Valley Vista Nursing and Transitional Care LLC

Inspectors wroteBased on interview and record review, the facility failed to address the pain level of one of three sampled residents (Resident 1) by failing to follow the physicians' order for pain management for Resident 1. This failure had the potential to place Resident 1 at risk for inadequate pain

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain medication cart 2 clean and store medications for one of three sampled resident (Resident 1) when Resident 1's medications were not stored separately after Resident 1 was transferred to the General Acute Care Hospital (GACH) on 6/27/2026. This failure had the potential to result in improper medication storage of Resident 1's medications which can lead to medication errors and potential harm to other residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate medical records when nursing staff failed to accurately document Resident 1's location of pain at the time of Oxycodone (a powerful, semi-synthetic opioid pain medication) administration for one of three sampled residents (Resident 1). This failure had the potential to result in inaccurate clinical documentation, ineffective pain management and compromised continuity of care for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure to administer medications as ordered by the physician for two of three sampled residents (Residents 1 and Resident 2). These deficient practices had the potential to delay Residents 1's and Resident 2's care and negatively affect residents' health and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the call light (an alerting device for nurses or other nursing personnel to assist a resident when in need) was within reach and the appropriate type of call equipment was placed and the pad call light (a specialty alerting device that have ultra-sensitive touch surface for patients with limited mobility for nurses or other nursing personnel to assist a resident when in need) for four of four four sampled residents (Residents 20, 34, 63, and 66) reviewed under environment task. This deficient practice had the potential to result in a delay of care and services, possible injury, and inability for Residents 20, 34, 63, and 66 to summon health care workers for assistance or adjust their beds for comfort as needed.

Inspectors wroteBased on interview and record review, the facility failed to inform and provide a written information to all adult residents concerning the right to accept and refuse medical surgical treatment and, at the resident's option to formulate an advance directive (a legal document indicating resident preference on end-of-life treatment decisions) to three of three sampled residents (Residents 8, 42, and 5) by the Social Services Director (SSD) by failing to: 1. Offer advance directive formulation information to Resident 8. 2. Complete the advanced directive acknowledgement form for Residents 42 and 5. The deficient practices violated the resident's rights and/or representative's right to ensure the resident's end-of-life treatment decisions were readily available for staff to honor and implement.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignity including the right to be free from physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the resident's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) for three of four sampled residents (Residents 20, 57, and 2) reviewed for physical restraints by failing to ensure: 1. Resident 20's use of restraint pillow tucked under the sheets had a physician's order, informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered), restraint assessment, and a care plan. [...]

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure the resident's drug regimen was free from unnecessary drugs for one of five sampled residents (Resident 46) reviewed for unnecessary medications by failing to ensure the facility obtained an informed consent (IC, a voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) on the use of Alprazolam Oral Tablet (a fast-acting prescription tranquilizer used to quickly calm the nervous system) 0.5 milligrams (mg, a unit of weight) tablet by mouth every six hours as needed for anxiety monitor for behavior (m/b) constant complaints of pain for 30 Days. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident in a nursing facility is screened for a mental disorder (MD - a medical condition that affects how you think, feel, and behave) or intellectual disability (ID - a lifelong condition that begins in childhood, characterized by significantly below-average intelligence and major difficulties managing everyday life skills, communication, and self-care) prior to admission and that individuals identified with MD or ID are evaluated and receive care and services in the most integrated setting for three of five sampled residents (Residents 42, 7, and 9) by failing to ensure the facility: 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (is a tool that ensures residents receive personalized, comprehensive, and goal-oriented care in a nursing home setting) for two of five sampled residents (Residents 11 and 46) reviewed for unnecessary medications by failing to ensure the facility developed and implemented a care plan for: 1. Resident 11's use of Xarelto (a prescription blood thinner). 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the comprehensive care plan (is a tool that ensures residents receive personalized, comprehensive, and goal-oriented care in a nursing home setting) is reviewed and revised by an interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs for three of three sampled residents (Residents 42, 5, and 71) reviewed for pressure injury (localized damage to the skin and/or underlying tissue usually over a bony prominence) by failing to review and revise the fall care plan of the resident to reflect the resident's use of low air loss mattress (LALM, a medical bed that slowly pumps continuous air through tiny, microscopic holes in its surface). The deficient practice had the potential for delayed and unnecessary care for residents. Cross reference F686.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents with pressure ulcers/injury (a skin and tissue injury caused by prolonged pressure on the skin, often over bony areas) receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for three of three sampled residents (Residents 42, 5, and 71) reviewed under pressure ulcer/injury by failing to ensure the low air loss mattress (LALM, a specialized bed mattress that helps prevent and treat pressure ulcers [bedsores] by using a continuous flow of air to regulate temperature and moisture on the skin) of the residents were set according to the residents` weight. The deficient practices had the potential for worsening of pressure injury to residents. Cross reference F657.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment was free of accident hazards for three (3) of five (5) sampled residents (Resident 1, 34, and 71) reviewed for environment task by failing to ensure the floor mats (a cushioned floor pad designed to help prevent injury should a person fall) did not have equipment or furniture on top of them. The deficient practices increase the risk of accidents such as falls with injuries, poisoning, and electrocution on residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents with urinary catheters (a thin, flexible, hollow tube inserted into the bladder to drain urine when a person cannot urinate normally) received proper care and services for three of four sampled residents (Residents 42, 5, and 1) reviewed for urinary catheter or urinary tract infection (UTI, a common infection that occurs when bacteria enters and multiplies in the urinary system, which includes the kidneys, bladder, and urethra) by failing to ensure: 1. Resident 42's urinary catheter did not have loops and was not touching the floor. The loop had urine on them with sediments (a substance settling at the bottom of a liquid). 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper documentation for peripherally inserted central catheter (PICC- is a long flexible tube placed in the arm that goes to a large vein near the heart to give medication or fluids for long time) line dressing for one (1) of one (1) sampled resident (Resident 80), as the resident`s PICC dressing did not have date, time, and staff initials in accordance with facility policy and procedure. This deficient practice had the potential to affect proper monitoring of dressing changes and infection control practices.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respiratory care provided to residents was consistent with professional standards of practice for six of six sampled residents (Residents 8, 42, 5, 50, 35, and 59) reviewed for respiratory care. The facility failed to ensure: 1. Resident 8's oxygen via nasal cannula (a lightweight, flexible plastic tube that delivers extra oxygen (supplemental oxygen) directly into the nostrils via two small, comfortable prongs) was changed per physician's order. 2. Resident 42's: a. Suction canister (is a temporary, secure storage container used in medical and clinical settings to collect bodily fluids (like blood, mucus, and saliva) that are extracted during surgeries, emergencies, or breathing treatments) was labeled with the name of the resident and the date it was last changed. b. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring and administering of all drugs and biologicals to meet the needs of each resident for one (1) of three (3) sampled resident (Resident 48) by failing to ensure the licensed nurses (LNs) administered Resident 48's 9 a.m. dose of divalproex sodium (a type of medication to treat epilepsy (a brain condition that causes a person to have repeated, unprovoked seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness]), manage the manic or mixed episodes of bipolar disorder (sometimes called manic-depressive disorder; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of one sampled resident (Resident 5) was free of any significant medication errors (means the observed or identified preparation or administration of medications or biologicals which are not in accordance with the prescriber's order, manufacturer's specifications, and accepted professional standards) reviewed for insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) use. The facility failed to rotate (a method to ensure repeated injections are not administered in the same area) Resident 5's subcutaneous (sq, beneath the skin) insulin administration sites. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one out of two sampled dietary aids (DA) specific competency and skills checklist for year 2024 and 2025 were completed. This deficient practice has the potential to negatively affect residents such as improper food handling and unsafe practices to prevent foodborne illness or cross contamination in the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Head [NAME] (HC) used the correct scoopers during tray line service for residents on small- portion diets including residents who are on level four (4) International Dysphagia Diet Standardization Initiative diet (a diet texture for individuals with severe swallowing difficulties) diet. This deficient practice has potential for residents who require small portions and are at risk for receiving inaccurate serving sizes, which has the potential to cause unintended weight gain or loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen by failing to: 1. Ensure pasteurized eggs (raw eggs that have not been heat-treated to kill harmful bacteria) were available for use. 2. Ensure cleaning logs were dated and kept up to date, including the cleaning logs for the ice machine. 3. Identify and address condensation observed in the freezer. 4. Ensure clean scoops were available for rice and oatmeal. 5. Ensure the measuring scoop for the thickener was properly stored instead of being placed on top of the container after use. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain medical records on each resident that are complete, accurately documented, readily accessible, and systematically organized to one (1) of 1 sampled resident (Resident 46) reviewed for pain management by failing to document timely and per facility policy the administration of pain medications oxycodone (a powerful, prescription-only opioid pain reliever [narcotic]) and ibuprofen (an over-the-counter and prescription medication used to reduce pain, fever, and inflammation). These deficient practices had a potential in the delay of medication administration and places Resident 46 at risk for undue pain.

Inspectors wroteBased on interview and record review, the facility failed to ensure staff followed the facility's Infection Prevention Control Policy to prevent the spread of infection, when facility failed to ensure the facility's Water Management Program (WMP - a written, step-by-step plan for buildings to ensure their water system was safe, clean, and efficient) was implemented as written. This failure had the potential to result in a lack of a structured plan and allows dangerous pathogens to thrive in the water system, that can lead to disease outbreaks in the facility and cause residents to get sick.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure the influenza (also known as the flu, a highly contagious viral infection that attacks the respiratory system) Vaccination Record consent was signed by the Licensed Vocational Nurse (LVN) and the witness signature was obtained for four of four sampled residents (Resident 15,51,50 and 28). 2. Ensure one of four sampled residents (Resident 28) had documented evidence that the pneumonia (an infection in one or both lungs that causes lungs to become inflamed and fill with fluid or pus) vaccine was offered and administered when the consent was signed 9/2025 for Resident 28. These failures had the potential to place staff and residents at risk for serious outcomes such as being hospitalized due to pneumonia and influenza.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Provide documented evidence of all employees screening, education, offering, and current Corona virus disease, COVID-19 (highly contagious respiratory illness caused by the SARS-CoV-2 virus) vaccination (medications used to prevent diseases usually given by injection) status. 2. Ensure COVID-19 vaccine screening was done for two of three sampled residents (Resident 50 and 51). These failures had the potential to place staff and residents at risk for serious outcomes such as being hospitalized due to COVID-19.

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident's entire drug/medication regime was managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being for one of five sampled residents (Resident 11) reviewed for unnecessary medications by failing to monitor for adverse effects (any unwanted, unpleasant, or harmful result caused by a medical treatment) on the use of Xarelto (a prescription blood thinner). This deficient practice could result in increased risk of a broad range of adverse consequences such as bleeding to Resident 11. Cross reference F656.

Inspectors wroteDuring an observation, interview, and record review, the facility failed to ensure drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable to one of two Medication Carts (Station 1 Medication Cart 1), by failing to ensure Medication Cart 1 did not have a/an: -Opened glucose test strip (a disposable plastic strip that, when paired with a digital meter, measures the amount of sugar (glucose) in a tiny drop of blood) vial with no open date. -A bottle of Megestrol Acetate Oral Suspension (a prescription liquid medication used primarily as an appetite booster) without an open date. [...]

Inspectors wroteThe facility failed to ensure residents received palatable and flavorful meals consistent with their preference and nutritional needs for one of one sampled resident (Resident 33). This deficient practice had the potential to decrease Resident 33's appetite, reduce food intake, and negatively affect their nutritional status and quality of life.

Inspectors wroteBased on interview and record review, the facility failed to implement its antibiotic (ATB - a medicine that fights bacterial infections by killing bacteria or stopping them from multiplying) stewardship program (a coherent set of actions which promote using antimicrobials responsibly) that includes antibiotic use protocols and a system to monitor antibiotic use for two of four sampled residents (Resident 46 and 66) when the facility failed to: 1. Ensure Resident 46's Ciprofloxacin HCl (a type of antibiotic) Oral Tablet 500 milligrams (mg - a unit of weight) for urinary tract infection (UTI - an infection in the bladder/urinary tract) had monitoring for its adverse effects (an unwanted, harmful, or unpleasant physical or mental reaction caused by a medical treatment, such as a medication or surgery). 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a person-centered care (CP, a plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs) for one of three sampled residents (Resident 1), by failing to:1. Develop a care plan to address Resident 3's multiple fractures (a partial or complete break, crack, or split in a bone). 2. Develop a care plan to address Resident 3's pain management. These failures had the potential to delay care and negatively affect Resident 3's well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the comprehensive care plan (a plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs) was revised for one of three sampled residents (Resident 2), when on 3/16/2026, Resident 2 was transferred to general acute care hospital (GACH) on a 5150 hold (involuntary, 72-hour psychiatric hospitalization for individuals deemed a danger to themselves or others due to mental illness). This deficient practice had the potential to delay provision of care and services for Resident 2.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free of any significant medication errors (means the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order, manufacturer's specifications, and accepted professional standards) for two of three sampled residents (Residents 1 and 3), by failing to ensure:1. Resident 1 received correct dose of Oxycodone Hydrochloride (a strong opioid [a class of powerful drugs used to treat moderate to severe pain by affecting the brain and nervous system] pain medication used to treat moderate to severe pain) for severe pain (seven (7) to 10 out of 10 on the numeric pain rating scale [a pain assessment tool that uses a scale ranging from zero [0 - no pain] to 10 [worst pain imaginable], to quantify pain intensity). 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to communicate a change of condition for one of four sampled residents, (Resident 1). Resident 1 was identified with shortness of breath (SOB- the feeling of needing more air, chest discomfort, or having difficulty breathing), but the facility staff failed to inform Resident 1's Primary Physician regarding the change of condition. This delay in notification resulted in Resident 1 requiring emergency services and the need for emergency transfer to a General Acute Care Hospital 1(GACH 1) for treatment.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice to meet the resident's physical, mental, and psychosocial (relating to the interrelation of social factors and individual thoughts and behavior) needs by failing to administer medications and treatments as ordered by the physician for two of three sampled residents (Resident 1 and 3), by failing to: 1. Ensure licensed staff administered Mupirocin External Ointment (a topical antibiotic used against superficial skin infections) to Resident 1 on 2/6/2026 and 2/7/2026 for the 7 a.m. administration time as ordered by the physician. 2. Ensure licensed staff administered Nystatin Powder (an antifungal medication used to treat skin infections) to Resident 1 on 2/6/2026 and 2/7/2026 for the 7 a.m. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that the comprehensive care plan (a plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs) was revised for one of three sampled residents (Resident 2) when on 1/19/2026, Resident 2 had an episode of desaturation (low blood concentration), multiple episodes of vomiting, and was transferred to General Acute Care Hospital (GACH). This deficient practice had the potential to delay provision of care for Resident 2 and negatively affect Resident 2's well-being.

Inspectors wroteBased on interview and record review, the facility failed to provide one of three residents (Resident 1) with the rights for making decisions related to care provided to Resident 1 in his primary understandable language. Resident 1 was discharged from the facility Against Medical Advice (AMA - when a resident leaves a healthcare facility against the advice of their doctor) without receiving discharge instructions related to the risks and benefits associated with leaving the facility AMA in Resident 1's preferred language of Spanish. This deficient practice resulted in the violation of Resident 1's right to be informed in a language the resident understands to weigh the risks and benefits in deciding to leave the facility AMA. Cross reference F627.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) for one of seven sampled residents (Resident 2). On 9/20/2025 at 6 a.m., who were both in the hallway had a physical altercation (a confrontation or fight involving physical contact or force) in which Resident 1 hit Resident 2's right side of the head on the door and punched Resident 2 on the left side of the face with a right closed fist. This deficient practice resulted in Resident 2 being subjected to physical abuse by Resident 1 while under the care of the facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was provided with discharge instructions in the language (Spanish) preferred by Resident 1 to fully understand the risks and benefits associated with leaving the facility against medical advice (AMA - when a resident leaves a healthcare facility against the advice of their doctor). This deficient practice resulted to Resident 1 being discharged on 9/20/2025 at approximately 10 a.m. without understanding the risks and benefits of leaving the facility AMA. Cross reference F552.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from unnecessary psychotropic medication (medications that affect the mind, emotions, and behavior) and the use of chemical restraints (any drug that is used for discipline or staff convenience and not required to treat medical symptoms) for one of three sampled resident (Residents 1) by failing to: 1. Provide ongoing re-evaluation of the need for psychotropic medication by failing to ensure PRN (given as needed or requested) Haloperidol (a medication used to treat mental health conditions to reduce hallucinations, delusions, and uncontrolled movements) was ordered with an end date (time at which a medication will no longer be dispensed and will be required to be re-prescribed). 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that the comprehensive care plan (a plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs) was reviewed and revised for one of three sampled residents (Resident 1) by failing to update Resident 1's care plan to reflect Resident 1's indwelling catheter (a flexible plastic tube inserted into the bladder that remains there to provide continuous urinary drainage). This failure had the potential to delay care and negatively affect Resident 1's well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice to meet the resident's physical, mental, and psychosocial (relating to the interrelation of social factors and individual thoughts and behavior) needs for one of three sampled residents (Resident 1) by failing to assess Resident 1's blood glucose (body's main energy source, regulated by the hormone insulin) level during a change in Resident 1's condition (a significant alteration in a resident's physical or mental state) on 11/15/2025. This deficient practice had the potential to place Resident 1 at risk for delayed care and negatively affect Resident 1's well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents with an indwelling catheter (a flexible plastic tube inserted into the bladder that remains there to provide continuous urinary drainage) receive proper care and services for one of three sampled residents (Resident 1), by failing to ensure Resident 1 received indwelling catheter care and monitoring. This deficient practice had the potential to place Resident 1 at risk for urinary tract infection (UTI- an infection in the bladder/urinary tract) and negatively affect Resident 1's well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide respiratory care consistent with professional standards of practice for one of three residents (Resident 1), by failing to: 1. Ensure Resident 1's oxygen concentrator (a medical device that provides a concentrated source of oxygen) was turned on and the nasal cannula (a medical device that provides supplemental oxygen therapy) was connected to Resident 1. 2. Follow physician orders for Resident 1's oxygen administration and peripheral oxygen saturation (spO2-the percentage of oxygen-carrying hemoglobin in the blood with a normal level for healthy people typically 95-100 percent [&-unit of measurement]) monitoring. These deficient practices had the potential for Resident 1 to experience shortness of breath, respiratory distress, and negatively affect Resident 1's well-being.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a tool that ensures residents receive personalized, comprehensive, and goal-oriented care in a nursing home setting) for two of four sampled residents (Resident 2 and Resident 3), by failing to develop and implement a care plan for the residents` discharge planning (a process where the facility staff, doctors, the resident and/or the resident's family collaboratively create a plan for after the resident leaves the facility, making sure the resident has the resources needed to stay safe at home or at another facility). This deficient practice had the potential to result in an unreasonable delay with the progress of Resident 2 and Resident 3's plan to be discharged from the facility to a community setting.

Inspectors wroteBased on interview and record review, the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one of four sampled residents (Resident 1) by failing to document the communications social services had with Resident 1 and the actions taken by social services regarding the resident`s discharge planning. This failure resulted in an incomplete medical record that is not in accordance with the facility's own policies and procedures.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light (an alerting device used to contact nursing personnel for assistance) for one of three sampled residents (Resident 1) was accessible and within reach. This failure had the potential to prevent Resident 1 from being able to contact facility staff for help as needed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the respiratory care for one of three sampled residents (Resident 1) was provided in accordance with professional standards of practice and per the doctor's orders, when Resident 1's nasal cannula (a flexible device that delivers extra oxygen through a tube and into the nose) was found inside Resident 1's mouth. This failure had the potential to decrease Resident 1's oxygen levels, leading to respiratory distress (when a person has difficulty breathing because there is not enough oxygen received in the lungs).

Inspectors wroteBased on observation, interview, and record review, the facility failed to:1. Ensure staff wear personal protective equipment (PPE) inside a novel respiratory precaution room for one of nine sample residents (Resident 5).2. Ensure a visitor wear PPE inside a novel respiratory precaution room (Resident 7) for one of seven sample residents.3. Ensure staff wear PPE inside a novel respiratory precaution room for two of nine sample residents (Resident 8 and Resident 9). These deficient practices increased the risk of COVID (highly contagious respiratory disease) transmission to other residents who were not infected.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a sanitary, orderly, and homelike environment for one of three sample residents (Resident 1) by failing to maintain cleanliness of Resident 1's room and restroom. This failure had the potential to negatively impact Resident 1's psychosocial well-being (refers to a resident's overall mental, emotional, and social health, encompassing aspects like happiness, life satisfaction, self-esteem, social functioning, and a sense of purpose).

Inspectors wroteBased on interview and record review, the facility failed to ensure residents rights to formulate an Advance Directive (AD, a legal document that outlines an individual's wishes regarding medical care in the event they become incapacitated and unable to communicate their preferences) for three of five sampled residents (Resident 20, 219, and 119) reviewed under the AD care area by failing to provide written information concerning the right to formulate an AD. This deficient practice had the potential to violate the residents' right to have their wishes honored regarding health care decisions.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from unnecessary psychotropic medication (medications that affect the mind, emotions, and behavior) and the use of chemical restraints (any drug that is used for discipline or staff convenience and not required to treat medical symptoms) for three of five sampled resident (Residents 219, 36, and 31) reviewed under the Unnecessary Medications, Chemical Restraints / Psychotropic Medications care area by failing to: 1. Obtain informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) prior to the administration of psychotropic medication for Resident 219. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents receiving enteral feeding (EF - also known as tube feeding, a method of supplying nutrients directly into the stomach) received appropriate care and services to prevent complications by failing to ensure Licensed Vocational Nurse (LVN) 5 did not use a syringe (a small hallow tube without a needle, fitted with a sliding plunger) to push (the act of depressing the plunger in a syringe to apply force in order to advance medications through the gastrostomy tube [GT or g-tube, a tube that is inserted into the stomach) medications through the GT for one (1) of 1 sampled resident (Resident 36) reviewed during the Tube Feeding care area. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents who received hemodialysis (HD, process of removing waste products and excess fluid from the body) received treatment consistent with professional standards of practice for one of one sampled residents (Resident 51) reviewed under the Dialysis care area by failing to ensure adequate communication with the HD Center regarding no documented assessments done before and after Resident 51's hemodialysis sessions. This deficient practice placed Resident 51 at risk for a delay in care and services and a delay in detecting complications resulting from HD.

Inspectors wroteBased on observation 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) for two of five sampled residents (Resident 36 and 31), by failing to: 1. Ensure Licensed Vocational Nurse (LVN) 5 administered medication per the physician prescribed orders when LVN 5 omitted (did not administer) amiodarone (medication to prevent and treat certain types of serious heart rhythm problems) and famotidine (a medication that reduces stomach acid production) on 7/2/2025 during the 9 a.m. medication pass observation for Resident 36. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the menu and did not meet nutritional needs of residents when [NAME] 1 did not level the number eight (8) scoop (1/2 cup [c, a unit of measurement]) for serving egg noodles. This failure had the potential to result in excess food served resulting to increased nutrient intake of 64 of 69 resident who received egg noodles causing unintended weight gain and ineffective therapeutic diet provisions of 16 of 20 residents on consistent carbohydrate diet (CCHO, a diet with the same amount of carbohydrate [macronutrient found in many foods and drinks, including sugars, starches, and fiber] each meal to manage high blood sugar).

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare food in a form designed to meet individual needs when puree (foods that are smooth with pudding like consistency) pasta was too dry, puree vegetables were watery, and puree meat did not hold its shape on the plate. These failures had the potential to result in difficulty in swallowing, chewing, decrease in food intake and nutrient intake to 9 of 9 residents on puree diet, resulting in unintended (not planned) weight loss and choking (when food gets stuck in your airway, blocking the flow of air to your lungs).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one (1) of 1 sampled resident (Resident 40) food allergy, food preferences and intolerances were honored when orange slices, cheese quesadilla and pasta were served at lunch on 6/30/2025. Resident 40 was allergic to oranges, had intolerances to milk and milk products and disliked pasta. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: 1. Kitchen equipment and utensils were not maintained in their proper condition, smooth and easy to clean. a. Vegetables reach-in freezer had ice buildup. b. Reach-in freezer shelves by the preparation area were cracked and stained with amber discoloration. c. Walk-in refrigerator blue shelves were cracked and chipped. 2. Four (4) of 4 cans were stored with non-dented cans. 3. Kitchen equipment and kitchen areas were not cleaned and sanitized. a. Ice machine internal parts had dry hard water buildup and black residues. b. The resident's refrigerator had green dirt. 4. Staff did not perform hand hygiene when washing soiled dishes then cleaning and touching clean resident's carts. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the reach-in freezer was maintained according to manufacturer's guidelines where there was a gap causing air to come in the reach in freezer resulting in ice buildup of 1 of 2 reach-in freezer. This deficient practice had the potential to result in danger zone temperatures (a range of temperatures in which food-borne bacteria could grow) that could lead to foodborne illness (illness caused by food contaminated with bacteria, viruses, parasites, or toxins) in 64 of 69 medically compromised residents who stored food in the resident's refrigerator and freezer.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain sanitary conditions in the food services department when four (4) flies (a type of insect) were observed in the kitchen during trayline (an area where foods were assembled from the steamtable to resident's plate). This failure had the potential to result in 64 of 69 residents, who received food from the kitchen, to acquire food borne illnesses (illness caused by consuming contaminated foods or beverages) by consuming potentially contaminated food.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide reasonable accommodation of resident needs and preferences to two of three sampled residents (Resident 12 and 47) investigated during review of environment facility task by failing to ensure the call light (an alerting device for nurses or other nursing personnel to assist a resident when in need) was within residents' reach. This deficient practice had the potential to result in Residents 12 and 47 not being able to call for facility staff assistance and delay in the provision of necessary care and services that can negatively affect residents' comfort and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive care plan (CP, a plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs) by failing to: 1. Develop and implement a CP for an actual fall for one of two sampled residents (Resident 219) reviewed during the Accidents care area. 2. Develop a CP to address residents' bowel and bladder incontinence (having no or insufficient voluntary control over urination or defecation) management and retraining one of two randomly sampled residents (Resident 119). These deficient practices had the potential to result in miscommunication among interdisciplinary staff, residents, and resident representatives resulting in a delay in care and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure services provided meet professional standards of quality in accordance with professional standards and comprehensive care plan for two of two sampled residents (Residents 25 and 31) by failing to ensure: 1. Subcutaneous (beneath the skin) insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) administration sites were rotated (a method to ensure repeated injections are not administered in the same area) for Resident 25. 2. Resident 31's Psychotropic medications (medications that affect the mind, emotions, and behavior) had documented evidence for the diagnosis of schizophrenia (a mental illness that is characterized by disturbances in thoughts). [...]

Inspectors wroteBased on interview and record review, the facility failed to implement their policy and procedure on cardiopulmonary resuscitation (CPR-an emergency procedure used to restart a person's heartbeat and breathing after one or both have stopped) by failing to ensure one of three Certified Nursing Assistants (CNA) (CNA 4) obtained her CPR certification credentialed by the American Red Cross (ARC-an organization providing disaster relief, blood donation services, and health education) or the American Heart Association (AHA-an organization focused on heart disease prevention, research, and education). This deficient practice had the potential to result in a delay for the provision of CPR to residents in emergency situations.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice to meet the resident's physical, mental, and psychosocial (relating to the interrelation of social factors and individual thoughts and behavior) needs for one of one sampled resident (Resident 31) by failing to obtain physician orders for hemoglobin (a protein in red blood cells that carry oxygen) monitoring before the administration of Epogen (a medication used to treat anemia [a condition where the body does not have enough healthy red blood cells] by creating more blood cells). This deficient practice had the potential for Resident 31 to experience adverse (unwanted, unintended result) cardiovascular (heart and blood vessels) reactions and stroke (loss of blood flow to a part of the brain).

Inspectors wroteBased on interview and record review, the facility failed to ensure residents who were incontinent (having no or insufficient voluntary control) of bowel and bladder received services and assistance for one of one sampled resident (Resident 119) by failing to implement the bowel and bladder retraining program when Resident 119 was identified as a candidate for retraining. This deficient practice had the potential to result in increased risk for urinary or bowel incontinence and negatively affecting Resident 119's psychosocial well-being (refers to a resident's overall mental, emotional, and social health, encompassing aspects like happiness, life satisfaction, self-esteem, social functioning, and a sense of purpose).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide respiratory care consistent with professional standards of practice for one of one resident (Resident 53) reviewed during Respiratory Care by failing to ensure Resident 53's nasal cannula (a medical device that provides supplemental oxygen therapy) was connected to the oxygen concentrator (a medical device that provides a concentrated source of oxygen). This failure had the potential for Resident 53 to experience shortness of breath, respiratory distress, and negatively affect Resident 53's well-being.

Inspectors wroteBased on interview and record review, the facility failed to complete a performance review for two of two Certified Nursing Assistants or CNAs (CNA 2 and CNA 3) once every 12 months. This deficient practice had the potential to result in placing residents at risk or reducing care quality.

Inspectors wroteBased on interview, and record review, the facility failed to ensure residents were free of unnecessary medication for one of one sampled residents (Residents 31) by failing to monitor Resident 31's hemoglobin (a protein in red blood cells that carry oxygen) levels to ensure Epogen (a medication used to treat anemia [a condition where the body does not have enough healthy red blood cells] by creating more blood cells) was indicated for Resident 31 prior to the administration of the medication. This deficient practice had the potential for Resident 31 to experience adverse (unwanted, unintended result) cardiovascular (heart and blood vessels) reactions and stroke (loss of blood flow to a part of the brain).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five (5) percent (% - out of one hundred). Two (2) medication errors out of 29 total opportunities contributed to an overall medication error rate of 6.9% affecting one (1) of five (5) residents observed for medication administration (Resident 36). The medication errors resulted when the facility failed to: 1. Ensure Licensed Vocational Nurse (LVN) 5 administered medication per the physician prescribed orders when LVN 5 omitted (did not administer) amiodarone (medication to prevent and treat certain types of serious heart rhythm problems) and famotidine (a medication that reduces stomach acid production) on 7/2/2025 during the 9 a.m. medication pass observation. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free of any significant medication errors (means the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order, manufacturer's specifications, and accepted professional standards) for one of one sampled resident (Resident 25) by failing to ensure subcutaneous (beneath the skin) insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) administration sites were rotated (a method to ensure repeated injections are not administered in the same area). Cross Reference F658.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident receive and consume foods in the appropriate nutritive content as prescribed by a physician to support the resident treatment and plan of care when one of two sampled resident (Resident 17) during a review of dining observation task, who was on a fortified diet (a diet that includes foods with added nutrients, like vitamins and minerals, that weren't naturally present in those foods) received fortified soup for lunches on 6/30/2025 and 7/1/2025. This deficient practice had the potential to cause weight loss for Resident 17.

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 by failing to: 1. Ensure the indwelling urinary catheter (a flexible tube placed in the bladder to drain urine) drainage bag (a urine collection bag connected to the catheter) was maintained off the floor for one of one sampled residents (Resident 20) reviewed during the Urinary Catheter or Urinary Tract Infections (UTI, an infection in the bladder/urinary tract) care area. This deficient practice had the potential to spread infections and illnesses among residents and staff. 2. Ensure food items were not left inside the clean linen storage. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide at least 80 square feet (sq. ft. - a unit of measurement) per resident in multiple resident bedrooms for 24 of 24 resident rooms (Rooms 1, 2, 3, 4, 5, 6, 7, 8, 10, 11, 12, 14, 15, 16, 17, 19, 20, 21, 22, 23, 24, 25, 26, and 27). This deficient practice had the potential to result in inadequate useable living space for all the residents and working space for the health caregivers, which could affect the safety and quality of life for the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Posted Nursing Staffing information was accurate. This deficient practice had the potential to result in residents, visitors, and facility staff not knowing how many staff were available to provide care to the residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice to meet the residents' physical, mental, and psychosocial (relating to the interrelation of social factors and individual thoughts and behavior) needs for two of three sampled residents (Resident 1 and Resident 2) by failing to: 1. Administer treatments as ordered by the physician for Residents 1 and 2. 2. Follow physician order for Resident 1's blood sugar (BS-body's main source of energy) monitoring. These failures had the potential to delay residents' care and negatively affect their well-being.

Inspectors wroteBased on interview and record review, the facility failed to develop a baseline care plan for one of two sampled residents (Resident 3) within 48 hours of Resident 3's admission. This failure had the potential to cause a delay of care for Resident 3 and negatively Resident 3's well-being.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from physical abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) for two of three sampled residents (Resident 2 and Resident 3). On 5/31/2025 at 9 p.m., Resident 2 and Resident 3 had a verbal altercation (an angry argument or disagreement expressed through words) in the smoking patio that led to a physical altercation (a confrontation or fight involving physical contact or force) where Resident 3 grabbed Resident 2 by the neck to choke Resident 2. This deficient practice resulted in Resident 2 being subjected to physical abuse by Resident 3 while under the care of the facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a written or electronic record containing all the information the resident needs to effectively manage their own health) for one out of three sampled residents (Resident 1) by failing to ensure Resident 1's care plan was developed and implemented after the physician gave an order for Resident 1 to self-administer medication. This deficient practice had the potential to result in inconsistent implementation of the care plan that may lead to a delay in or lack of delivery of care and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) was free from significant medication errors by failing to ensure the physician orders were followed. The facility failed to ensure Resident 1's cephalexin oral tablet (a medication, taken by mouth, used to treat bacterial infections) 500 milligrams (mg - unit of measurement) was administered at the scheduled time on multiple dates. This deficient practice placed Resident 1 at risk for untreated infections and had the potential for the development of multidrug-resistant organisms (MDRO - bacteria that becomes resistant to multiple types of antibiotics [a medication that inhibit the growth of bacteria], making them harder to treat).

Inspectors wroteBased on interview and record review, the facility failed to develop and implementa comprehensive, person-centered care plan with measurable objectives and interventions for one of four sampled residents (Resident 2) when the facility did not create and implement a care plan that addressed Resident 2's refusal of indwelling urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) care. This deficient practice placed Resident 2 at risk for not receiving the necessary services and assistance that can result in resident injury or serious condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 2) with indwelling urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) received proper care and services by failing to: 1. Ensure Resident 2's indwelling urinary catheter had an order. 2. Ensure Resident 2 was monitored for the presence of urinary tract infection (UTI- an infection in the bladder/urinary tract). 3. Ensure licensed nurses provided and documented Resident 2's urinary catheter care. These deficient practices had the potential to cause Resident 2 urinary catheter-associated complications including UTI, discomfort, and pain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary respiratory care and services for one of three sampled residents (Resident 1) by failing to: 1. Ensure Resident 1's oxygen tubing was dated when it was changed. 2. Ensure Resident 1's oxygen tubing was kept inside an oxygen supplies bag when not in use. 3. Ensure Resident 1's oxygen tubing was not touching unclean surfaces. These deficient practices had the potential for Resident 1 to develop respiratory (organs and structures in the body that allow a person to breathe) diseases or infections.

Inspectors wroteBased on interview and record review, the facility failed to report within two hours an incident of an alleged abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) for two of three sampled residents (Resident 1 and 2). The abuse incident happened on 5/1/2025 at 7:30 p.m. and was reported to the State Survey Agency on 5/2/2025. This deficient practice had the potential to result in unidentified abuse in the facility and placed Resident 1 and Resident 2 at risk of further abuse.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive person-centered care plan (a document designed to facilitate communication among members of the care team that summarizes a resident's health conditions, specific care needs, and current treatments) and implement care plan interventions for one of three sampled residents (Resident 1) to address Resident 1's: 1. Use of Clozapine (a medication primarily indicated for the treatment of schizophrenia [a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions]). 2. The use of Ativan (a medication used to treat anxiety [a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome]). 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices for one of three sampled residents (Resident 1) when: 1. The facility failed to accurately document Resident 1 ' s monitoring for mood disorder on the medication administration records (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident). 2. The facility failed to accurately document Resident 1 ' s side effect of the inability to sit still for clozapine (a medication used to treat severely ill patients with schizophrenia [a mental illness that is characterized by disturbances in thought]). These deficient practices resulted in inaccurate documentation of Resident 1 ' s records.

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents received care consistent with professional standards of practice for one of three sampled residents (Resident 1) by failing to ensure vital signs (measurements that indicate the status of a person's body's vital functions and are used to assess overall health) were taken prior to discharging Resident 1 home on 4/18/2025, as indicated in the facility's policy. This deficient practice had the potential for delay in Resident 1's care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain sanitary, orderly, and homelike environment for one of three sample residents (Resident 1) by failing to maintain cleanliness of Resident 1's floor. This failure had the potential to spread infection and negatively impact Resident 1's psychosocial well-being (refers to a resident's overall mental, emotional, and social health, encompassing aspects like happiness, life satisfaction, self-esteem, social functioning, and a sense of purpose).

Inspectors wroteBased on interview and record review, the facility failed to implement resident-centered care plan for one of three sampled residents (Resident 1). This deficient practice could have delayed in providing Resident 1's care needs.

Inspectors wroteBased on interview and record review the facility failed to ensure residents received treatment and care in accordance with professional standards of practice to meet the resident's physical, mental, and psychosocial (relating to teh interrelation of social factors and indivudial thoughts and behavior) needs for one of three sampled residents (Resident 1) by failing to: 1. Administer medications and treatments as ordered by the physician. 2. Provide Resident 1 with enough Oxygen supply to last during clinic appointments. These deficient practices had the potential to place Resident 1 at risk for unrelieved shortness of breath, respiratory complications, and negatively affect Resident 1's life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement and maintain an infection 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 one of three sampled residents (Resident 1) by: 1. Failing to maintain clean and sanitary floors in Resident 1's room. 2. Failing to keep Resident 1's bedside commode (portable toilet-a chair with a bucket or receptacle designed to be used by people with limited mobility who cannot easily reach a regular bathroom) clean and disinfected. This deficient practice had the potential to place Resident 1 at risk for acquiring infection and negatively affect Resident 1's quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that two of six emergency exit doors (Exit Door 1 and Exit Door 2) were free from obstructions. This deficient practice had the potential to prevent prompt evacuation of residents and staff due to obstruction of egress (designated emergency exit door) access in the event of an emergency.

Inspectors wroteBased on interview and record review, the facility failed to respect resident ' s rights for one of six sampled residents (Resident 1). Resident 1 had an appointment which was cancelled without Resident 1 being informed. This failure denied Resident 1 the right to receive clear and understandable information about their health condition(s), treatment option(s), and the right to an active participation in personal healthcare plan.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from abuse for two of seven sampled residents (Resident 1 and Resident 2). On 12/23/2024, Resident 1 was subjected to verbal abuse, while Resident 2 was subjected to physical abuse, both by another resident, Resident 3. This deficient practice affects the safety and well being of the residents, exposing the residents to unnecessary physical and mental trauma. Findings A review of Resident 1's admission Record indicated an admission date of 9/20/2024 with the diagnoses of generalized osteoarthritis (having pain, stiffness, or tenderness to joints during movement), Alzheimer's disease (a brain disorder that gradually destroys memory and thinking skills), and lack of coordination (having difficulty in controlling muscles or movement). [...]

Inspectors wroteBased on interview and record review, the facility failed to protect one of three sampled residents (Resident 1) from physical and verbal abuse (deliberately aggressive or violent behavior with the intention to cause harm by one resident towards another) on 11/11/2024. Resident 2 was witnessed striking Resident 1 three times on the top of the right foot and yelling at Resident 1. This deficient practice resulted in Resident 1 being subjected to physical and verbal abuse by Resident 2 while under the care of the facility and caused emotional distress and pain to Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from misappropriation of property (the intentional, illegal use of the property or funds of another person for one's own use or other unauthorized purpose) for one of three residents (Resident 3) when the facility failed to replace Resident 3's missing book. This deficient practice resulted in Resident 3 book not being replaced. Findings During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included muscle weakness (generalized), depression (a mental health condition that involves a persistent low mood and loss of interest in activities that are usually enjoyable), and essential (primary) hypertension (HTN-high blood pressure). [...]

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive (complete) person-centered care plan (a document that outlines a resident ' s care needs and how they will be addressed) for one of three sampled residents (Resident 1), who was identified as high risk (an identified concern that is likely to cause the resident to experience increased injury or harm) for falls. As a result, on 10/19/2024 at around 1:30 p.m., Resident 1 fell requiring immediate transfer to General Acute Care Hospital 1 (GACH 1) for further evaluation. Resident 1 sustained a facial contusion (an injury to the skin and underlying tissue on the face) and nasal laceration (an injury to the nose).

Inspectors wroteBased on interview and record review, the facility failed to protect the resident ' s right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) for one of three sampled residents (Resident 1) on 10/11/2024 when Resident 2 punched Resident 1 on the face. This deficient practice resulted in Resident 1 being subjected to physical abuse by Resident 2 while under the care of the facility.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from physical abuse for one of four sampled residents (Resident 1) when on 9/20/2024 at 7:15 a.m. Resident 2 was trying to touch Resident 1 on her right upper arm. Resident 1 told Resident 2 to get off me. Resident 2 grabbed Resident 1 by the shoulder and hit Residents 1's right upper arm. This deficient practice resulted in Resident 1 being subjected to abuse while under the care of the facility.

Inspectors wroteBased on interview and record review the facility failed to ensure residents received treatment and care in accordance with professional standards of practice to meet the resident's physical, mental, and psychosocial needs for one of two sampled resident (Resident 3), by failing to schedule Resident 3's neurologist (a medical specialty that deals with the disorders of the nervous system) appointment due to episodes of seizure (a sudden, uncontrolled burst of electrical activity in the brain) as ordered by the physician. This deficient practice had the potential to result in a delay of necessary care and treatment the resident needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the peripheral intravenous catheter (peripheral IV, a flexible plastic tube that is inserted into a vein to deliver fluids and medications) was labeled with the insertion date for one of one sampled resident (Resident 1). This deficient practice placed the resident at risk for infection due to missed dressing changes and lack of assessment and monitoring of the site.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 23 sample residents (Resident 216) who had a behavior of ingesting foreign objects (when a person swallows objects that may be inserted/ingested into the body accidentally or intentionally that is not meant to be eaten such as batteries, paper clips, nails, pins, screws, coins, plastic, pens) was supervised to prevent ingesting a paper clip and batteries by failing to: 1. Monitor and supervise Resident 216 to ensure the resident did not have episodes of self-harm behavior (the resident ingested a paper clip on 8/19/2024 and ingested batteries on 8/25/2024) in accordance with the care plan focusing on risk for injury. 2. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure kitchen staff were routinely trained and evaluated for competency skills to ensure the Dietary [NAME] was able to verbalize proper cooling procedures of food. This failure had the potential to result in harmful bacteria growth and cross contamination (a transfer of harmful bacteria from one place to another or one object to another) that could lead to foodborne illness (illness caused by food contaminated with bacteria, viruses, and other toxins) in 70 of 70 medically compromised residents who received food and have food prepared from the kitchen staff.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure pharmaceutical services meet the needs of residents by failing to safeguard the access and disposition (the process of returning and/or destroying) of unused medications. This deficient practice had the potential for loss of accountability, that could affect the controls against drug loss and diversion (illegal transfer of a controlled substance or other medication from a lawful to an unlawful channel of distribution or use), and theft. During a medication storage inspection on 08/27/24 at 9:55 am, inside the medication room, observed a bucket with a red plastic biohazard bag liner and a wide lid cover which had a paper taped to it with the statement Please do not throw away med cups, syringes, ETC, here. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain the kitchen in a clean, safe, and sanitary condition in which food was stored, prepared, and served in accordance with professional standards of food service safety by: 1. Failing to ensure the Dietary [NAME] (DC) follow facility policy for proper cooling process for foods prepared in advance of service. 2. Failing ensure the resident refrigerator (refrigerator for food brougfhgt in by family members) was in working order and ensure the food items stored in the refrigerator and freezer were dated and labeled. [...]

Inspectors wroteBased on observation, interview and record review, facility failed to: 1. Clean and disinfect a frequently used and visibly soiled toilet surface shared by residents in room [ROOM NUMBER] and 23. 2. Clean and disinfect the surface of dispensers filled with alcohol-based hand rub placed in hallways next to rooms next to resident rooms 22, 24, 25, 26, 27. 3. Disinfect and clean dried dark colored smears observed on door frame of room [ROOM NUMBER]. These deficient practices had the potential to result in pathogen (germ) exposure by disease causing microorganisms and placed the facility residents and staff at risk for developing symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever that could lead to other serious medical complications and unnecessary hospitalization of residents and staff.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of one sampled resident (Resident 32), had a Resident Representative (RR- An individual chosen by the resident or authorized by State or Federal law to act on behalf of the resident) with legal authority to make medical decisions for the resident. This failure had the potential to result in violation of Resident 32's rights to receive treatment.

Inspectors wroteBased on observation and interview facility failed to provide a safe, clean, and sanitary environment for residents by: 1. Failing to clean and disinfect a [NAME] and [NAME] bathroom (a bathroom that has 2 doors and is accessible to two bedrooms) shared by five residents in room [ROOM NUMBER] and 23. This deficient practice had the potential to expose the residents to disease causing microorganisms and could cause vomiting and diarrhea, severe dehydration, resulting in unnecessary hospitalization, and even death. 2. Failing to ensure shower curtains in resident shower rooms [ROOM NUMBERS] were not visibly dirty. This deficient practice has the potential to cause infection to residents when dirty shower curtains in both resident shower rooms [ROOM NUMBERS] were kept in use.

Inspectors wroteBased on interview and record review, the facility failed to investigate and report allegations of abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish) for one out of 23 sampled residents (Resident 215) to the State Agency (SA), to the Long Term Care Ombudsman (LTC Ombudsman -an official appointed to investigate individuals' complaints against maladministration), and to the local law enforcement in accordance with the facility's policy and procedures (P&P) titled Abuse Reporting and Investigation updated on 11/2018, by failing to report an allegation of employee-to-resident altercation within two hours after the allegation occurred on 8/20/2024. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: 1. Residents 37 and 49 received their PASARR Level II (Level II) evaluations and determinations (determines the appropriate settings for the resident and recommends what specialized services and/or rehabilitative services the resident needs) when admitted to the facility. 2. Residents 37 and 49 Level II care plans were based on the recommendations of Level II evaluations and determinations. These deficiencies have the potential for Residents 37 and 49 to miss specialized services and or rehabilitative services as indicated by Level II evaluations and determinations.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide at least 80 square feet (sq. ft. -unit of measure) per resident in multiple resident bedrooms for 24 of 24 resident rooms, (rooms 1,2, 3,4,5,6,7,8,10,11,12,14, 15, 16, 17, 19, 20, 21, 22, 23, 24, 25, 26, and 27). This deficient practice had the potential to result in inadequate useable living space for all the residents and working space for the health caregivers, which could affect the safety and quality of life for the residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a safe, functional, and comfortable environment for all residents when one of two showers (Shower room [ROOM NUMBER]) was observed on 8/19/2024 without a shower valve. This deficient practice had the potential to affect the resident's quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a comfortable and homelike environment for two of three sampled residents (Resident 1 and Resident 2) when the smell of cigarette smoke entered the facility from the smoking patio into a resident's room, through the hallway, and into Resident 1 and Resident 2's room. This deficient practice had the potential for Residents 1 and 2 to become uncomfortable making them leave their room and wander around the facility. This can also affect their psychosocial wellbeing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 1), who has impaired cognition (ability to think and make decisions), was supervised and monitored by failing to: 1. Ensure Resident 1 did not leave the facility unnoticed and unsupervised. 2. Ensure all the exit alarms were checked for functionality. These deficient practices resulted to Resident 1 ' s elopement on 6/8/2024 from an unknown exit in the facility. The resident had the potential to experience harsh environment/weather conditions, deterioration in mental and physical health due to interrupted medical care and treatment, suffer injury, pain, serious impairment, or death. On 6/12/2024 Resident 1 went to police station and asked for assistance in contacting the resident ' s conservator. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one of five sampled residents (Resident 4) was assisted on eating safely and treated with respect and dignity in a manner that promoted maintenance or enhancement of the quality of life. Certified Nursing Assistant 3 (CNA3) was not at eye level to Resident 4 while assisting the resident to eat. This deficient practice had the potential for Resident 4 to choke and had the potential to affect the resident ' s sense of self-worth and self-esteem.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled residents (Resident 2) had the right to be free from physical abuse (willful infliction of injury resulting physical harm, pain, or mental anguish) on 12/6/2023 at 7 a.m. when Resident 1, who had recent history of striking out, was impulsive, aggressive and was able to walk around unassisted, hit Resident 2 several times on the face and body. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for one of three sample residents (Resident 1) by: a. Failing to develop and implement Resident 1 ' s care plan interventions regarding risk for disturbance in sleep pattern related to insomnia (trouble falling and/or staying asleep). b. Failing to develop an individualized care plan with interventions for Resident 1 ' s behavior, psychotropic medication (any drug that affects behavior, mood, thoughts, or perception), and schizoaffective disorder (a mental condition that causes both a loss of contact with reality and mood problems) care plans. These deficient practices placed the resident at risk for not receiving the necessary services and treatment to meet his medical, physical, mental, and psychosocial needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure Resident 1 did not exit the facility without the facility staff's knowledge on 11/21/2023 for one of three sampled residents (Resident 1). This failure had the potential for Resident 1 to sustain an accidental injury while outside the facility's premises.

Inspectors wroteBased on interview and record review, the facility failed to implement their policies and procedures by not monitoring for specific target behaviors on the use of Quetiapine (Seroquel, antipsychotic medication used to alter brain chemistry to help reduce hallucinations [false perception of objects or events involving the senses], delusions [believing thoughts to be real but are actually false or unreal] and disordered thinking) and Risperidone (antipsychotic medication) for one of three sampled residents (Resident 1). This deficient practice had the potential to result in inconsistent monitoring and placed the resident at risk for receiving unnecessary medication and unrecognized adverse reactions(any unexpected or dangerous reaction to a drug).

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for six of nine sampled residents (Resident 2, 3, 4, 7, 8, and 9), by failing to: 1. Develop a care plan addressing Resident 2 and Resident 3's refusal to receive coronavirus disease (COVID-19, an acute disease in human caused by coronavirus). 2. Develop a care plan addressing Resident 2' refusal to receive pneumococcal vaccine (an injected medicine that can protect against and often prevent pneumococcal [a type of bacteria] infections [when the immune system fights off the bad germs to get better]). 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide quality of care in accordance with professional standards of practice to meet the resident's physical, mental, psychosocial needs for one of one sampled resident (Resident 5) by failing to follow-up the resident's hematologist (a doctor who specializes in researching, diagnosing, treating, and preventing blood disorders and disorders of the lymphatic system (lymph nodes and vessels)/oncologist's (a doctor qualified to diagnose and treat tumors) recommendations for a urologist (a doctor who specializes in the study or treatment of the function and disorders of the urinary system) consult. This deficient practice had the potential to result in a delay of care and services for Resident 5.

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose a medication that was refused by one of four sampled residents (Resident 4). Resident 4 was refusing molnupiravir (Lagevrio, an antiviral medication) and the licensed nurse refused to take it back and left the medication with Resident 4, who was not assessed as able to do self-administration (the act of administering something to oneself) of medications. This deficient practice denied Resident 4's right to refuse a medication and the potential for the medication to be taken by another resident if not properly disposed.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free from any significant medication errors (administration of medication which as not in accordance with accepted professional standards and principles) by: 1. Failing to administer molnupiravir (medication used to treat Coronavirus Disease 2019 [COVID-19, highly contagious viral respiratory infection that spreads from person to person through droplets released when an infected person cough, sneezes or talks]) to Resident 1 as ordered by physician. 2. Failing to ensure Licensed Vocational Nurse 1 (LVN 1) obtain a physician's order for molnupiravir before offering to Resident 1 after the stop date. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement infection control measures for three of three sampled residents (Resident 7, 8 and 9) by failing to ensure Certified Nursing Assistant 1 (CNA 1) wore protective goggles while providing care for residents who were placed on isolation precautions, (are used to help stop the spread of germs from one person to another) for Coronavirus Disease 2019 (COVID-19, highly contagious viral respiratory infection that spreads from person to person through droplets released when an infected person cough, sneezes or talks) for Residents 7, 8, and 9. This deficient practice had the potential to result in the spread of the COVID-19 to all residents and staff.

Inspectors wroteBased on interview and record review, the facility failed to offer the pneumococcal vaccine (a drug that helps the immune system develop immunity from pneumococcal pneumonia [an infectious bacterial lung disease]) to one of five sampled residents (Resident 2), when Resident 2 became eligible to receive the vaccine. This deficient practice had the potential to result in increased risk for pneumococcal infections which may lead to serious health complications such as pneumonia (an infection that inflames your lungs' air sacs), meningitis (inflammation of brain and spinal cord membranes, typically caused by an infection), and bloodstream infections.