters on 07/01/2026 as ordered by the physician. These deficient practices could place residents who receive respiratory care at an increased risk of developing respiratory complications and a decreased quality of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 (Resident #1 and #3) of 5 residents observed for infection control issues in that: 1. The facility failed to ensure LVN E performed hand hygiene before and after medication administration for Resident #1. 2. There was no signage observed outside of Resident #3's room indicating enhanced barrier precautions prior to entering room. These failure could place residents, employees, and visitors at risk of communicable diseases.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents had the right to a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and support for daily living safely for 1 of 4 resident rooms in the secured unit (Resident room [ROOM NUMBER]) reviewed for environment.1. The facility failed to ensure Resident room [ROOM NUMBER], was thoroughly cleaned and sanitized.2. The facility failed to properly cover a shattered window in Resident room [ROOM NUMBER]. This deficient practice could place residents at risk of living in an unsanitary environment and a diminished quality of life due to an unclean and unfunctional environment.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure the resident's right to be informed, in advance, of the care to be furnished for 1 of 3 residents (Resident #1) reviewed for consent for secured unit placement. Resident #1 was placed in the secured unit (a unit that is designed to provide specialized, dementia-specific skilled nursing care to adults with Alzheimer's disease or related disorders) without prior consent based on information of the benefits, risks, and options available. This failure could affect residents by placing them at risk of not being informed of treatment options.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure a resident was free from involuntary seclusion for 1 of 3 residents (Resident #1) reviewed for involuntary seclusion. The facility failed to ensure Resident #1 met criteria to be placed in the secured unit per secured unit criteria on 03/11/26. This failure could place residents at risk of isolation, decreased quality of life, and psychosocial harm.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial need that were identified in the comprehensive assessment for 1 of 3 residents (Resident #1) reviewed for comprehensive person-centered care plans.1. The facility failed to ensure Resident #1 was care planned for the use of Lorazepam (a psychotropic medication used to treat anxiety).2. The facility failed to ensure Resident #1 was care planned for the use of the Wander Guard (A discreet wearable device that tracks movement and triggers automated security responses when a resident nears a restricted area).3. [...]

Inspectors wroteBased on interview and record review, the facility failed to obtain a written, signed and dated order from the attending physician for 1 of 3 residents (Resident #1) whose records were reviewed for physician services. The facility failed to obtain a physician's order for Resident #1 to be in the secured unit. This failure could place residents at risk for incorrect treatment decisions, evaluation, and treatment plans compromising patient safety due to insufficient information records.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure resident medical records were kept in accordance with accepted professional standards and practices. The facility must maintain medical records on each resident that are complete and accurately documented for 1 of 3 residents (Resident #1) reviewed for clinical records. The facility failed to document a change in condition or progress note to reflect the placement of the Wander Guard (A discreet wearable device that tracks movement and triggers automated security responses when a resident nears a restricted area) on Resident #1. The facility failed to document a change in condition or progress note to reflect the placement of Resident #1 in the secured unit (a unit that is designed to provide specialized, dementia-specific skilled nursing care to adults with Alzheimer's disease or related disorders). [...]

Inspectors wroteBased on interview and record review the facility failed to ensure residents were free from misappropriation and exploitation of property for 1 of 6 residents reviewed for misappropriation of property. (Resident #2) The facility failed to protect Resident #2 from misappropriation/exploitation by allowing housekeeping to take money from Resident #2 for housekeeping's own well-being and personal expenses, exact date unknown. This failure could place residents who resided in this facility at risk of misappropriation of property.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from chemical restraints that were not required to treat the residents' medical symptoms for 1 (Resident #1) of 3 residents reviewed for unnecessary medications. The facility failed to have an adequate indication for the use of the medication Zyprexa (Olanzapine- atypical antipsychotic) for Resident #1. This failure could put residents at risks of receiving unnecessary psychotropic medications.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles for 1 (wound care cart) of 7 medication carts. The facility failed to ensure that the wound care cart was secured and lock when it was left unattended by LVN A. These failures could place residents at risk of injury to other residents if medication left unsecured were consumed.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure the assessment accurately reflected the resident's status for 3 (Resident #4, Resident #11, and Resident #13) of 10 residents reviewed for MDS assessment. Resident #4's quarterly MDS assessment dated [DATE] failed to indicate Resident #4 had falls on 07/28/25 that resulted in major injury, on 09/09/25 that resulted in minor injury, and on 10/02/25 that resulted with no injury. Resident #11's quarterly MDS assessment dated [DATE] failed to indicate Resident #11's behavior of physical aggression that occurred on 09/23/25. Resident #13's quarterly MDS assessment dated [DATE] failed to indicate Resident #13's behaviors of delusions and refusal of care that occurred on 09/16/25. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs, for 1 (Resident #4) of 5 residents reviewed for care plans. The facility failed to develop a comprehensive person-centered care plan for Resident #4 to address the use of a fall mat. This failure could place the residents at risk of not receiving appropriate interventions and care to meet their current needs. Record review of Resident #4's face sheet dated 10/21/25 reflected a [AGE] year-old female admitted on [DATE] with diagnoses that included: [...]

Inspectors wroteBased on interviews and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices that were complete and accurately documented for 2 (Resident #4 and Resident #13) of 10 residents reviewed for accuracy of records. LVN E failed to document Resident #4's change of condition for a fall on 09/05/25. LVN F failed to document Resident #13's change of condition for aggressive behavior on 10/10/25. LVN D failed to document Resident #13's vital signs correctly on the change of condition form on 10/14/25 for a fall that occurred on 10/13/25. The DON failed to document Resident #13's vital signs correctly on the change of condition form on 10/21/25 for an incident of aggressive behavior that occurred on 10/10/25. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program, designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 residents (Resident #1) reviewed for infection control practices, in that: CNA A used cleansing wipe multiple times when performing incontinent care for Resident #1. This failure place residents who use cleansing wipes during incontinent care at-risk for urinary tract infections due to cross contamination.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the residents' right to be free from were verbal and physical abuse by a resident for 6 of 6 residents (Residents #5, #71, #82, #88, #95, #99) reviewed for abuse, in that: 1. The facility failed to ensure Resident #71 was free abuse when Resident #88 hit Resident #71 on the head on 01/24/25. 2. The facility failed to ensure Resident #71 was free from abuse when Resident #88 had a physical altercation with Resident #71 on 04/05/25. 3. The facility failed to ensure Resident #82, and Resident #99 were free from abuse when Resident #88 had a physical altercation with Resident #82 and Resident #99 on 06/04/25. 4. The facility failed to ensure Resident #5 was free from abuse when Resident #88 entered Resident #5's room and attempted to pull Resident #5 from her wheelchair on 06/22/25. 5. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan that described the services to be provided to attain or maintain the residents' highest practicable physical, mental, and psychosocial needs, for 1 (Resident #88) of 4 residents reviewed for care plans in that: The facility failed to implement individualized interventions to address Resident #88's behaviors of aggression toward other residents from 01/24/25 through 06/28/25. This failure could place residents at risk of injuries and their medical, physical and psychosocial needs not being met. [...]

Inspectors wroteBased observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 (Resident #6, Resident #96, and Resident #66) of 7 residents reviewed for infection control, in that:1) The facility failed to ensure that LVN D performed hand hygiene for at least 20 seconds prior to and after medication administration for resident #6. 2) The facility failed to ensure that CNA H and CNA I followed the Enhanced Barrier Precautions (EBP) when they did not wear a gown while providing perineal/foley care to Resident #96.3) The facility failed to ensure that LVN G and LVN J put on PPE when they entered Resident #66's room who was on isolation precautions. [...]

Inspectors wroteBased on observations, interview and record review, the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preference for 1 (Resident #6) of 9 residents reviewed for call lights. The facility failed to ensure Resident #6 had the call light within reach in the morning while in bed. This failure could place residents at risk of being unable to obtain assistance or help when needed and in the event of an emergency. Record review of Resident #6's face sheet dated 07/23/25 reflected a [AGE] year-old-female with an initial admission date of 12/06/22. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents had the right to formulate an advance directive for 1 (Resident #100) of 8 residents reviewed for Advance Directives. The facility failed to ensure Resident #100's OOH-DNR was completed. The OOH-DNR form did not have the physician's signature. This failure could affect all residents who have implemented Advance Directives and established their choice not to be resuscitated at risk of receiving CPR against their wishes.

Inspectors wroteBased on interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury to the State Survey Agency for 1 of 2 Residents (Resident #1) who were reviewed for misappropriation of property in that: The facility failed to report when Resident #1 gave CNA T money to buy gift cards. This failure could place residents at risk for potential abuse/misappropriation of property/exploitation due to not having allegations reported as required.

Inspectors wroteBased on record reviews and interviews, the facility failed to send a copy of the residents' discharge notice, prior to discharge, to the representative of the Office of State Long-Term Care (LTC) Ombudsman of the residents' transfer or discharge and the reasons for the move for 1 of 4 (Resident #105) reviewed for notifying the LTC Ombudsman of the residents' discharge, in that: Resident #105 was discharged to family member who was traveling to [NAME] and was planning to admit to another LTC facility on 05/15/2025 without a notice to the LTC state ombudsman. This failure could place residents at risk of not knowing their rights and receiving the services of the state LTC Ombudsman. Record review of Resident #105's electronic face sheet dated 07/24/2025 reflected the resident was a [AGE] year-old male admitted to the facility on [DATE] and a discharge date of 05/15/2025. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident who was given medications by enteral means received appropriate treatment and services to prevent complications for 1 of 2 residents (Resident #90) reviewed for gastrostomy tubes in that: LVN C did not check for residual of Resident #90's gastrostomy tube (G-Tube) prior to administering medications. This failure could place residents with G-tube at risk of medical complications, or a decline in health due to inappropriate G-tube management and not following appropriate procedures. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that a resident who needs respiratory care was provided such care, consistent with professional standards of practice for 2 of 4 residents (Resident#100 and Resident#52) reviewed for oxygen in that: 1. Resident #100 received oxygen at 2.5 LPM via nasal cannula without a physician's order. 2. The facility failed to ensure that Resident #52 received oxygen as prescribed. These deficient practices could affect the residents who received oxygen continuously and could result in residents receiving incorrect or inadequate oxygen support and could result in a decline in health.

Inspectors wroteBased on observation, interviews, and record review the facility failed to ensure, in accordance with accepted professional standards and practices, medical records were maintained on each resident that were complete, accurately documented, readily accessible, and systematically organized for 2 of 7 residents (Resident #48 and Resident #93) reviewed for resident records. 1. The facility failed to ensure a physician order was written for isolation precautions for Resident #48 on 07/15/2025. 2. The facility failed to ensure a physician order was written for dietary diet for Resident #93 on 07/19/2025. 1. Record review of Resident #48's electronic face sheet dated 07/22/2025 reflected the resident was a 77 -year-old female admitted to the facility on [DATE] with an original admission date of 11/27/2020. Resident #48 had diagnoses which included the following: [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure residents were free from neglect for 1 (Resident #1) of 5 residents reviewed for abuse/neglect, in that: The facility failed to ensure Resident #1, who required 2 or more staff per her care plan was provided with the appropriate number of staff while in the shower chair. As a result, the resident had a fall when she was left unattended and sustained a broken toe. This failure could place residents at risk of emotional distress, fear, decreased quality of life, and further neglect.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 5 residents (Residents #1) reviewed for care plans. 1. The facility failed to implement the care plan to ensure Resident #1's was a 2 person assist for shower/bath. 2. The facility failed to implement the care plan to ensure Resident #1's was a 2 person assist for transferring. These failures could place residents at risk of not receiving the necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to implement its written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, for 1 of 5 residents (Resident#1) reviewed for abuse and neglect, in that: The facility failed to implement their Abuse Neglect Exploitation (ANE) policy when the facility failed to ensure Resident #1, who required 2 or more staff per her care plan was provided with the appropriate number of staff while in the shower chair. As a result, the resident had a fall when she was left unattended and sustained a broken toe. This failure could place residents at risk of abuse and neglect.

Inspectors wroteBased on interview and record review, the facility failed to ensure that all alleged violations involving neglect, were reported immediately to the State Survey Agency, not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, for 1 of 5 residents (Resident #1) reviewed for abuse/neglect. The facility failed to report Resident #1's fall with injury on 02/05/25, where Resident #1 sustained a fractured right great toe. State Survey Agency was not notified of the fall with injury within 2 hours. The incident occurred on 02/05/25 at 10:42 am and was not reported. The facility failed to report Resident #1's FM's allegation of resident neglect related to the Resident #1's fall with injury on 02/05/25, where Resident #1 sustained a fractured right great toe. FM alleged resident neglect. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 3 residents (Resident #1), reviewed for pharmaceutical services, in that: LVN C failed to verify Resident #1's morphine was accounted for when completing a narcotic count on 12/06/24. Resident #1's Morphine Sulfate Oral Solution 20mg/5ml was missing and not found. This failure could place residents at risk for not receiving medication as ordered.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare, store, distribute, and serve foods in accordance with professional standards for food service safety in the facility's only kitchen. Dietary Aide A failed to effectively restrain her hair while getting snacks in the kitchen. This failure placed the 92 residents, who received their meals from the facility's only kitchen, at risk for food contamination and food borne illness.

Inspectors wroteBased on interview and record review the facility failed to ensure that a resident who is fed by enteral means receives the appropriate treatment and services to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities and nasal pharyngeal ulcers for 1 of 1 resident (Resident #2) reviewed for gastrostomy feedings in that: The facility did not transcribe and initiate Resident #2's enteral feeding order of 65ml for 22 hours, leading to 6 pound weight loss between 10/11/24 and 12/09/24. This failure placed resident at risk for not receiving their required daily nutritional intake placing the resident at risk for weight loss.

Inspectors wroteBased on interviews and record review, the facility failed to develop and implement a person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 2 of 4 residents (Resident #1 and Resident #3) reviewed for comprehensive care plans. 1. The facility did not include Resident #1's rash on her care plan. 2. The facility did not include Resident #3's rash on her care plan. This failure could place residents at risk for not receiving appropriate treatment and services.

Inspectors wroteBased on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 4 residents (Resident #1) reviewed for medical records accuracy, in that: The facility failed to ensure Resident #1's skin observation tool documentation accurately reflected Resident #1's rash. This deficient practice could affect residents whose records are maintained by the facility and could place them at risk for errors in care, and treatment.

Inspectors wroteBased on interview and record review, the facility failed to to ensure all residents had the right to formulate an advance directive for three (Residents #30, #3, and #57) of 24 reviewed for advanced directives, in that: 1. The facility failed to ensure Resident #30's OOH-DNR was completed correctly. The OOH-DNR form did not have the physician's signature in the appropriate place. 2. The facility failed to ensure Resident #3''s OOH-DNR was completed correctly. The OOH-DNR form did not hat the physician's signature in the appropriate place. 3. The facility failed to ensure Resident #57's OOH-DNR was completed correctly. The OOH-DNR form did not have the signature for witness 2 in section E. These failures could affect all residents who have implemented Advance Directives and established their choice not to be resuscitated at risk of receiving CPR against their wishes.

Inspectors wroteBased on interviews and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 25 residents who receive insulin services. The facility failed to keep an updated calibration log documenting the control solution testing results for the facility's blood glucose meters. This failure could result in not determining if the glucometers were functioning properly and/or obtaining false glucometer readings.

Inspectors wroteBased on observation and interview the facility failed to establish procedures to ensure that water was available to essential areas when there is loss of normal water supply. The facility failed to ensure the emergency water supply was readily available and stored in a safe and sanitary manner. The facility's emergency water supply was stored two blocks from the facility in a warehouse. This failure could place residents at risk of serious risk for complications from water that might be contaminated due to poor sanitary conditions. In an interview on 05/14/24 at 3:00 PM, The DM said the emergency water supply was across the street in the laundry department. The kitchen has a 7-day supply of food and once hurricane season starts she would order extra supplies of foam plates, cups, utensils and would order extra food supplies. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the resident's representative of a transfer or discharge and the reasons for the move in writing and in a language and manner they understand and failed to send a copy of the notice to the Office of the State Long-Term Care Ombudsman, for 1 Resident (Resident #97) of 24 residents reviewed for hospitalizations. The facility failed to send a written notice of a transfer to Resident #97's RP and to the Office of the State Long-Term Care Ombudsman as soon as practicable after Resident #97 was transferred to the hospital. These failures could place residents at risk of not having access to available advocacy services, discharge/transfer options, and appeal processes.

Inspectors wroteBased on interview and record review, the facility failed to provide to the resident and the RP a written a notice of bed-hold policy before, or at the time of transfer for 1 Resident (Resident #97) of four residents reviewed for transfers. The facility did not provide written information on the facility's bed-hold policies to Resident #97 or to his RP when resident was sent to the hospital. This failure could place residents at risk for not receiving a notice of the facility's bed hold policy before/upon transfer and not having the necessary information to decide on whether to incur bed hold payments and have the opportunity for the resident to return to the facility.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident's medical and nursing needs and describes the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 6 residents (Resident #40), reviewed for care plans. The facility failed to ensure Resident #40's comprehensive care plan dated 04/17/2024 reflected she had an order for O2 at 2 Lpm via N/C continuously. These deficient practices could place residents in the facility at risk of not being provided with the necessary care or services and no having personalized plans developed to address their specific needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident who needs respiratory care was provided such care consistent with professional standards of practice for 2 of 6 residents (Resident #40, and Resident #3) reviewed for oxygen in that: 1. Resident #40's oxygen was administered at 2.5 Lpm instead of 2.0 Lpm via nasal cannula as ordered by physician. 2. Resident #3's oxygen was administered at 4 Lpm instead of 2 Lpm via nasal cannula as ordered by the physician. This failure could place residents who received oxygen at risk of developing respiratory complications and a decreased qualify of care.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to establish and maintain an infection prevention and control program, designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, for 2 of 2 Residents (Resident #17, and Resident #11) that were reviewed for infection control and transmission-based precautions policies and practices, in that: The facility failed to ensure CNA K performed proper pericare (incontinent care) for Resident #17 and #11. The facility failed to ensure CNA K performed hand hygiene during incontinent care on Resident #17. The facility failed to ensure CNA L performed hand hygiene during incontinent care on Resident #11. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents for 1 of 2 residents (Resident #1 ) reviewed for accidents and supervision, in that: 1. The facility failed to ensure Resident #1 received supervision to prevent Resident #1 from eloping from the facility undetected on 04/29/2023. The non-compliance for Resident #1 was identified as Past Non-Compliance. The Immediate Jeopardy (IJ) began on 04/29/2023 and ended on 05/01/2023. The facility corrected the non-compliance before the investigation began. This failure could place the residents with exit seeking behaviors and repeated falls at risk for injury or death.

Inspectors wroteBased on interview, and record review, the facility failed to inform residents in advance of the risks and benefits of proposed care and treatment for 1 of 5 residents (Resident #4) reviewed for resident rights, in that: The facility failed to ensure consent forms were properly completed or signed by a responsible party prior to administration of an antipsychotic medication (Nuplazid) for Resident #4. This failure could place residents who received psychoactive medications without informed consents and placed additional 27 residents who received psychoactive medications at risk of receiving treatments without informed consent.

Inspectors wroteBased on observation, record review and interview the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for one resident (Resident #3) of five residents reviewed for abuse, neglect, and exploitation. The facility failed to conduct an investigation of Resident # 3's transfer by a mechanical life when the straps tore, and Resident #3 was placed at potential of injury. This deficient practice could place residents at risk for abuse, neglect, and not having their needs met.

Inspectors wroteBased on interview and record review, the facility failed to ensure that all alleged violations involving neglect, were reported immediately to the State Survey Agency, not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, for 1 of 6 residents (Resident #4) reviewed for abuse/neglect. The facility failed to report Resident #4 had an unwitnessed fall on 09/03/23. Resident #4 sustained a laceration to right eyebrow and acute fifth metacarpal neck fracture (little finger fracture). The facility failed to report Resident #4 was observed on 09/28/23 with redness to right forehead and right eyelid with no mention of how the redness occurred. The facility failed to report Intake #477220 to State Survey Agency within 24 hours for Resident #4's injury of unknown origin. Incident occured on 01/10/2024 at 7:30 p.m. [...]

Inspectors wroteBased on observation, record reviews and interviews, the facility failed to thoroughly investigate allegations of abuse and neglect for 1 of 5 residents (Resident #3) reviewed. The facility did not have evidence a thorough investigation was completed for Resident #3 who had an incident during a transfer with the use of a mechanical lift. This failure could place residents at risk of incidents not being thoroughly investigated.

Inspectors wroteBased on interview and record review the facility failed to consult with the resident's physician when there was a significant change in the resident's physical, mental or psychological status for 1 of 3 residents (Resident #1) reviewed for notification of change of condition. The facility failed to notify the resident's physician when Resident #1 was noticed with discoloration to her outer lower leg on 11/29/2023. On 12/19/2023 at 3:40 p.m., an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 12/21/2023, the facility remained out of compliance at a severity level of actual harm and a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could affect residents with injuries by placing them at risk of delayed medical treatment, hospitalization, and decline in condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of three residents reviewed for quality of care, in that: The facility failed to ensure Resident #1 was accurately assessed after being discovered with abnormal discoloration to her lower outer left leg on 11/29/2023. Between 11/29/2023 to 12/08/2023, Resident #1 was observed crying and with facial grimacing. Resident #1 was diagnosed with a left ankle fracture. On 12/19/2023 at 3:40 p.m., an Immediate Jeopardy (IJ) was identified. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure drug records were in order and that an account of all controlled drugs were maintained and periodically reconciled for 2 of 4 residents (Resident #1 and Resident #2) being reviewed for pharmacy services. The Facility did not ensure that Resident #1 and Resident #2's narcotics were reconciled as being given from the resident's eMAR to the resident's narcotic reconciliation form on the medication cart. This failure could place residents at risk of not receiving their narcotic medications and drug diversion.

Inspectors wroteBased on interview, and record review, the facility failed to ensure medical records were accurately documented, for one Resident (Resident #1) of 3 residents reviewed for accuracy of medical records. The facility failed to document Resident #1's discoloration to her outer lower left leg in the Progress Notes. This failure could place all residents with discoloration of not receiving adequate care and services.

Inspectors wroteFACILITY Medication Storage and Labeling Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals used within the facility were labeled and stored in accordance with currently accepted professional standards, which included the appropriate cautionary instructions with the expiration date, for 4 of 6 medication storage locations (nurse medication cart D wing, nurse medication cart A wing, nurse medication cart C wing, and back station medication storage room). 1. The facility failed to prevent nurse medication cart D wing from containing 3 (three) expired dicyclomine (used to treat certain types of intestinal problems such as irritable bowel syndrome) capsules 10 milligrams (mg) in an opened bag with an expiration date of 09/2022. 2. [...]