Valley View Skilled Nursing and Rehabilitation

Inspectors wroteBased on observation, interview and record review, the facility failed to obtain approval from the Department of Health Construction Review Services program, prior to removing carpets and installing laminate flooring in the facility. The failure to obtain the required approval prior to starting remodeling project, put residents at risk for illness, injury, and unsafe living conditions.

Inspectors wroteBased on observation and interview, the facility failed to ensure residents were provided a homelike environment for 2 of 4 units (100 Unit and 200 East Unit) and 1 of 1 dining room. The failure to ensure resident rooms were free of wall scrapes, broken or missing window screens, and unpleasant stains, and ensure dining areas were free of clutter, placed residents at risk for a less than homelike environment and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to properly prepare 1 of 1 resident (Resident 106) reviewed for discharge and complete the appropriate transfer notifications for 7 of 7 residents (Residents 104, 24, 8, 13, 2, 69, & 85) reviewed for hospitalization. The failure to offer bed holds (Residents 8, 2, & 85), provide a written transfer notice (Residents 2 & 85), provide report to receiving facilities (Residents 104, 8, 24, 13, 2, 69, & 85) and prepare resident for discharge (Resident 106) placed residents at risk for a disruption in their continuity of care, an undesired room change upon readmission, not having the opportunity to make informed decisions about their transfer/discharge rights, and inappropriate transfers.

Inspectors wroteBased on interview and record review, the facility failed to ensure Preadmission Screening and Resident Review (PASRR - a process to determine if a potential nursing home resident had mental health/intellectual disability needs which required further assessment/treatment) assessment was accurate to reflect the mental health conditions for 1 of 6 residents (Resident 10) and PASRR level 2 referrals were coordinated timely for 2 of 6 residents (Residents 11 & 8) reviewed for PASRRs. This failure placed residents at risk of inappropriate nursing home placement and/or not receiving timely and necessary services to meet their mental health needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure accurate and complete pre/post Hemodialysis (HD- mechanical way of eliminating waste from the body when the kidneys no longer functioned) for 3 of 3 residents (Residents 86, 24, & 13) reviewed for Dialysis. This failure placed the residents at risk for unintended health consequences and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure proper storage and labeling of medications for 2 of 4 medication rooms (West I and [NAME] II units), 2 of 4 medication carts (Central Medication Cart and [NAME] I Unit Medication Cart), and 1 of 4 treatment carts (West II Treatment Cart) reviewed for medication storage. This failure placed residents at risk for receiving incorrect medications, ineffective treatment, accidental ingestion of medication, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to: ensure staff used appropriate Hand Hygiene (HH) during resident care for 3 residents (Resident 85, 110, & 6) who were observed for care; ensure staff used appropriate Personal Protective Equipment (PPE - disposable barriers such as gloves, eyewear, and gowns used to prevent exposure to infectious materials) for 1 (Resident 85) and 1 supplemental resident (Resident 96) reviewed for Enhanced Barrier Precautions (EBP - an infection control intervention designed to reduce the transmission of multidrug-resistant organisms); and ensure staff prevented clean linens from coming into contact with soiled surfaces. These failures placed residents and staff at risk for exposure to and development of contagious, communicable infectious diseases.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure informed consents explaining the potential risks, benefits, and alternatives of the use of bed mobility rails, vaccines, and/or treatment at the facility were obtained from the resident or their representative prior to implementation for 1 of 2 residents reviewed for physical restraints (Resident 82), and 1 of 5 residents (Residents 2) reviewed for immunizations. In addition, the facility failed to ensure Resident 2 had the cognitive ability to understand the risks prior to signing informed consents. These failures placed residents and/or their representatives at risk of not being fully informed of the potential risks, benefits, and alternatives to treatments, including vaccines and mobility devices.

Inspectors wroteBased on Observation, Interview, and record review the facility failed to ensure that Care Plans (CP) were comprehensive and person-centered for 3 of 21 sample residents reviewed (Resident 86, 26, & 5) This failure placed residents at risk for unmet care needs, frustration, and negative health outcomes. Findings Included .<Facility Policy>According to the facility's 08/01/2025 Hemodialysis (HD) policy the facility would provide the necessary care and treatment to meet the special medical and nursing needs of the residents receiving hemodialysis. The policy showed residents would not receive blood pressures on the arm that a hemodialysis device was located. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the following: Administration of bowel care protocol in accordance with physician orders, administration of medications within the parameters set by physician orders, and completion of treatments for devices and wounds per physician orders for 3 of 21 sample residents (Residents 9, 107, & 110). These failures placed residents at risk for medication errors, untreated pain, and poor health outcomes. Findings Included .<Facility Policy>According to the facility's January 2026 Care and Maintenance of Central Venous Catheter (CVC - flexible tube inserted into a large vein and threaded towards the heart) policy, the facility staff would change the dressings on central lines based on the type of dressing every seven to ten days. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 1 supplemental resident of 1 resident (Resident 6) reviewed for non-pressure skin alterations and 1 of 1 resident (Resident 5) reviewed for constipation/diarrhea (loose stools) were provided quality care and services. The failure to ensure resident skin issues were assessed, treated, and/or monitored, and the failure to initiate the facility bowel care protocol left residents at risk for unmet care needs, pain/discomfort from constipation, and a decreased quality of life.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure residents were free of accident hazards for 3 of 7 (Residents 26, 19, & 9) residents reviewed for accidents. This failure to ensure resident rooms were free of no longer needed safety interventions, resident mattresses were placed correctly on bed frames, and periodic safety assessments were completed placed residents at risk of injury, unmet needs, and diminished quality of life.<Facility Policy>According to the facility's revised 01/2026 Incidents and Accidents policy, falls and accidents would be investigated and new interventions determined to be necessary to prevent recurrence would be documented in the resident's record.

Inspectors wroteBased on interview and record review, the facility failed to ensure 1 of 3 residents (Resident 1) reviewed for Pressure Ulcer/Pressure Injury (PU/PI) was provided with the necessary treatment and services consistent with professional standards of practice to promote healing and/or prevent worsening. The failure to establish a routine monitoring procedure necessary when using an air mattress (a specialized bed surface with inflatable air chambers that inflate and deflate in cycles to continuously redistribute a person's weight, preventing pressure sores [bedsores] by improving circulation and relieving sustained pressure on vulnerable areas like hips, shoulders, and heels, especially for bedridden individuals) and ascertain its proper functioning placed residents at risk for deterioration in skin condition, pain, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare and serve food under sanitary conditions for 1 of 4 nursing units (West One Unit) observed during mealtime. Failure to cover food items, secure lids of the dirty wash rag bin, ensure staff distributed and served food under sanitary conditions, and maintained a clean/sanitary meal cart placed residents at risk of acquiring food-borne illnesses and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to prepare and serve food under sanitary conditions in 1 of 1 kitchen. Failure to perform proper hand hygiene and glove use, properly clean kitchen equipment, adequately monitor food cooking temperatures, and ensure staff distributed and served food under sanitary conditions. These failures placed residents at risk of decreased nutritional intake, cross contamination leading to food-borne illness, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure newly admitted residents were informed in a timely manner (prior to or upon admission) of their rights and responsibilities and provided services as a resident in the facility for 3 (Resident 85, 139, & 339) of 5 residents reviewed. This failure placed residents at risk of not understanding their rights, a reduced ability to self-advocate, and a diminished quality of life.

Inspectors wrote<room [ROOM NUMBER]- Bathroom> Observations on 12/08/2024 at 9:39 AM and 12/09/2024 at 2:12 PM showed a long screw with a pointed sharp tip sticking out of the wall between the toilet and the sink. In an interview on 12/13/2024 at 9:51 AM, Staff L stated there was a missing hook that should be covering the screw. <room [ROOM NUMBER]> Observations on 12/08/2024 at 10:04 AM showed room [ROOM NUMBER] bed B with deep gouges and exposed drywall under the resident's wall light. In an interview and observation on 12/13/2024 at 9:51 AM, Staff L stated the area needed to be repaired. <room [ROOM NUMBER]> Observations on 12/09/2024 at 8:48 AM showed room [ROOM NUMBER] bed B with deep gouges and exposed drywall on the wall at the head of resident's bed. In an interview and observation on 12/13/2024 at 9:51 AM, Staff L stated the area needed to be repaired. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the menu was followed for 3 of 6 residents (Residents 83, 3, & 16) whose meals were observed during tray line. Failure to follow the menu as directed, according to the dietician approved spreadsheet, and provide accurate portion sizes, placed residents at risk of unmet nutritional needs, and potential negative outcomes.

Inspectors wroteBased on observation, interview and record review, the facility failed to prepare food in a manner that ensured meals were appetizing and palatable for 4 of 6 residents (Resident 43, 6, 74, 85) reviewed. This placed residents at risk for a decreased nutritional intake and dissatisfaction with meals.

Inspectors wroteBased on interview and record review, the facility failed to ensure the arbitration agreement was explained in a form and manner that the resident and/or their representative understood for 3 of 3 residents (Resident 49, 23, and 43) reviewed for arbitration (a procedure used to settle a dispute using an independent person mutually agreed upon by both parties) agreement. This failure placed residents at risk for lacking understanding of the legal document signed, forfeiture (loss or giving up of something) of the right to a jury or court, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement their Grievance policy for 1 of 2 residents (Resident 1) reviewed for grievance reporting. The failure to report, initiate, investigate, and log grievances placed residents at risk for not having grievance resolution delayed or incomplete, feelings of frustration, and a diminished quality of life.

Inspectors wroteBased on observation, record review, and interview the facility failed to ensure missing narcotics were reported to the State Survey Agency (SSA) within the required timeframe for 1 of 2 Narcotic Ledgers (East 2 Narcotic Ledger) reviewed for accuracy. Failure to complete required reporting of missing resident narcotics placed the residents at risk for further misappropriation of resident narcotic medications and the potential for uncontrolled pain. These failures placed the facility at risk for possible diversion of controlled substances.

Inspectors wroteBased on observation, record review, and interview the facility failed to complete a thorough investigation of missing controlled substances (Narcotic Medications) for 1 of 2 Narcotic Ledgers (East 2 Narcotic Ledger) reviewed for accuracy. Failure to complete a thorough investigation placed residents at risk for uncontrolled pain, further misappropriation of resident narcotic medications, and possible staff diversion of controlled substances.

Inspectors wroteBased on interview and record review, the facility failed to ensure a system by which residents/representatives received required written notices at the time of transfer/discharge, or as soon as practicable for 3 of 4 residents (Residents 65, 18, and 39) reviewed for hospitalizations and 1 supplemental resident (Resident 139) reviewed. Failure to ensure written notification to the resident and/or the resident's representative of the reasons for the discharge in writing and in a language and manner they understood, placed residents at risk for a discharge that was not in alignment with the resident's stated goals for care and preferences.

Inspectors wroteBased on interview and record review, the facility failed to provide the resident and/or the resident's representative with a written notice of the facility's bed-hold policy, at the time of transfer or within 24 hours, for 3 of 4 sample residents (Resident 65, 18, & 39) reviewed for hospitalization and 1 supplemental resident (Resident 139) reviewed. This failure placed the residents and their representatives at risk of not being informed of their right to, and the cost of, holding the resident's bed while hospitalized that was necessary for decision-making.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Care Plans (CP) were updated as needed to reflect changes in residents' care needs for 2 of 5 residents (Residents 3 & 39) reviewed for CP's. The facility failed to provide care conferences for 2 of 5 residents (Residents 39 & 49) reviewed. The failure to update CPs with changes in residents' health status and conduct care conferences placed residents at risk for unmet care needs, unnecessary care, and frustration.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide assistance with Activities of Daily Living (ADL), related to cleanliness and grooming for 3 (Residents 18, 22, & 3) of 18 sample residents reviewed for ADLs. Facility failure to provide residents who were dependent on staff for assistance with shaving (Resident 18), bathing (Residents 22 & 3), and nail care (Resident 18), placed the residents at risk for poor hygiene, long facial hair, embarrassment and diminished quality of life.

Inspectors wroteBased on observation, record review, and interview the facility failed to follow provider orders for 1 of 2 residents (Resident 35) reviewed for bed rails, failed to provide oxygen monitoring for 1 of 1 residents (Resident 27), failed to follow treatment as ordered by the physician, monitor, and document bruises for 3 of 12 residents (Residents 139, 15, and 45) reviewed for skin issues, and failed to provide interventions for nutrition refusals for 1 of 7 residents (Resident 71) reviewed for nutrition. These failures placed the residents at risk for poor clinical outcome and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents with vision deficits were assessed and provided assistive devices to maintain vision abilities for 1 of 2 residents (Resident 39) reviewed for vision needs. These failures placed Resident 39 and other residents at risk for unmet care needs and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure 2 of 5 residents (Resident 71 & 1) reviewed for Pressure Ulcers (PU- injury to the skin and underlying tissue due to prolonged pressure), received necessary care and services, consistent with professional standards of practice, to promote healing, and prevent new ulcers from developing. Failure to timely monitor, assess, report, and implement wound prevention recommendations and interventions placed residents at risk for deterioration in skin condition(s), pain, and diminished quality of life. <Facility Policy> Review of the revised 11/2024 Pressure Injury Prevention and Management policy, the facility was committed to the prevention of avoidable pressure injuries and to provide treatment and services to heal the injury, prevent infection and the development of additional pressure ulcers/injuries. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the resident environment was free of accident hazards for 2 of 6 units (East Central 2 & [NAME] Central 2) sampled for accidents. This failure to store chemicals safely, placed residents at risk for exposure to unsafe chemicals.

Inspectors wroteBased on observation, record review, and interview the facility failed to ensure Narcotic Ledgers were accurate for 1 of 2 Narcotic Ledgers (East 2 Narcotic Ledger) reviewed for accuracy. Failure to ensure accurate account of resident narcotic medications placed the residents at risk for uncontrolled pain, decreased quality of life, and possible diversion of controlled substances.

Inspectors wroteBased on observation, record review, and interview the facility failed to ensure expired medications were removed timely from use in 2 of 2 medication carts (West 1 & East 2), 1 of 2 medication storage rooms (East 2 medication room), and cleanliness was maintained for 2 of 2 medications carts (West 1 & East 2 carts) reviewed for medication storage. This failure placed residents at risk of receiving expired medications, ineffective medications, potential infections, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure prompt dental services were provided for 1 of 5 residents (Resident 39) reviewed for dental services. This failure placed residents at risk for oral discomfort and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to keep all Protected Health Information (PHI) in the residents' records confidential and out of view from unauthorized individuals for 4 of 84 residents (Resident 340, 80, 10, & 39). This failure placed all former and current residents at risk for a violation of their right to privacy.

Inspectors wrote<Shower Room> Observations on 12/08/2024 at 9:36 AM showed a shower room on West-1 unit with a shower drain cover full of debris and dried hair. The floor was dry. A log documenting shower room cleaning was found in the room. Staff documented in this log the last date of cleaning was listed as 08/28/2023. Observations on 12/10/2024 at 8:27 AM showed staff assisting a resident in the West-1 unit shower room. On 12/10/2024 at 8:48 AM, staff brought the resident out of the shower room, at which time observations showed the shower drain still contained the same debris and hair previously noted from 12/08/2024, two days earlier. Observations on 12/10/2024 at 8:55 AM showed Staff J (Registered Nurse Manager) enter the West-1 unit shower room and upon exit the drain was clean. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure an effective pest control program was in place to prevent insects from entering and or gathering in resident rooms for 3 (Resident 49, 43, & 22 rooms) of 18 sample resident rooms and common areas (West Central Sink, Second Floor Hallway, [NAME] Central Office, & Kitchen/Dining Room) of the facility. This failure placed residents at risk of infection and contributed to a less than homelike environment.

Inspectors wroteBased on interview and record review, the facility failed to submit complete and accurate direct care staffing information to the Centers for Medicare and Medicaid Services (CMS - a federal agency managing health care programs and health insurance standards) for Quarter 1 (January 1, 2024 through March 31, 2024) reviewed for Payroll Based Journal (PBJ - mandatory reporting of staffing information based on payroll data) submission. This failure effected the accuracy of Nursing Home (NH) staffing level data collected by CMS and had the potential to impact provision of resident care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess and document wound characteristics, monitor, and implement interventions to mitigate worsening of non-pressure skin issues for 4 of 6 sampled residents (Resident # 1, 2, 3 & 4) reviewed for skin and non pressure wound management. This failure placed residents at risk for unidentified wounds, wound decline, infection, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain clean, sanitary surfaces and equipment in the kitchen in accordance with standards for food service safety. The failure to maintain a clean/sanitized kitchen placed residents at risk for cross-contamination (a physical spread of germs), food-borne illnesses.

Inspectors wroteBased on interview and record review, the facility failed to update the Facility Assessment (FA - a required document that comprehensively assesses the level and type of care provided, the demographic profile of the resident population, and the numbers and competencies required of the staff) to accurately reflect the resources the facility determined were necessary for day-to-day resident care and emergency operations. The failure to assess staffing needs according to the facility census placed the residents as risk for not receiving needed care, services, and resources.

Inspectors wroteBased on interview and record review, the facility failed to inform residents of their rights and responsibilities, services provided by the facility and facility rules and regulations both orally and in writing and receive receipt of the information acknowledged in writing for 3 of 3 residents (Residents 2, 96, & 23) reviewed for arbitration agreements and 8 of 8 residents (Residents 3, 5, 32, 34, 36, 45, 73, & 82) represented at the Resident Council meeting. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the ombudsman information was reviewed with residents and information was discussed on how to file a complaint with the state agency for 8 (Resident 3, 5, 32, 34, 36, 45, 73, & 82) of 8 residents who regularly attended monthly Resident Council Meetings (RCMs). The failure to not provide accessible ombudsman information and not provide residents with information on how to file a complaint with the state agency, left residents at risk for not having rightful resources available to them.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the state survey inspection results were made available for 8 (Residents 3, 5, 32, 34, 36, 45, 73, and 82) of 8 residents who regularly attended monthly resident council meetings.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain a safe, clean, comfortable, and homelike environment without safety risks for 20 of 107 residents (Resident 65, 23, 53, 84, 3, 45, 74, 36, 37, 47, 91, 21, 6, 14, 41, 59, 46, 2, 92, & 16) reviewed for facility environment. The failure to maintain adequate lighting, clean carpets, absence of odors, working window blinds, and operational hand sanitizer dispensers placed residents at risk for unsatisfactory living conditions and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide written notification to residents or their Resident Representative (RR) of the reason for transfer/discharge and/or to properly notify the Office of State Long-Term Care Ombudsmen (SLTCO - an advocacy group for residents in a nursing home) of discharges to the hospital for 3 of 3 residents (Residents 6, 18, & 96) reviewed for hospitalization. These failures denied the resident and/or their RR information of their rights regarding transfer/discharge from the facility, placed residents at risk for diminished protection from being inappropriately discharged , prevented access to an advocate who could inform residents of their options and rights, and failed to ensure the SLTCO was aware of facility practices and activities related to transfers and discharges.

Inspectors wroteBased on observation, interview, and record review, the facility failed to reassess 1 (Resident 48) of 5 residents reviewed for weight (wt) loss, identify interventions to prevent wt loss for two (Resident 17 & 48) of 5 residents reviewed for wt loss, and offer 2 (Resident 17 & 74) of 2 residents reviewed for food preferences, culturally appropriate foods, resulting in wt loss. Failure to identify wt loss interventions and offer culturally appropriate foods resulting in wt loss placed resident at risk for continued wt loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to schedule sufficient staff to provide care and services for 7 (Resident 3, 32, 36, 34, 82, 5, & 45) of 7 residents reviewed. This failure prevented residents from receiving; assistance with Activities of Daily Living (ADLs) for Resident 65, 100, 3, & 82; and restorative nursing services (a program that helped residents maintain or improve independence with ADLs) for Resident 52. This failure prevented the facility from maintaining an odor free environment on 1 of 2 floors in the building. These failures placed residents at risk for unmet care needs, diminished quality of life, and other negative outcomes.

Inspectors wroteBased on interview and record review the facility failed to maintain a system of records for accurate reconciliation of narcotic drugs for 3 of 4 medication carts. The failure to count and acknowledge the count was accurate - narcotic drugs through reconciliation at shift change, placed residents at risk for potential financial loss, not receiving narcotic pain medication, and possible drug diversion.

Inspectors wroteBased on interview and record review, the facility failed to ensure mail was being delivered timely and unopened to 1 (Resident 5) of 1 residents reviewed. By not ensuring mail was delivered, unopened, and in a timely manner placed residents at risk for lack of privacy and autonomy.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were informed and provided with written information concerning the right to accept, refuse, or formulate an Advanced Directive (AD - legal documents reflecting a resident's wishes if they became incapacitated) for 2 (Residents 52 & 74) of 27 residents reviewed for ADs. The failure to offer assistance to formulate an AD placed residents at risk of not having a Power of Attorney (POA - surrogate decision maker) when unable to make their own healthcare or financial decisions.

Inspectors wroteBased on interview and record review the facility failed to provide Skilled Nursing Facility Advanced Beneficiary Notices (SNF-ABN) to 1 of 4 residents (Resident 65) reviewed for beneficiary notices. The failure to provide residents the information regarding changes in their Medicare services, including potential financial liability and appeal rights, deterred residents from exercising their right to decide on continuation of skilled services and costs associated, as required by the Medicare Program.

Inspectors wroteBased on interview and record review the facility failed to ensure the Preadmission Screening and Resident Review (PASRR - a screening process for residents who have indicators of intellectual disability, related disability, or serious mental illness) was followed for 1 (Resident 75) of 6 residents reviewed for PASRR. The facility failed to ensure a PASRR Level I was corrected upon admission to include serious mental illness which would have required a PASRR Level II (a more in-depth screening). This failure placed the resident at risk of not receiving the appropriate mental health services needed and placed them at risk for diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the appropriate services to maintain and ensure that resident's ability to perform activities of daily living (ADLs) do not diminish, for two of three (Resident 17 & 74) residents reviewed as non English speaking residents. The facility failed to implement the use of alternative communication methods, such as a communication board in the language they understood to ensure their needs were met consistently. This failure placed the residents at risk of experiencing a decline in their physical well-being, psychosocial well-being, and their quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide hygiene according to resident needs and preferences for 2 of 4 residents (Resident 65 & 100) reviewed for Activities of Daily Living (ADL) for dependent residents. The failure to provide oral care and supplies to Resident 65 or provide showers and facial hair trimming to Resident 100 placed both residents at risk for poor self-esteem, isolation from others, infection, and diminished quality of life.

Inspectors wroteBased on observations, interview, and record review the facility failed to communicate and implement individualized activity plans for 1 of 3 (Resident 74) residents reviewed for activities. Failure to consistently implement group or individual activity plans left the resident at risk for boredom, isolation, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 of 6 (Resident 52) residents reviewed for Restorative Nursing Programs (RNP) received the care and services they were assessed to require. These failures placed residents at risks for declines in Range of Motion (ROM) or functional status, and other negative health outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were secured for 3 of 25 (Resident 36, 74, & 89) residents observed with medications left in their rooms. This failure placed residents at risk for receiving wrong medications, and non-assessed, self-administration of medications by residents.

Inspectors wroteBased on interview and record review the facility failed to provide Specialized Rehabilitative (Rehab) Services according to Physician Orders (POs) for 1 of 3 residents (Resident 65) reviewed for therapy services. The failure to provide physical and occupational therapy to Resident 65 placed them at risk for decline in physical and functional mobility, deterioration of muscle strength and diminished quality of life.