Villa Del Sol Post Acute

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the room temperature of two of twelve sampled residents (Resident 3 and Resident 13) was within normal range (71-81 Fahrenheit [a temperature scale used to measure freezing and boiling degrees under standard atmospheric pressure]). The thermostat of Resident 3 and Resident 13's room was 85 degrees Fahrenheit. This failure resulted in Resident 3 and Resident 13 feeling uncomfortable and frustrated and had the potential to negatively affect their quality of life.

Inspectors wroteBased on interview and record review the facility failed to ensure one of three residents' (Resident 1) prescription (physician ordered) medications were acquired and administered in a timely manner. The failure resulted in a disruption of Resident 1's treatment plan and had the potential to delay recovery and put Resident 1's health at risk.

Inspectors wroteBased on interview and record review the facility failed to ensure one of one resident's (Resident 1) blood glucose (simple sugar - the body's primary source of energy) level was checked prior to insulin (hormone that removes excess sugar from the blood can be produced by the body or given artificially via medication) administration. The failure had the potential to result in hypoglycemia (low blood glucose).

Inspectors wroteBased on interview and record review the facility failed to ensure one of one resident's (Resident 1) medical records were accurate. This failure resulted in an inaccurate depiction of resident status.

Inspectors wroteBased on interview and record review, the facility failed to ensure Certified Nurse Assistant (CNA) 1 did not allow a resident (Resident 1) who was assessed as a fall risk, had a history of a fall, and required substantial/maximum assistance (helper does more than half of the effort) from staff for transfers and mobility, ambulate to the bathroom alone, and without assistance for one of three sampled residents (Resident 1). This failure resulted in Resident 1 falling from the bed on 11/8/2025 and had the potential for Resident 1 to sustain more serious injuries such as brain injury, fractures (a partial or complete break in the bone), and death. Resident 1 was transferred to a General Acute Hospital (GACH) for further evaluation.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive, person centered care plan for two of ten sampled residents (Resident 19 and Resident 23) by failing to:A. Ensure a comprehensive care plan was initiated for Resident 19 addressing hearing needs and physical therapy ([PT], a rehabilitation profession that restores, maintains, and promotes optimal physical function) services. B. Develop, and implement a comprehensive, person centered care plan addressing Resident 23's toenail fungal infection as recommended by the podiatrist. These failures had the potential to result in unmet needs for Residents 19 and 23, negatively affecting their well being and contributing to poor resident outcomes.

Inspectors wroteBased on interview and record review, the facility failed to ensure two out of four sampled residents (Resident 13 and 89) received Restorative Nursing Assistance services ([RNA] services focused on helping residents regain or maintain physical mobility) as indicated in the care plan. These failures had the potential to result in physical decline.

Inspectors wroteBased on interview and record review, the facility failed to ensure bowel and bladder frequency was documented according to facility documentation practices for one of one sample resident (Resident 14). This failure had the potential to result in delay of diagnosis and treatment of bowel or bladder issues.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess, and address the resident's preferences by making reasonable efforts to accommodate her needs, and document regarding a preferred seating location in the activity room for one of two sampled residents (Resident 43):These failures have the potential to cause emotional distress, decreased satisfaction with care, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide accurate information in the Minimum Data Set ([MDS], a resident assessment tool) for one of five sampled residents (Resident 19) who had aggressive physical (any intentional action that causes or is intended to cause bodily harm, pain, or injury to another person, or oneself) and verbal behavior (communication intended to harm, control, or intimidate another person) symptoms receiving medication. This deficient practice had the potential to result in inaccurate assessments and services for the resident due to inaccurate MDS assessment and care screening.

Inspectors wroteBased on interview and record review, the facility failed to ensure a comprehensive, person centered care plan was revised and updated after an unwitnessed second fall on 3/17/2026 that resulted in a cut to the left temple (the area on either side of the head behind the eyes) for one of five sampled residents (Resident 7). This failure had the potential to result in repeated falls and injuries for Resident 7. During a review of Resident 7's admission Record, the admission record indicated that Resident 7 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses included Parkinson's disease (a progressive disorder of the nervous system characterized by tremors, muscle rigidity, and slow, imprecise movements), dementia (a progressive decline in cognitive functioning), syncope (a temporary loss of consciousness), and a history of falls. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide nail care to one of four sampled residents (Resident 89). This failure resulted in Resident 89 having long, unclean fingernails and had the potential to result in infections.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to implement the podiatrist (a medical specialist dedicated to the prevention, diagnosis, and treatment of disorders of the foot, ankle, and lower leg) recommended treatment for a toenail fungal infection for one of three sampled residents (Resident 23). This failure resulted in a delay in necessary foot care services and had the potential to negatively affect Resident 23's physical health and psychosocial well being.

Inspectors wroteBased on interview and record review, the facility failed to ensure a performance review for one of two Certified Nurse Assistants (CNA 9) was completed at least once every 12 months. This failure had the potential to result in poor resident health outcomes.

Inspectors wroteBased on observation, interview and record review the facility failed to:a. Ensure one of five residents (Resident 91) received ondansetron (medication to treat nausea and vomiting) in a timely manner. As a result, Resident 91was not treated for nausea and vomiting for seventeen hours, which had the potential to cause discomfort. b. Maintain accurate documentation of hydrocodone acetaminophen (a controlled medication [medications with a high potential for abuse] used to manage moderate to severe acute and chronic pain) tablet on the controlled drug record ([CDR], a document indicating the inventory and administration of controlled substances) sheet, affecting one resident (Resident 5) in one of two inspected medication carts (Station 2 Medication Cart). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the fruit cup and health shake (nutrient dense beverage) as indicated on one of five residents breakfast menu (Resident 12). This failure had the potential to result in loss of appetite and cause unplanned weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff followed infection control practices for three of 30 sampled residents (Resident 8, 32 and 37) when:a. The facility failed to ensure padded side rails that were wrapped with porous foams were disinfected properly for two of six sampled residents (Resident 8 and 37).b. The facility failed to ensure the laundry hamper for Resident 32 was free from bowel residue. These failures had the potential to increase the risk of cross-contamination (the transfer of bacteria, viruses, microorganisms or other harmful substances from one surface to another through improper or unsanitary equipment, procedures, or products) and spread infection among the residents, staff and visitors.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of physical abuse for one of two sampled residents (Resident 2), when Resident 2 reported to facility staff that she (Resident 2) was handled roughly by two hospital staff at a General Acute Care Hospital (GACH 1) prior to her admission to the facility (4/9/2026). And, they failed to report an injury of unknown origin when an Xray (a procedure that takes pictures of the inside of the body to diagnose broken bones and other injuries) taken on 4/24/2026 confirmed Resident 2 had a displaced fracture (when a broken bone snaps into two or more pieces and moves, causing the ends to become misaligned) of the proximal (closer to the point of attachment) shaft of the right femur (largest bone extending from the hip to the knee [hip fracture]). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident (Resident 1), who had a history of falls and was assessed as a high fall risk, room door remained open for visibility for one of five sampled residents (Resident 1). This failure had the potential to prevent nursing staff from observing Resident 1 and identifying her care and safety needs in a timely manner.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident (Resident 1), who had a history of falls and was assessed as a high fall risk, care plan interventions were revised after Resident 1 had an unwitnessed fall on 1/31/2026. This deficient practice had the potential for the nursing staff to be unaware of Resident 1's current fall risk precautions and interventions that could delay and/or affect delivery of her care.

Inspectors wroteBased on interview and record review, the facility failed to ensure an effective grievance process was implemented that ensured resident concerns were documented, investigated, and resolved in a timely manner for three of four sampled residents (Resident's 1, 2, and 4). These failures resulted in the complaints not being documented, investigated, or resolved, leaving residents without recourse for lost belongings and creating a pattern of unresolved concerns.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) remained clean, comfortable, and remained in a dignified manner. This failure resulted in Resident 1 being left undressed from the waist down and lying in urine-soiled linens for an extended period. Resident 1 was not able to receive her scheduled shower due to being cold from being soiled. These failures placed Resident 1 at risk for skin breakdown and infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four sampled resident's (Resident 1) call light (device that allows residents to request assistance from nursing staff) was accessible and within reach. This deficient practice resulted in the inability of Resident 1 to use his call light to obtain assistance to empty his urinal and the potential for a delay in care.

Inspectors wroteBased on interview and record review the facility failed to ensure they obtained a credible Physicians Orders for Life- Sustaining Treatment ([POLST] a portable medical order form for seriously ill or frail individuals that translates that provides specific instructions for medical professionals when a person can't speak for themselves) for one of three sampled residents (Resident 1) By failing to: 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to document an indication for a psychotropic medication (medication that affects the brain) to be administered to one of three sampled residents (Resident 11) who was given Ativan due to anxiety with no manifestation. This deficient practice resulted in Resident 11 not being monitored for psychiatric behaviors and had the potential to experience unwanted adverse side effects.

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to ensure soiled gown was not left on the floor near the trash can. This deficient practice had the potential to spread infection.

Inspectors wroteBased on interview and record review the facility failed to ensure one of two sampled residents (Resident 1) did not elope from the facility on 6/2/2025 at 1:30 p.m. The facility failed to: 1. Accurately assess Resident 1 for wandering (walk around without any clear purpose or direction) and elopement risk to prevent the resident from leaving the facility unsupervised. 2. Ensure on 6/2/25 at 1:30 p.m. Resident 1 was supervised while he was on the patio. 3. Ensure staff followed facility's policy and procedure (P&P) titled, Elopement and Wandering Residents dated 12/19/2022, which indicated facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of one sampled residents (Resident 1) who resided at the facility and was transferred to General Acute care hospital (GACH) was readmitted to the facility after Resident 1 was cleared by GACH to return to the facility on [DATE]. This deficient practice resulted in Resident 1 remaining at the GACH after Resident 1 was deemed appropriate for discharge back to the facility but was denied readmission by the facility. Resident 1 did not return to the facility. This deficient practice resulted in Resident 1 ' s temporary loss of residence and had negative psychosocial outcome, as evidenced by vocalizations of depression (feeling of sadness and loss of interest), sadness and anxiety.

Inspectors wroteBased on observation. interview and record review, the facility failed to implement infection control measures by failing to: A. Ensure Legionella (a type of bacteria that is naturally found in [NAME] environments, such as lakes and streams) water testing was done annually per the facility's policy and procedure. B.Ensure Resident 57's visitors wore personal protective equipment (PPE, clothing and equipment worn or used to provide protection against hazardous substances and/or environments) while visiting Resident 57, who was on enhanced barrier precaution (EBP, infection control intervention using gown and gloves during high contact with a resident, designed to reduce transmission of multi-drug resistant organisms). This failure had the potential to result in compromised infection control measures to prevent the potential spread of infection among residents, staff, and visitors.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive care plan for two of five sampled residents (Resident 2 and Resident 80) when the facility failed to update and implement a comprhensive care plan for: 1. Oral care and hygiene and refusal of the activity of daily living (ADL, basic tasks that enable people to care for themselves and live independently include eating, dressing, bathing, using the toilet, and moving around) for Resident 2. 2. When there was a change in condition that required resident to need a one-on-one feeder and diet change from regular texture to puree texture for Resident 80. This deficient practice had the potential to negatively affect the quality of life and wellbeing for Resident 2 and Resident 80 to prevent them from achieving their highest practical well-being.

Inspectors wroteBased on interview and record review the facility failed to ensure performance reviews for two of two Certified Nurse Assistants (CNA 1 and 2) were completed at least once every 12 months. The deficient practice had the potential to result in poor resident care and health outcomes.

Inspectors wroteBased on interview and record review, the facility failed to monitor for adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have) related to the use of duloxetine (a medication used to treat mental illness) between 3/15/2025 and 4/3/ 2025 in two of six residents sampled for unnecessary medications (Resident 40 and 64) The deficient practice of failing to define and monitor adverse effects related to treatment with psychotropic (medications that affect brain activities associated with mental process and behavior) medications increased the risk that Residents 40 and 64 could have experienced adverse effects related to the use of duloxetine leading to impairment or decline in mental or physical condition or functional or psychosocial status.

Inspectors wrote(Cross-reference F760) Based on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five percent (%). Six medication errors out of 34 total opportunities contributed to an overall medication error rate of 17.65 % affecting two of five residents observed for medication administration (Residents 25 and 35.) The medication errors noted were as follows: 1. Late administration of magnesium oxide (a mineral supplement) to Resident 25. 2. Late administration of aspirin (a medication used to prevent blood blots) to Resident 25. 3. Late administration of vitamin C (a vitamin supplement) to Resident 25. 4. Late administration of multivitamins (a vitamin supplement) to Resident 25. 5. Late administration of gabapentin (a medication used to treat pain) to Resident 25. 6. [...]

Inspectors wrote(Cross-reference F759) Based on interview and record review, the facility failed to ensure its residents were free from significant medication errors by A. Administering gabapentin (a medication used to treat pain) later than allowed by the physician's order on 4/2/25 in one of five residents observed for administration (Resident 25.) The deficient practice of failing to administer gabapentin in accordance with the physician order's time frame increased the risk that Resident 25 may have had complications related to gabapentin being dosed too frequently including drowsiness, dizziness, or difficulty breathing possibly resulting in hospitalization. B. The facility failed to hold blood pressure medication for Resident 46 and Resident 81 when blood pressure was lower than the ordered parameters (standards to measure set by physician, before administering medication). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe and sanitary food storage and preparation practices in the kitchen when: 1. Previously cooked Ham with a use by date of 3/24/2025 was stored in the walk-in refrigerator. 2. One can opener blade was worn and dented with the potential to harbor harmful bacteria. Stove and oven were dirty with dried food debris, sticky and greasy residue on the range (stove) and inside the oven. The knobs on the range (stove and oven) had dried brown and red color residue. The shelf under food preparation counter had crumbs and food debris. 3. TCS foods- texture modified fish was held on the steam table during lunch service with a temperature of 125F (TCS Time/Temperature Control for safety Food formerly potential hazardous food). [...]

Inspectors wroteBased on interview and record review, the facility's Quality Assessment and Assurance committee ([QAA] a group of facility staff who identifies, evaluates, and implements measures to improve the quality care and life for the residents in the facility) and Quality Assurance Performance Improvement ([QAPI] a group who takes a systemic, interdisciplinary, comprehensive, and data driven approach to maintaining and improving safety and quality in nursing homes while involving residents and families, and all nursing home caregivers in practical and creative problem solving) committee failed to ensure effective oversight of the facility's plan of correction (POC) of the deficient practices identified during the previous recertification survey (4/12/2024) thereby affecting 84 of 84 residents. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement the antibiotic stewardship program (the effort to ensure that [antibiotics - medicines that fight bacterial infections in people and animals] are used only when necessary and appropriate) for two of eight sampled residents (Resident 60 and Resident 69) as evidenced by: A. Failing to identify the indication (reason) for use and assess antibiotic time out (an active reassessment of an antimicrobial prescription 48-72 hours after first administration) of Bactrim (a prescription drug that's used to treat or prevent certain infections) for Resident 60. B. Failing to assess, monitor, and evaluate adverse reaction (an undesired effect of a drug) and side effects of prophylactic (preventative) Bactrim (a medicine or course of action used to prevent disease) use for Resident 69. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of the five sampled residents (Resident 67) had a call light within reach. This failure had the potential to result in a delay or inability for the resident to obtain necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure one out of three sampled residents (Resident 70) had their Level 1 Preadmission Screening and Resident Review ([PASARR], a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) completed accurately. This deficient practice had the potential to delay care for Resident 70 and had the potential Resident 70 would not receive the proper level of care or services required.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain good oral hygiene for one of two samples residents (Resident 2) when there were white and orange material on Resident 2's lips and teeth. This deficient practice resulted in Resident 2's care needs not being met and had the potential to result in psychological harm, tooth decay and infection.

Inspectors wroteBased on observation interview and record review the facility failed to position one out of six residents (Resident 78) in an upright position when assisting with feedings This deficient practice had the potential to cause the resident to have difficulty in swallowing and aspirate (accidental inhalation of food liquid or other materials in the lungs) resulting in hospitalization.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow up with the Pain Management Doctor (PMD) for one out of three residents (Resident 46) when the PMD had ordered pain medication that Resident 46 was allergic too. This deficient practice had the potential for Resident 46's pain to go untreated.

Inspectors wroteBased on observation, interview, and record review, the facility failed to remove one expired fluticasone/salmeterol (a medication used to treat breathing problems) inhaler from the medication cart affecting Resident 17 in one of two inspected medication carts (Middle Medication Cart.) The deficient practice of failing to remove and replace Resident 17's expired fluticasone/salmeterol inhaler from the cart increased the risk that it could have been ineffective when used to treat or prevent breathing problems possibly leading to health complications resulting in hospitalization or death.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the standardized recipes for lunch menu was followed and provide residents a variety of food option on 4/1/2025 when: One resident (Resident 60) who was vegetarian and on minced and moist diet did not receive the vegetarian option and vegetarian menu was not prepared. Resident 60 who was on minced and moist texture diet (food modified to texture where biting is not required, and minimal chewing required the pieces of food can fit through the gap between the prongs of a standard dinner fork) received chopped carrots instead of minced and moist carrots. This deficient practice had the potential to result in inadequate nutrition status, meal dissatisfaction and increased choking and aspiration risk for resident 60 who is on minced and moist diet texture.

Inspectors wroteBased on interview and record review, the facility failed to develop comprehensive and resident-centered pressure ulcer (localized damage to the skin and/or underlying tissue usually over a bony prominence) Care Plans for two of three sampled residents (Residents 2 and 3). These deficient practices had a potential for Resident 2 and 3 ' s documented pressure ulcers to experience a delay in wound healing or to show no signs of improvement.

Inspectors wroteBased on interview and record, the facility failed to revise one of three sampled residents (Resident 3) pressure ulcer (localized damage to the skin and/or underlying tissue usually over a bony prominence) Care Plan after Resident 3 ' s pressure ulcer/injury stage 1 (intact skin with a localized area of redness and/or changes in sensation, temperature, or firmness) progressed to a pressure ulcer/injury stage 3 (Full-thickness loss of skin. Dead and black tissue may be visible). This deficient practice had the potential for Resident 3 to experience delayed wound healing and treatment.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 3) pressure ulcers (localized damage to the skin and/or underlying tissue usually over a bony prominence) were assessed by the treatment nurse (TN 1) after Resident 3 was readmitted to the facility on [DATE]. This deficient practice had the potential to result in a delay in treatment for Resident 3 ' s pressure ulcers.

Inspectors wroteBased on interview and record review the facility failed to ensure two of three sampled residents (Resident's 1 and 2) rights were upheld and protected when the facility did not address Resident's 1 and 2's concerns regarding the facility's removal of the Sit-to-Stand (SS-specialized medical device used to assist individuals with limited mobility in transitioning form a seated to standing position) lift. Resident's 1 and 2 were not given an alternative and had to be placed in a Hoyer (medical device that uses a sling to transfer a resident) lift for transfers. This deficient practice resulted in Resident's 1 and 2 rights being violated and led to Resident's 1 and 2 feeling anxious, powerless, frustrated, humiliated, angry and distrustful toward the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who was at risk for pressure injuries (skin damaged caused by prolonged or intense pressure) and had a right abdominal fold Moisture-Associated Skin Damage (MASD - moisture associated skin damage caused from prolonged exposure to moisture) was frequently repositioned and not left sitting in her wheelchair for a prolonged period of time after the facility's removal of the Sit to Stand (SS - specialized medical device used to assist individuals with limited mobility in transitioning form a seated to standing position). This deficient practice resulted in Resident 1 sitting in her wheelchair for four hours causing discomfort and increased risk of skin breakdown and infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident, who was assessed at risk for falls, and who had a history of getting out of bed unassisted, did not fall and sustain a head injury for one out of five sampled residents (Resident 4). The facility failed to: 1. Ensure the nursing staff followed interventions, per Resident's 4's Care Plan titled, Risk for Falls dated 7/1/2024, to reduce Resident 4's risk for falls by increasing the frequency of monitoring rounds. 2. Ensure the nursing staff, who provided care to Resident 4, were made aware of what the time frame was for frequent monitoring for Resident 4 and other residents assessed at risk for falls and who had a history of getting out of bed unassisted. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure a resident, who underwent a right total knee replacement (a surgical procedure to replace damaged parts of the knee joint with artificial parts to relieve pain and improve movement) and complained of a pain level of eight out of 10 on a pain rating scale from a zero to 10 (an 11 eleven point scale where pain is rated from zero to 10; 0=no pain, 1-3=mild pain, 4-6=moderate pain, and 7-10=severe pain, and 10=worst imaginable pain) was medicated for pain for one out of three sampled residents (Resident 1). The facility failed to: 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure an Interdisciplinary Team ([IDT] team members from different departments working together, to set goals, make decisions that ensure residents receive the best care) Care Conference meeting, involving one of three sampled residents (Resident 3) was initiated after Resident 3 refused to go to hemodialysis ([HD], a treatment that filters a person ' s blood to remove waste products when kidneys are no longer functioning properly.) on the scheduled days. This deficient practice violated Resident 3 ' s right to be an active participant to discuss the resident ' s plan of care and services with the IDT and possible delayed discussion of needed care and services.

Inspectors wroteBased on observation, interview and record review, the facility failed to aggressively treat skin breakdown, prevent progression of contact dermatitis (a condition in which the skin becomes red, sore, or inflamed after direct contact with a substance) and promote rapid skin healing process for two of six (6) residents (Resident 22 and Resident 40) by failing to: 1. Implement Documentation of Wound Treatments policy and procedure (P&P) by including Resident 22 and Resident 40's response to the treatment ordered for contact dermatitis. 2. Consult a dermatologist (a medical practitioner specializing in the diagnosis and treatment of skin disorders) for diagnosis and treatment of skin rashes in a timely manner. 3. Inspect all residents in the facility in a timely manner for possible contact and spread of skin rashes. 4. [...]

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure mirtazapine (a medication used to treat mental illness) was used for a medical condition diagnosed and documented in the resident's clinical record for one of five residents sampled for unnecessary medications (Resident 74) 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five percent (%). Eight medication errors out of 30 total opportunities contributed to an overall medication error rate of 26.67 % affecting one of four residents observed for medication administration (Resident 532.) The medication errors noted were as follows: 1. Omitted dose of Symbicort (a medication used to treat breathing problems) 2. Omitted dose of Preservision AREDS2 (a multivitamin supplement) 3. Late administration of aspirin (a medication used to prevent blood clots) 4. Late administration of lisinopril (a medication used to treat high blood pressure) 5. Late administration of gabapentin (a medication used to treat pain) 6. Late administration of vitamin c (a vitamin supplement) 7. Late administration of zinc sulfate (a mineral supplement) 8. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer ten doses of Symbicort inhaler (a medication used to treat breathing problems) between 4/1/2024 and 4/10/2024 for one of four residents observed for medication administration (Resident 532.) The deficient practice of failing to administer Symbicort inhaler per the physician's order increased the likelihood that Resident 532 could have developed worsening asthma (a breathing condition characterized by life-threatening inflammation and constriction of the airway) possibly resulting in hospitalization or death.

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Ensure five expired insulin (a medication used to control high blood sugar) pens and one expired insulin vial were removed from the medication cart affecting Residents 36, 38, 50, and 67 in one of two inspected medication carts (Station 2 Medication Cart). 2. Ensure two unopened insulin pens and one unopened insulin vial were stored in the refrigerator according to the manufacturer's requirements affecting residents 1, 14, and 35 in one of two inspected medication carts (Middle Medication Cart.) 3. Secure a medication in a locked storage area for one of six (6) residents (Resident 22) by leaving Hydrocortisone ([corticosteroid-anti-inflammatory] cream medication used to relieve itching) 2.5 % ([%] unit of measurement) at Resident 22's bedside unattended, without a physician's order. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow lunch menu and portion sizes as written for residents on mechanical soft (a type of texture-modified diet for people who have difficulty chewing and swallowing) and pureed (pudding consistency food that does not required chewing) diet. 18 residents on the mechanical soft diet received 3 ounces (oz - a unit of measure of weight) of ground roast beef instead of 4 oz and seven residents on the pureed diet received 3 oz of pureed roast beef instead of 5 1/3 oz per the food portion and serving guide. This deficient practice had the potential to result in meal dissatisfaction, decreased nutritional intake and weight loss.

Inspectors wroteBased on observation, interview, and record review the facility failed to prepare food by methods that conserved texture and appearance. The texture of the pureed (food prepared with a pudding consistency that does not require chewing) diet was lumpy, not smooth with large pieces of pasta present requiring chewing before swallowing. During a taste test the food required chewing and moving around in the mouth before swallowing. This deficient practice had the potential to result in meal dissatisfaction, decreased intake, risk for unplanned weight loss and placed 7 residents on the pureed diet at risk for choking.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe and sanitary food storage and preparation practices when: 1. One large pan of previously prepared creamy salad dressing was stored in the walk-in refrigerator with a use by date of 4/7/2024 exceeding the storage period. One open container of raw liquid eggs was stored together in the same container with six ham sandwiches. Dry powdered milk stored in a large bin with dates 9/23/2023-3/22/2024 was expired and one large expired bag of raisin bran cereal with an open date of 10/2/2023 was stored in the dry storage area. Several items in the walk-in freezer were not dated and labeled, one bag of frozen beef patties, one large bag of frozen shrimp and one box of frozen vegetables stored in the walk-in freezer were not covered, open and exposed to freezer environment. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure the medication administration record (MAR - a record of all active physician orders and medications administered to a resident) was not falsified by documenting that Symbicort (a medication used to treat breathing problems) was administered eight times between 4/1/2024 and 4/10/2024 when it was unavailable in the facility for one of four residents observed for medication administration (Resident 532.) 2. [...]

Inspectors wroteBased on interview, and record review the facility failed to offer the pneumonia (PNA) (an infection of the lungs) vaccinations (medication to prevent a particular disease) for two of six sampled residents (Resident 8 and Resident 48). This deficient practice placed Resident 8 and Resident 48 at a higher risk of acquiring and transmitting pneumonia to other residents in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to : a. Provide privacy for two of three sampled residents (Resident 44 and Resident 337) by not closing the privacy curtain for Resident 44 and not covering Resident 337's back side while coming back from the shower. b. Not completely covering Resident 70 body after her shower. These deficient practices had the potential for the residents (Resident 44,337 and 70) to experience loss of dignity,self-esteem felt embarrassed and ashamed.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one out of three sampled residents (Resident 58) had a functioning call light. This deficient practice had a potential to result in inability of the resident to obtain care and services as needed.

Inspectors wroteBased on interview, and record review, the facility staff failed to explain a room change and give notice of room change for one out of three sampled resident's (Resident 337) . This deficient practice had the potential to affect Resident 337's self-esteem and self-worth.

Inspectors wroteBased on interview and record review, the facility failed to create a resident-centered care plan (a set of instructions for providing individualized care to a resident for an identified area of concern) for the target behavior of withdrawal from activities of interest related to the use of mirtazapine (a medication used to treat mental illness) for one of five residents sampled for unnecessary medications (Resident 74.) The deficient practice of failing to create a resident-centered care plan to address problematic behaviors increased the risk that psychotropic medications (medications that affect brain activities associated with mental processes and behavior) used to manage those behaviors would not be periodically reevaluated as intended. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two of three sampled residents (Resident 51 and Resident 36) was free of accident by: A.Failing to properly position Resident 51 while eating lunch. This deficient practice had the potential for Resident 51 to aspirate (food, drink, or foreign objects are breathed into the lungs) and choke (occurs when the airway is obstructed by food, drink, or foreign objects) on her food. B.Failing to ensure a thorough assessment was conducted to address safety needs during bowel and bladder elimination, for one of three residents (Resident 36), who was legally blind (a person with a visual acuity of 20/200 (even with glasses or contacts, reader can only read the first letter at the top of [NAME] chart [a tool to assess visual acuity]). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately account for one dose of a controlled medication (medications with a high potential for abuse) affecting Resident 23 in one of two inspected medication carts (Station 2 Medication Cart.) This deficient practice increased the risk of diversion (any use other than that intended by the prescriber) of controlled medications and that Resident 23 could have received too much or too little medication due to lack of documentation possibly resulting in serious health complications requiring hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to ensure a medication regimen review (MRR - an initial or periodic review of a resident's medication regimen to identify and potential problems with medication dosing, interactions, duplications, etc.) was completed and documented upon admission for one of five residents sampled for unnecessary medications (Resident 42.) The failure to ensure Resident 42's medications were reviewed by a pharmacist and document the review in his medical record upon admission increased the risk that he could have experienced adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have) related to issues with his medication therapy possibly leading to impairment or decline in his mental or physical condition or functional or psychosocial status.

Inspectors wroteBased on observation, interview and record review, the facility failed to observe infection control measures on one of one sampled resident (Resident 2) by failing to perform hand hygiene in between resident contacts. This deficient practice had the potential to transmit infectious microorganisms and increase the risk of infection to the residents.

Inspectors wroteBased on interview and record review, the facility failed to implement their protocol for Antibiotic Stewardship for one of three sampled residents (Resident 62). Resident 62 was prescribed antibiotic drug without meeting the criteria, before being screen for tooth infection (commonly occur when bacteria invade the pulp and spread to surrounding tissues). This deficient practice had the potential for resident to develop antibiotic resistance (not effective to treat infection) from unnecessary or inappropriate antibiotic use.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident who had a history of verbal behavior towards another resident did not verbally abuse and physically abuse other residents for one of two sampled residents (Resident 1). The facility failed to 1. Ensure Resident 2 was supervised continuously to prevent verbally abusing Resident 1 by calling her fat, ugly and bitch as indicated in Interdisciplinary Team Recommendations (IDT- group of professional and direct care staff that have primary responsibility for the development of a plan for the care of a resident) dated 2/12/2024 to prevent another resident-to-resident altercation between Resident 1 and Resident 2 which can lead to verbal and physical abuse. 2. Informed Resident 2's physician to address Resident 2's continued name calling of fat, ugly and bitch towards staff and Resident 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one out of three sampled residents (Resident 1) did not elope (leave without notice or authorization) from the facility on 10/7/2023, between 7:00 p.m. to 9:40 p.m. a. The facility failed to monitor Resident 1 at least every two hours and keep the resident safe in the facility premises. The last time resident was seen was at 7:00 p.m. and the resident was identified missing at 9:40 p.m. on 10/7/2023. b. The facility failed to ensure the front door alarm was audible and functioning between 7:00 p.m. and 9:40 p.m. on 10/7/2023, to allow for a timely response to prevent the elopement of Resident 1. The facility did not have documented evidence the alarm in the front entrance was fully functional on 10/7/2023. The last documented evidence the alarm was checked was on 10/2/2023, five days prior to the incident. [...]

Inspectors wroteBased on observation, interview and record review, for three of four sampled residents who required assistance with activities of daily living (Residents 1, 2 and 3), the facility failed to: 1. Provide a clean and home-like environment to Residents 1 and 2 upon admission. 2. Provide timely care, when Resident 3 used the call light to request assistance in changing the wet, soiled brief. Certified Nurse Assistant (CNA) 2 did not attend to Resident 3. This deficient practice had the potential to place the residents at risk for physical discomfort, an unsafe and unclean environment, with the potential for the spread of infection and the potential to result in skin breakdown and or pressure ulcers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control practices to prevent the development and transmission of communicable diseases and infections. The facility failed to: a. ensure Licensed Vocational Nurse 2 (LVN 2) and Certified Occupational Therapist Assistant (COTA) doff (removed) and discard N95 (a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) mask used for resident care in the Red zone (designated isolation area for residents who tested positive for Corona virus- 19 [COVID-19, a highly contagious infection, caused by a virus that can easily spread from person to person]) prior to exiting the Red zone and after the resident care encounter and don (put on ) a new one. b. [...]