Vineland Post Acute

Inspectors wroteBased on interview and record review, the facility failed to prevent a fall for one of three sampled residents (Resident 1) by failing to create a care plan for the use of a tab alarm (a safety monitoring device connected to the resident's clothes and onto a bed or chair/wheelchair that alarms to notify caregivers once contact is separated). This deficient practice denied Resident 1 an outlined, personalized set of interventions for staff to implement for the specific use of the tab alarm, resulting in Resident 1 encountering a fall and requiring hospitalization for further evaluation.

Inspectors wroteBased on interview and record review, the facility failed to prevent a fall for one of three sampled residents (Resident 1) by failing to: 1). Develop a care plan for the use of a tab alarm (a safety monitoring device connected to the resident's clothes and onto a bed or chair/wheelchair that alarms to notify caregivers once contact is separated). 2). Implement the use of a tab alarm correctly as ordered. These deficient practices resulted in Resident 1 encountering a fall and sustaining an acute fracture which required hospitalization for further evaluation. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of five sample residents (Resident 4) was free from significant medication errors by failing to:1. Ensure Resident 4's physician orders were followed. 2. Ensure licensed nurses administered Resident 4's scheduled medications on time. On 1/13/2026, Resident 4's scheduled 9 a.m. medications were administered at 11:33 a.m. (one hour and 33 minutes after the allowable administration time). 3. Ensure Resident 4 received the docusate sodium oral capsule (a medication, taken by mouth, used to soften stool) 250 milligrams (mg - unit of measurement) before the medication was documented as administered in the resident's Medication Administration Record (MAR). These deficient practices had the potential to cause Resident 4's medical condition to worsen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to readmit one of three sampled residents (Resident 1) from the General Acute Care Hospital (GACH). On 12/17/2025, Resident 1 was discharged to the GACH and was for readmission back to the facility on [DATE]. The facility only readmitted back Resident 1 on 12/23/2025. This deficient practice resulted to a violation of Resident 1's right to be readmitted back to the facility.

Inspectors wroteBased on interview and record review, the facility's licensed nursing staff failed to provide care in accordance with professional standards to three of three sampled residents (Residents 2, 24, and 4) reviewed for insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) use by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (sq - beneath the skin) insulin administration sites. This deficient practice had the potential for adverse effect (unwanted, unintended result) of the same site subcutaneous administration of insulin such as excessive bruising, lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin). Cross reference F760.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plans, and the residents' choices by failing to administer and document skin care treatments per the physician's orders to the urethral (a hollow tube that lets urine, a waste product, leave the body) orifice penile shaft (the external opening where urine exits the urethra), the bilateral upper arms and legs, and the face on multiple shifts in December 2025 for one of one sampled resident (Resident 25). These deficient practices had the potential to result in the development and / or worsening of skin infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received appropriate treatment and services to prevent complications in the feet from medical conditions for one sampled resident (Resident 25) by failing to provide and document treatments per the treatment orders to the right foot- second toe diabetic ulcer (an open sore or wound on the foot of a person with diabetes [DM-a disorder characterized by difficulty in blood sugar control and poor wound healing]) and the left heel diabetic ulcer on multiple shifts in December 2025. These deficient practices had the potential to result in worsening of diabetic foot ulcers and infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment was free of accident hazards for three of four sampled residents (Resident 31,5, and 22) reviewed for accidents by failing to ensure: 1. Resident 31 did not use her personal heating blanket (a blanket with thin, insulated electric wires or heating elements built into the fabric) in the facility without staff supervision. 2. Resident 5's floor mat (its main purpose is to soften the impact if the resident falls out of bed, which helps prevent serious injuries like fractures) did not have any equipment or furniture on top of them. 3. Resident 22 did not self-administer medications left unattended on her overbed table without a physician's order. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure resident's medical records were updated to show documented evidence that advanced directives (a legal document indicating resident preference on end-of-life treatment decisions) were discussed with one of thirteen (13) sampled residents (Resident 26) reviewed for advance directive by failing to ensure Resident Representative was provided with advance directive formulation information. These deficient practices violated the resident's rights and/or representative's right to be fully informed of the option to formulate their advanced directives.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care consistent with professional standards of practice to prevent pressure ulcer/injury (localized damage to the skin and/or underlying tissue usually over a bony prominence) to two of four sampled residents (Residents 24 and 22) reviewed for pressure ulcers by failing to set the low air loss mattress (LALM - a special type of air mattress that uses a constant, gentle flow of air through microscopic holes to keep the skin dry and prevent pressure wounds) according to the resident's weight and per physician's order. These deficient practices had the potential for development and worsening of pressure ulcers/injuries to residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were incontinent of urine received appropriate treatment and services to prevent urinary tract infections (UTI - an infection in the bladder/urinary tract) for two of two sampled residents (Resident 25 and 36) by failing to: 1. Ensure indwelling suprapubic catheter (a hollow tube inserted into the bladder to drain urine through a small opening in the lower abdomen) care was provided per physician's orders and facility policy and procedure (P&P) for Resident 25 on multiple dates in 12/2025. 2. Ensure that Registered Nurse (RN) 1 cleaned the urinary catheter tubing during Resident 25's indwelling catheter care per facility P&P during an indwelling catheter care observation on 12/17/2025. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents with a urostomy (a surgically created opening on the abdomen that allows urine to exit the body) received appropriate treatment and services in accordance with professional standards of practice for one of two sampled residents (Resident 25) by failing to ensure suprapubic catheter (a hollow tube inserted into the bladder to drain urine through a small opening in the lower abdomen) and urostomy site care was provided per physician's orders and facility policy and procedure (P&P) for Resident 25 on multiple dates in 12/2025. These deficient practices had the potential for cross-contamination (the physical movement or transfer of harmful bacteria from one person, object or place to another) and urinary tract infection (UTI - an infection of the urinary system). Cross-reference F690.

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 one of one sampled resident (Resident 4) reviewed for respiratory care by failing to ensure Resident 50's oxygen via nasal cannula (NC - a simple, two-pronged device that delivers extra oxygen to the nose) was not touching the floor. The deficient practice had the potential for residents to develop complications such as shortness of breath and desaturation (low levels of oxygen in the blood) and respiratory infections.

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 one of four sampled residents (Resident 19) reviewed during the Medication Administration task, by failing to: 1. Ensure Licensed Vocational Nurse (LVN) 1 administered medication per the physician prescribed orders when LVN 1 omitted (did not administer) folic acid (a dietary supplement that helps the body make red blood cells) 400 micrograms (mcg - a unit of measurement) on 12/16/2025 during the 9 a.m. routine medication pass (a structured process of administering medications to ensure residents receive medications safely, accurately, and timely). 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five (5) percent (%). Two (2) medication errors out of 28 total opportunities contributed to an overall medication error rate of 7.14%, affecting 2 of four (4) residents observed for medication administration (Resident 19 and 5). The medication errors resulted when the facility failed to: 1. Ensure Licensed Vocational Nurse (LVN) 1 administered medication per the physician prescribed orders when LVN 1 omitted (did not administer) folic acid (a dietary supplement that helps the body make red blood cells) 400 micrograms (mcg - a unit of measurement) on 12/16/2025 during the 9 a.m. routine medication pass (a structured process of administering medications to ensure residents receive medications safely, accurately, and timely) to Resident 19. 2. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to discard from use one opened, expired insulin (a medication used to control high blood sugar levels) Lantus (brand name glargine, a long -acting insulin) Solostar (type of insulin injection device) pen stored at room temperature for Resident 4, in accordance with manufacture's requirements and facility policy and procedures, in one of one medication carts (Medication cart 2). This failure increased the risk for Resident 4 to receive insulin that was compromised (decreased) in efficacy and potency (strength of a medication) for treating Resident 4's blood sugar levels potentially resulting in high or uncontrolled blood sugar levels and diabetic coma (a life-threatening complication that can result from very high blood sugar or very low blood sugar levels).

Inspectors wroteBased on interview and record review, the facility failed to keep updated vaccination (medications used to prevent diseases usually given by injection or by mouth) documentation and administer the 2025/2026 influenza (flu) vaccine (medication used to prevent a highly contagious respiratory illness, which spreads easily through the air or when people touch contaminated surfaces) for one of five sampled residents (Resident 13) reviewed during the Infection Control task. This deficient practice had the potential to result in the spread of influenza among residents, visitors, and staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents' bedrooms meet the requirement of 80 square feet (a unit of measure) per resident in multiple resident bedrooms for 18 of 20 rooms (Rooms 1, 2, 3, 4, 5, 6, 7, 8, 9, 11, 12, 13, 24, 16, 17, 18, 19, and 20). This deficient practice had the potential to result in inadequate space to provide safe nursing care, privacy for the residents, and limit the residents' ability to maneuver personal care devices.

Inspectors wroteBased on observation, interview, and record review, the facility failed to enforce its own policy related to a safe, sanitary environment and infection control when a shared bathroom was noted with overflowing toilet paper in the trash, stool and urine noted inside the toilet bowl for one of three sampled residents (Resident 1). This deficient practice had the potential to transmit infectious microorganisms and increase the risk of infection for the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe and homelike environment by failing to provide room temperatures between 71 degrees Fahrenheit (°F - unit of measure) to 81 °F for seven of 38 sampled residents (Residents 1, 2, 3, 4, 5, 6, and 7). This deficient practice had the potential to result in uncomfortable temperatures related to cold weather compromising the health and safety of Residents 1, 2, 3, 4, 5, 6, and 7.

Inspectors wroteBased on interview and record review, the facility failed to protect one of three sampled residents (Resident 1) from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm by one resident towards another that results in bodily injury) and verbal abuse (harsh and insulting language directed at a person) when on 11/17/2024 at 7 a.m. Resident 2 struck Resident 1, pushed the bedside table towards Resident 1 causing him (Resident 1) to fall on the floor as he attempted to get up from the bed to move out of his (Resident 2) way, and yelling profanities (a type of language that includes dirty words and ideas) at Resident 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 97) was provided a homelike environment by failing to: 1. Ensure the residents' overhead lamp with a pull-on cord had lamp covers on for Residents 42 and 149. 2. Maintain two of two shower rooms when shower floors were observed with peeling paint. 3. Ensure Resident 33's floor mats were in good condition and did not have a torn segment. These deficient practices had the potential to violate the resident's right to living in a safe, comfortable, and homelike environment.

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, equipment, or material that is attached or adjacent to the resident's body, cannot be removed easily by the resident, and restricts the resident's freedom of movement or normal access to his/her body) for three of four sampled residents (Residents 25, 21, and 33) investigated during review of the physical restraints care area when the facility failed to: 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide in-services regarding the use of physical restraints. This deficient practice placed the residents are risk for the inappropriate use of physical restraints.

Inspectors wroteBased on observation, interview and record review, the facility failed to post in a visible and prominent place daily the actual hours worked by licensed and unlicensed nursing staffing directly responsible for resident care per shift. This deficient practice resulted in the actual staffing information not being readily accessible and available to residents and visitors. The deficient practice had the potential to cause inadequate staffing.

Inspectors wroteBased on interview and record review, the facility failed to assess residents' ability to self-administer medication for one of four sampled residents (Resident 36) investigated under the accidents care area when Resident 36 was not reassessed for medication self-administration upon re-admission to the facility and quarterly according to Resident 36's care plan. This deficient practice had the potential for medications errors during self-administration of medication for Resident 36.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain privacy of confidential information for one of one sampled resident (Resident 42) when Licensed Vocational Nurse (LVN 2) left Resident 42's electronic health record (EHR-a digital version of a patient's paper chart) open, unattended, and out of sight of LVN 2. This deficient practice violated Resident 42's right to privacy and confidentiality of their medical records.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for two of five sampled residents (Residents 21 and 33) investigated during review of the physical restraints (any manual method, physical or mechanical device, equipment, or material that is attached or adjacent to the resident's body, cannot be removed easily by the resident, and restricts the resident's freedom of movement or normal access to his/her body) care area when Residents 21 and 33 did not have a care plan for placing the bed against the wall. This deficient practice had the potential to result in inconsistent implementation of the care plan that may lead to a delay in care or lack of delivery of care and services for the residents.

Inspectors wroteBased on interview and record review, the facility failed to address the resident's needs for a home health agency referral prior to discharge for one of one sampled resident (Resident 48) reviewed under discharge care area. This deficient practice placed the resident at risk for not receiving the necessary care and services related to the resident's discharge goals and needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who was incontinent of bladder received the appropriate treatment and services to prevent urinary tract infections (UTI, an infection in the bladder/urinary tract) for one of two sampled residents (Resident 41) being investigated under urinary catheters (a hollow tube inserted into the bladder to drain or collect urine) by failing to ensure the resident's urinary drainage bag was not lying flat on the floor. This deficient practice had the potential to result in Resident 41 to develop a catheter associated urinary tract infection (CAUTI, an infection of the urinary tract caused by a tube [urinary catheter] that has been placed to drain urine from the bladder [an organ inside the body that stores urine until it can be excreted]).

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident who received hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) was assessed after dialysis treatment and to document the assessment for one of one sampled resident (Resident 18) investigated during a review of dialysis care area. This deficient practice had the potential for unidentified complications such as swelling, pain, bleeding, and bruising and had the potential to result in lack of provision of necessary treatment and services after dialysis treatment.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pharmaceutical services to meet the needs of residents for one of five sampled residents (Resident 21) reviewed under the unnecessary medications care area and one of four sampled residents (Resident 15) reviewed under medication administration facility task by: 1. Failing to monitor side effects related to the use of psychotropic medications (a broad class of drugs that affect the mind, emotions, and behaviors) and for signs of bleeding were not conducted on 10/18/2024 for Resident 21. These deficient practices had the potential for side effects to be missed and cause a delay in care for Resident 21. 2. Failing to indicate the aspirin (used as a pain reliever or blood thinner) dosage for Resident 15. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of four sampled residents (Resident 19) observed during medication administration facility task by failing to implement Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDRO, microorganisms, mainly bacteria, that are resistant to one or more classes of antibiotics] that uses targeted isolation gown and glove use during high contact resident care activities) when: 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote the resident rights to examine the results of the state inspection results (a survey to determine compliance with state and federal regulations) of the facility by failing to post survey results in a place that is prominent and accessible (a place where individuals wishing to examine survey results do not have to ask to see them) to residents, family members, and legal representatives of residents. This deficient practice had the potential for residents' and their representatives to not have access to the most recent survey results.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents' bedrooms meet the requirement of 80 square feet (a unit of measure for length) per resident in multiple resident bedrooms for 18 of 20 rooms (Rooms 1, 2, 3, 4, 5, 6, 7, 8, 9, 11, 12, 13, 14, 16, 17, 18, 19, and 20). This deficient practice had the potential to result in inadequate space to provide safe nursing care, privacy for the residents, and limit the residents' ability to maneuver personal care devices.

Inspectors wroteBased on interview and record review, the facility failed to maintain documentation and demonstrate evidence of ongoing Quality Assurance and Performance Improvement (QAPI - is a data driven and proactive approach to quality improvement) program by: 1. Failing to provide documentation of the written QAPI plan (guides the nursing home's quality efforts and serves as the main document to support implementation of QAPI). 2. Failing to provide documentation of data collection and analysis at regular intervals to include care plan, weights, and narcotics, which were identified by the facility as a problem issue in the facility. These deficient practices had the potential for systemic failures to go uncorrected and no improvement to the facility's delivery of care for all residents.

Inspectors wroteBased on interview, and record review, the facility failed to implement infection control policy and procedure by failing to implement and monitor the measures the facility had in place for water testing and monitoring of water management plan (identify hazardous conditions and take steps to minimize the growth and transmission of Legionella [a bacteria that can cause Legionnaire's disease (a serious type of pneumonia [an infection that inflames the air sacs in one or both lungs]) and Pontiac fever (a mild flu-like illness caused by exposure to Legionella bacteria)] and other waterborne pathogens in building water system) for 11 out of 11 months (12/19/2022 to 11/12/2023). [...]

Inspectors wroteb. A review of Resident 36's admission Record indicated the facility admitted the resident on 10/20/2023 with diagnoses including cerebral infarction (also known as an ischemic stroke - the disrupted blood flow to the brain due to problems with the blood vessels that supply it) and paroxysmal atrial fibrillation (a type of abnormal heartbeat that occurs intermittently and stops on its own within seven days). A review of Resident 36's History and Physical, dated 10/23/2023, indicated the resident had fluctuating capacity to understand and make decisions. A review of Resident 36's MDS, dated [DATE], indicated the resident had the ability to usually understand others and usually make self-understood. The MDS the resident an anticoagulant used during the last seven days since admission. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents receive care consistent with professional standards of practice to prevent pressure ulcers (a skin injury that breaks down the skin and underlying tissue) from developing for two of two sampled residents (Resident 12 and 139), by: 1. Failing to offload (minimizing or removing weight placed on the foot to help prevent and heal ulcers) a resident's heels while the resident was in bed as ordered by the physician for Resident 12. 2. Failing to develop and implement an individualized plan of care for Resident 139 who had an unstageable full thickness skin or tissue loss - depth unknown (UTD, when the stage is unclear) on the sacral coccyx (tailbone). These deficient practices placed the resident at risk of discomfort and development of new pressure ulcers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder and admitted with an indwelling urinary catheter, will be assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization was necessary to prevent urinary tract infections (UTI, common infections that happen when bacteria, often from the skin or rectum, enter the urethra [duct that transmits urine from the bladder to the exterior of the body during urination], and infect the urinary tract) for one of four sampled residents (Resident 36) by failing to: 1. Complete indwelling urinary catheter assessment timely for Resident 36. 2. Accurately assess the genitourinary system for Resident 36, who had an indwelling urinary catheter. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a presence of a registered nurse (RN) onsite at least 8 hours a day, 7 days a week. This deficient practice had the potential to result in the provision of substandard quality of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 20) was free from unnecessary medication when Licensed Vocational Nurse 3 (LVN 3) was observed during medication pass administering docusate sodium (a stool softener) and lactulose (a synthetic sugar used to treat constipation) without verifying if the resident had loose stool per doctors' orders. On 11/1/2023, 11/5/2023, 11/8/2023, 11/9/2023, and 11/10/2023, Resident 20 had loose stool or diarrhea. This deficient practice resulted in Resident 20 to continue to have loose stools and had the potential of dehydrating (cause a person to lose a large amount of water) the resident.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was free from unnecessary drugs for two of five sampled residents (Residents 14 and 16) investigated under unnecessary medications by failing to: 1. Provide nonpharmacological interventions (any type of health intervention which is not primarily based on medication) prior to administering as needed (prn) lorazepam (used to treat anxiety) to Resident 14. 2. Monitor an objective and measurable behavioral manifestation for the use of Risperdal for Resident 16. These deficient practices had the potential to result in adverse reaction or impairment in the resident's mental and/or physical condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe storage and handling of medications by failing to: 1. Destroy disposed medications in an unusable form when disposed medications were observed in one of two medication carts (Med Cart 1). This deficient practice had the potential to result in loss, diversion, or accidental exposure. 2. Label influenza medication vial (a multi-use vial) with date it was opened inside one of one medication refrigerator (Med Ref 1). This deficient practice had the potential to result in administration of ineffective medication.

Inspectors wroteBased on observation, interview, and record review, the kitchen staff failed to ensure the proper storage of food in accordance with professional standards for food service safety for 35 out of 38 residents by: 1. Failing to label an opened container of oatmeal found in the dry storage area with the date it was opened. 2. Failing to label the following food items found inside the designated resident refrigerator with the date it was received, the date it was opened, and a resident identifier: a. Bottle of ketchup b. Container of strawberry Activia yogurt c. Bottle of Ensure (a meal replacement powder providing complete, balanced nutrition) d. Yema e. Container of [NAME] ice cream f. Box of [NAME]-Dazs ice cream g. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care in a manner that maintained or enhanced a resident's dignity and respect for one of two sampled residents (Resident 20) by failing to ensure Resident 20's indwelling urinary catheter bag (also known as Foley catheter, is a hollow flexible tube inserted in the bladder through the urethra to drain urine) was covered with a privacy bag. This deficient practice had the potential to affect resident's sense of self-worth and self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light was within reach of the resident for two of three sampled residents (Resident 4 and Resident 21). This deficient practice had the potential to result in the residents not being able to call for facility staff assistance and had the potential to result in a delay in or lack of necessary care and services that can negatively affect the resident's comfort and well-being.

Inspectors wroteBased on interview and record review, the facility failed to provide documented evidence that information regarding advance directives (AD - written statement of a person's wishes regarding medical treatment made to ensure those wishes were carried out should the person be unable to communicate to a doctor) was discussed to the resident and/or the resident's representative for one of five sampled residents (Resident 28) investigated under advance directives. This deficient practice had the potential to delay emergency treatment or the potential to force emergency, life-sustaining procedures against the resident's personal preferences and or violate the resident's rights and/or representative's right to be fully informed of the option to formulate their advance directives.

Inspectors wroteBased on interview and record review the facility failed to refer one out of five sampled residents (Resident 11), who had a positive Preadmission Screening and Resident Review I (PASRR- a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) to the appropriate state designated authority for a level II PASRR (a person-centered evaluation that is completed for anyone identified by the Level 1 Screening as having, or suspected of having, a PASRR condition, i.e., serious mental illness [SMI], intellectual disability [ID], developmental disability [DD], or related condition [RC]) evaluation. This deficient practice had the potential to result in inappropriate placement and unidentified specialized services for Resident 11.

Inspectors wroteBased on interview, and record review the facility failed to ensure a resident who was not able to carry out activities of daily living (ADLs) received the necessary services to maintain good personal hygiene for one of three sampled resident (Resident 21). This deficient practice had the potential for Resident 27 having poor grooming and personal hygiene and could negatively impact the resident`s quality of life and self-esteem.

Inspectors wroteBased on interview and record review the facility failed to ensure one of three sampled resident (Resident 20) received treatment and care in accordance with professional standards of practice to meet the resident's physical, mental, and psychosocial needs by failing to monitor ammonia levels for Resident 20, who was receiving lactulose (a synthetic sugar used to treat constipation) three times a day for hyper ammonia (a metabolic condition characterized by raised levels of ammonia [a waste product that's normally processed in your liver and is removed through your urine]). This deficient practice had the potential for Resident 20 to have an abnormal ammonia level.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure licensed nurses documented nonpharmacological interventions (interventions that do not directly involve medication) attempted prior to administering an opioid (class of drugs used to reduce pain) to treat a resident's pain for one (Resident 89) out of one sampled resident investigated for pain management. This deficient practice had the potential to increase Resident 89's risk of experiencing side effects and adverse reaction (an unexpected or unintended effect suspected to be caused by a medicine) to the use of an opioid.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure Licensed Vocational Nurse 3 (LVN 3) had the competency skills to care for one out of three sampled resident (Resident 20) when LVN 3 was observed during medication pass administering docusate sodium (a stool softener) and lactulose (a synthetic sugar used to treat constipation) without checking if the resident had loose stools. This deficient practice had the potential for Resident 20 to continue to have loose stools and placed the resident at risk for dehydration.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a medication error rate of less than five percent. There were two medication errors during medication observation pass out of 28 opportunities resulting in a 7.14% error rate. This deficient practice placed the resident at risk for potential adverse effects of the medication due to not administering as ordered by the physician.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents' bedrooms meet the requirement of 80 square feet (a unit of measure) per resident in multiple resident bedrooms for 18 of 20 rooms (Rooms 1, 2, 3, 4, 5, 6, 7, 8, 9, 11, 12, 13, 14, 16, 17, 18, 19, and 20). This deficient practice had the potential to result in inadequate space to provide safe nursing care, privacy for the residents, and limit the residents' ability to maneuver personal care devices.