Vintage Faire Nursing & Rehabilitation Center

Inspectors wroteBased on interview and record review, the facility failed to ensure a Registered Dietitian (RD -licensed healthcare expert who handles patient nutrition) was on site enough time to carry out the responsibilities of kitchen and dietary oversight for a census of 94 residents who eat from the kitchen when the RD did not conduct any kitchen or sanitation audits (evaluation of food service operation to ensure compliance with food safety laws and hygiene standards), in-service trainings (education about food safety to employees) and observation of meal preparations or tray line (food assembly location used in healthcare facilities) services. This failure placed the residents at risk of compromised food safety, insufficient nutritional care and risk for foodborne illness (any sickness caused by eating harmful bacteria, viruses or toxic chemicals).

Inspectors wroteBased on interview and record review, the facility failed to ensure professional standards of practice were met for two of five sampled residents (Resident 4 and Resident 5) when Resident 4 and Resident 5's Registered Dieticians (RD) nutritional assessments were not completed and the RD did not complete in-person nutritional assessments on the residents at the facility. This failure had the potential to negatively impact Resident 4 and Resident 5's overall physical and nutritional health.

Inspectors wroteBased on observation and interview, the facility failed to ensure dignity was maintained for one of five sampled residents (Resident 1) when personal hygiene items (attends - single-use, highly absorbent garments designed to manage, contain, and absorb urine and fecal leaks for individuals with loss of bladder or bowel control, and personal hygiene wipes - pre-moistened, disposable cloths designed for gentle, effective cleaning of the sensitive genital and anal areas) were left on Resident 1 small 3 drawer dresser in public view. This failure had the potential to negatively effect Resident 1's right to maintain a dignified existence, negatively affecting Resident 1's psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled resident (Resident 4) whom received enteral (a method of delivering liquid nutrition directly into the stomach or small intestine using a tube) feedings was positioned correctly during enteral feeding when, Resident 4's head of bed position was at approximately 20 to 25 degree angle while receiving nutrition via an enteral feeding. This failure had the potential to negatively effect Resident 4's health and well-being by placing Resident 4 at risk for aspirating (breathing in) her enteral feeding potentially resulting in aspiration pneumonia (a lung infection that occurs when food, liquid, saliva, or vomit is accidentally breathed into the airways and lungs).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of five sampled resident (Resident 2) received appropriate respiratory care as needed when, Resident 2 was receiving oxygen at 3 liters per minute (LPM - a unit of measurement for the rate of flow of oxygen) via a nasal canula (NC - a lightweight, flexible tube with two small prongs that sit inside the nostrils to deliver supplemental oxygen) and there was no physician's order for oxygen use in place. This failure had the potential to negatively affect Resident 2's health and well-being with negative health consequences such as lung and brain damage related to receiving unordered, unmonitored oxygen therapy.

Inspectors wroteBased on observation and interview, the facility to ensure food was stored safely for one of five sampled residents (Resident 5) when, Resident 5 had nine single serve [brand name] yogurts stored on Resident 5's overbed table for three days. This failure had the potential to cause foodborne illness, with a potential to negatively effect Resident 5's health and well-being if consumed.

Inspectors wroteBased on interview and record review the facility failed to ensure three of three (3) current sampled residents (Resident 1, Resident 4, and Resident 5), had person-centered care plans (a personalized document outlining a resident's health, support, and personal needs) when:1. Resident 1 did not have a care plan developed and implemented for diagnoses of hypertension (HTN, High blood pressure-the force of blood against your artery walls is consistently too high, making your heart work harder), medication for depression (feelings of sadness), and medication for prevention of blood clots (pooling of blood).2. Resident 4 did not have a care plan developed and implemented for diagnoses of HTN, chest pain, and a stroke (blood flow to the brain is suddenly interrupted, causing brain cells to die due to lack of oxygen). 3. [...]

Inspectors wroteBased on interview and record review the facility failed to report to the Department an injury of unknown source in accordance with the facility's abuse policy and procedure (P&P) for one of four sampled residents (Resident 4) when on 10/30/25, Resident 4 was found with an unexplainable bruise and bump to the left side of her forehead. This failure denied the Department the ability to conduct a timely investigation and placed Resident 4 at risk for abuse. In addition, the facility failed to comply with state and federal reporting regulations.

Inspectors wroteBased on interview and record review, the facility failed to timely review and revise person-centered comprehensive care plans (a detailed document outlining a person's healthcare needs, goals, and the specific care and support they will receive, including how, when and by whom) for 3 of 27 sampled residents (Residents 25, 28, and 47) when, 1. Resident 25's comprehensive care plan for chronic pain lacked personalized non-pharmacological (healthcare approaches that don't primarily rely on medication) interventions that were to be used prior to offering pain medications, 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate treatment and services were provided in a timely manner to three of twenty-seven sampled residents (Resident 3, Resident 25, and Resident 28) when: 1. Resident 3's physician order for therapy to evaluate for possible use of a brace to both contracted hands/fingers was not carried out in a timely manner; 2. Resident 25's physician order for therapy to evaluate for possible use of a brace for left hand contracture was not carried out in a timely manner; and, 3. Resident 28's contracted left hand was not assessed of the need for contracture management after developing a pressure ulcer from the contracture on 3/29/25. These failures placed Resident 3, Resident 25, and Resident 28 at risk for contracted hands/fingers to worsen and a pressure ulcer to develop or worsen.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of twenty-seven residents' (Resident 17) medical records were complete and accurate when Resident 17's dialysis (a medical treatment that removes waste products and excess fluid from the blood when the kidneys are not functioning properly) medical record was in another resident's (Resident 21) clinical records. This failure had the potential to result in Resident 17's private health care information and personal information being disclosed to the unauthorized person.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure assessments were completed accurately for 2 or 27 sampled residents (Resident 25 and Resident 28), when: 1. Resident 25's and Resident 28's weekly nursing evaluations were not completed accurately for the presence of pain and pressure ulcers (localized damage to the skin and underlying soft tissue, usually over a bony prominence, caused by prolonged or severe pressure); and 2. Resident 28's change of condition evaluation did not accurately reflect the location and/or description of the pressure ulcer located on the left thumb. These failures had the potential for Resident 25 to have inadequate pain relief and emotional distress and for Resident 28 to have delayed wound healing.

Inspectors wroteBased on interview and record review, the facility failed to accurately complete a Pre-admission Screening and Resident Review (PASRR, a required assessment for individuals with mental illness, intellectual or developmental disabilities, or related conditions, so that a determination of need, appropriate setting, and a set of recommendations for services to be included in the individual's plan of care is provided) for one of twenty-seven sampled residents (Resident 46) when, Resident 46's level I PASRR did not reflect his diagnosis of bipolar (a mental disorder characterized by periods of extreme mood swings, and causes shifts in mood, energy, activity levels, and concentration) and diagnosis of lack of expected normal psychological development in childhood (refers to a developmental delay in one or more areas such as a way a person thinks, interacts with and communicates with others [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure care plans were developed and implemented for 1 of 27 sampled residents (Resident 79) when, Resident 79's care plan for depression was not developed and implemented. These failures had the potential to negatively affect Resident 79's psycho-social well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of twenty-seven sampled residents (Resident 64) received activities that met their interests and needs when Resident 64 did not attend group activities and in room activities had not been provided since 9/9/24. This failure had the potential to affect Resident 64's psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to provide appropriate blood glucose (BG; sugar in the blood) monitoring for a diabetic (blood sugar disease) condition for one of twenty-seven sampled residents (Resident 77) when, Resident 77's blood sugar check order did not contain monitoring parameters (when to notify the provider) related to the blood sugar readings and Resident 77's high blood sugar readings were not reported to the Medical Doctor (MD). This failure could have contributed to unsafe blood glucose monitoring without proper notification of the medical doctor and could have impacted the Resident 77 well-being, including the wound healing process.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that one of twenty-seven sampled residents (Resident 28) received the necessary treatment and services consistent with professional standard of practices to prevent a pressure ulcer (PU - localized damage to the skin and underlying soft tissue, usually over a bony prominence, caused by prolonged or severe pressure) from developing and to promote healing when: 1. Interventions were not developed to prevent a PU from occurring to Resident 28's left contracted (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) hand; and 2. A wound evaluation was not completed when a PU was identified to Resident 28's left hand; and 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a census of 89 residents were safe from accidental hazards when: 1. Resident 63 kept cigarettes and a lighter in her purse, unsecured in her room, and received oxygen (O2) via nasal canula (NC- tubing that delivers oxygen into resident's nose); 2. Smoking paraphernalia (items used to smoke which may include cigarette wrapper or cigarette paper, and tobacco) items were observed to be unsecured and on top of Resident 65's bed and Resident 65 did not have a lock box in the room; and These failures exposed residents, staff, and visitors to be at risk of burns, fire, and/or explosion while in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 2 of 27 sampled residents' (Resident 30 and Resident 79) nutrition and hydration requirements were met when: 1. Nutritional recommendations of the Registered Dietitian (RD) to address Resident 30's significant weight loss were not followed. 2. Resident 79's significant weight loss was not addressed and monitored. These failures had the potential to result in Resident 30 not to receive the necessary intervention to prevent further weight loss and Resident 79's continued weight loss, negatively affecting Resident 30 and Resident 79's health and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of twenty-seven sampled residents (Resident 77) who received parenteral fluids (delivery of fluid or medication through a vein) was provided services consistent with professional standards of practices when: 1. Resident 77's PICC (Peripherally Inserted Central Catheter; a thin, soft, long catheter (tube) that is inserted into a vein in the arm with the tip of the catheter positioned in a large vein that carries blood into the heart to provide medications) clear dressing was not changed within seven days according to the physician order; and, 2. There was no care plan created in relation to Resident 77's PICC line. These failures had the potential to result in a PICC line malfunction and/or infection for Resident 77.

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify, assess and treat pain to the extent possible for one of twenty-seven sampled residents (Resident 25), when 1. Resident 25 did not receive a pain medication as ordered when he had rated his pain level between 4-6 (on a pain scale of 0- 10 ( 0 = no pain and 10 = severe pain), and 2. Resident 25 did not have a pain regimen for pain level of 7 to 10. These failures resulted in the potential for inadequate pain relief and emotional distress for Resident 25.

Inspectors wroteBased on observation, interview, and record review, the Attending Physician/Medical Doctor/Medical Director (MD) failed to provide blood glucose (sugar, BG) monitoring parameters for diabetic (blood sugar disease) condition, and physician oversight for one of twenty-seven sampled residents (Resident 77) when, Resident 77's blood sugar monitoring orders from February 2025 and March 2025 did not provide parameters for management of blood sugar. This failure could have contributed to unsafe blood sugar monitoring with high or low blood sugar levels.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that two of three certified nursing assistants (CNA 1 and CNA 2) had the appropriate competency to provide individualized resident care for a census of 89 residents when, CNA 1 and CNA 2 were not aware of how to access the resident [NAME] (a concise, centralized, and easily accessible record of essential resident information, used by staff to quickly summarize resident care and guide daily actions) in the residents medical record. This failure had the potential for resident centered interventions not to be implemented with the risk for residents not to meet their identified goals or suffer declines in their Activities of Daily Living.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate behavioral health treatment and services to meet the psychosocial needs for one of twenty-seven sampled residents (Resident 46), when 1. Resident 46's mental health consult notes and therapy recommendations via telehealth care (use of technology, video, or phone to provide long distance mental health care) dated 9/19/24 were not communicated to the Medical Doctor (MD) and the licensed nursing (LN) staff; and, 2. Resident 46 displayed episodes of anger and was refusing his treatments and medications, including his medication, and the resident's psychological evaluation (a comprehensive evaluation focused on the diagnosis, treatment and prevention of mental, emotional and behavioral disorders) and/or consultation was not provided as ordered by the physician on 2/13/25. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure the psychosocial well-being of one resident (Resident 79), in a sample of 27, when there was no documented evidence of Social Services following up with Resident 79 following initiation of three separate psychotropic (drugs that affect the mind and brain to treat mental health conditions) medication. These failures, due to lack of documented follow-up from social services, had the potential to negatively effect Resident 79's mental health and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow safe disposition and destruction of controlled prescription medications (a drug with the potential for misuse and abuse) based on facility's policy with a census of 89 when controlled medication disposal bins or containers (where unused prescribed medications were held for ultimate safe disposal) were not secured, sealed, and rendered unusable (medication that has been altered in a way that it was no longer available for use) to prevent unauthorized access and risk of drug diversion (unsafe drug acquisition and unauthorized use by someone other than for whom it is prescribed) when stored in the shared Interim Director of Nursing (DON) and Assistant Director of Nursing (ADON) office. These failures had the potential to contribute to unsafe medication handling and risk of drug diversion.

Inspectors wrote3. A review of Resident 25's admission RECORD, indicated Resident 25 was admitted to the facility with a diagnosis that included anxiety disorder, unspecified. A record review of Resident 25's physician order dated 1/20/25 indicated Mirtazapine (a medication used to treat depression) 7.5mg (milligram - a metric unit of mass) 1 tablet at bedtime for appetite stimulation related to depression. A record review of Resident 25's clinical document titled; Psychotropic/Behavior Management IDT Review dated 3/14/25 indicated the Interdisciplinary team (IDT - group of professionals from different disciplines or fields who work together on a project or task, leveraging their unique expertise to achieve a common goal) made a recommendation to discontinue the Mirtazapine. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure accurate medication labeling practices were followed when a blood pressure (BP-the force of blood pushing against the walls of arteries as heart pumps blood throughout the body) medication label was not updated with a new hold parameter (a number reflecting a change in the order for direction of use) for one resident (Resident 440) with a census of 89. This failure had the potential for Resident 440 to not receive blood pressure medication as prescribed to manage fluctuations in blood pressure.

Inspectors wroteBased on interview and record review the facility failed to develop and implement a coordinated plan of care with Hospice (provides comfort and support for individuals facing a terminal illness, focusing on improving quality of life during the final stages of life) for two of two sampled residents (Resident 28 and Resident 47), when 1. The facility did not invite or include Resident 28's and Resident 47's hospice staff in the facility's interdisciplinary team (IDT - group of professionals from different disciplines or fields who work together to assess, coordinate, and plan resident care) meetings for care coordination, 2. The facility did not ensure that the hospice agencies nurses progress notes, IDT notes, and plan of care updates were available to the facility staff for Resident 28 and Resident 47. [...]

Inspectors wroteBased on interview, and record review the facility failed to ensure one of five sampled residents (Resident 23) received vaccine (a process whereby a person is made resistant to a disease by the administration of vaccines) education prior to administration of Pneumococcal (vaccine to prevent pneumonia) and Influenza (a contagious respiratory illness cause by influenza viruses) vaccines. These failures resulted in Resident 23 to not be aware or informed of the benefits, risks, and potential side effects of the immunizations, prior to receiving the vaccines.

Inspectors wroteBased on interview and record review, the facility failed to ensure quality care was given to one of four sampled residents (Resident 1), when the Medical Doctor (MD) was not notified when Resident 1 had six days of low body temperature. This failure could have contributed to Resident 1 being found unresponsive on 2/1/25 and transferred to [ACUTE CARE HOSPITAL NAME] for further evaluation and treatment in the Hospital Intensive Care Unit (ICU).

Inspectors wroteBased on interview, and record review, the facility failed to maintain the hydration status for 1 of 4 sampled residents (Resident 1) when Resident 1's fluid intake was not monitored and documented accurately. This failure resulted in Resident 1 being hospitalized for dehydration (a condition that occurs when the body loses too much water and other fluids that it needs to work properly) and an electrolyte imbalance (the body's mineral levels are too high or too low).

Inspectors wroteBased on interview, and record review, the facility failed to ensure the Physician Orders for Life-Sustaining Treatment [POLST- a legal document communicating the resident's medical wishes for end-of-life care] was completed accurately for 7 of 25 sampled residents (Resident 22, Resident 62, Resident 79, Resident 491, Resident 3, Resident 63, and Resident 78), when: 1. Resident 22's POLST did not contain the resident representative (RR- the person who acts on behalf of the Resident) contact information, 2. Resident 62's POLST did not include Resident 62's contact information; and the date Resident 62 signed was missing, 3. Resident 491's POLST did not contain Resident 491's conservator (CON) 1 (a person who manages the resident's financial and healthcare issues when the resident is not able) contact information; and the date signed was missing, 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a clean, comfortable, and homelike environment for 4 out of 46 facility rooms (Room A, Room B, Room C and Room D) when: 1. The floor in Room A, under the nightstand, next to the first bed, contained stained, broken tiles and trash, 2. Room B had two areas of deep scratches in the drywall behind the first bed, 3. Room C had two deep scratches in the dry wall behind the second bed, the bathroom door had a broken, jagged edged striker plate (protective plastic disc used to prevent the bedroom doorknob breaking the bathroom door) partially covering a splintered, cracked area in the door, the bathroom sink was pulling away from the wall; and, 4. The toilet in Room D had been leaking for an unknown period of time. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure necessary care and services were provided for 2 of 25 sampled residents (Resident 3 and Resident 8), when: 1. Resident 3 and Resident 8's nails were not cleaned and trimmed; and 2. Resident 3 did not receive showers as per her shower schedule. These failures had the potential for Resident 3 and Resident 8 to experience decreased self esteem from poor hygiene, poor skin integrity, and scratches which could lead to infection for Resident 8.

Inspectors wrote2c. A review of Resident 53's admission Record indicated Resident 53 was admitted to the facility in 2024 with diagnoses including acute respiratory failure with hypoxia (an absence of enough oxygen in the tissues to sustain bodily functions), acute respiratory failure with hypercapnia (excessive carbon dioxide in the bloodstream), and chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs) with (acute) exacerbation. During an observation on 4/22/24, at 9:12 a.m., Resident 53 was observed lying in bed receiving oxygen at three LPM via nasal cannula via an oxygen concentrator. No oxygen in use signs were posted outside Resident 53's room. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe medication disposition practices for a census of 91 residents, when discontinued and discharged medications were stored and disposed of with no documentation and without cosignatory of the licensed staff. This unsafe practice could put the facility at risk of drug diversion and prescription medications mishandling.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe medication use and monitoring in three out of seven residents (Resident 342, Resident 33, Resident 343) reviewed for unnecessary drug use when: 1. Resident 342's high risk blood thinner medication, called Apixaban (or Eliquis, drug used to prevent blood clot formation and can cause bleeding) was not monitored and care planned (Care Plan, a document that listss resident's medical issues and how the nursing staff should monitor and care for the resident) for safe use, 2. Resident 33's heart medication called metoprolol (a medication used to lower blood pressure and heartbeat) was not monitored according to hold parameters per doctor's order, 3. Resident 33's pain medication called Celebrex was continued upon admission without reassessment of its safe use and potential for side effects; and, 4. [...]

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure safe use and monitoring of psychotropic medications (drugs used to treat mental health such as anxiety, depression, or anger outburst) in four out of seven residents (Resident 33, Resident 342, Resident 343, and Resident 390) reviewed for unnecessary medication use (when medications are used without adequate monitoring or without adequate indication) when: 1. Resident 33's antidepressant medication called citalopram (or Celexa, a drug used to treat depression and anxiety) was not monitored for resident specific symptoms and behaviors that affected the mental health of the resident, 2. Resident 342's antidepressant medication called Effexor (or venlafaxine, a mood elevating drug that helps with depression and anxiety) was not monitored for resident specific behavior or symptoms of depression and anxiety, 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe medication storage practices in three out of three medication rooms and two out of the four medication and treatment carts for a census of 91 when: 1. The Automated Dispensing Device (or ADD, an electronic medication storage device that controls access and usage of prescription medications) was stored in the same room as a hopper (a disposal and washing/rinsing device where bedpans [container used to collect urine or feces, shaped to fit under a person lying or sitting in bed], urinals [urine bottle, a bottle for urination for residents who find it impossible or difficult to get out of bed to urinate], and other body fluids were disposed), and the room was accessible to nursing assistants. The room's temperature log was not consistently monitored or documented, 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the therapeutic diets prescribed by the physician were followed for 3 of 90 residents receiving meals (Resident 5, Resident 344, and Resident 8) when: 1. Salt packets were added to Resident 5's meal tray, 2. Resident 344 did not receive his prescribed diet texture; and, 3. Resident 8's therapeutic diet order change was not confirmed/obtained from the physician. These failures had the potential to adversely affect Resident 5 and Resident 8's health and well-being and put Resident 344 at risk of choking or decreased oral intake which could lead to weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage practices for a total of 90 residents who received food from the kitchen when: 1. Food items available for use were stored in undated and unlabeled containers, 2 The unit snack/nourishment refrigerator contained ice buildup in the freezer, food debris, and stains, 3. The unit snack/nourishment refrigerator contained moldy foods and foods past their use by dates; and, 4. The unit snack/nourishment refrigerator did not have a temperature log. These failures had the potential to expose the facility residents to expired foods and placed these residents at risk of food borne illnesses (eating or drinking something that is contaminated with germs that can cause illness).

Inspectors wroteBased on interview, and record review, the facility staff failed to maintain complete and accurate medical records in accordance with accepted professional standards for 3 of 25 sampled residents (Resident 390, Resident 3, and Resident 8) when: 1. Resident 390's wound care was not documented in a timely manner on 4/14/24, 2. Resident 3 and Resident 8's records indicated nail care was provided, but Resident 3 and Resident 8 had long dirty nails; and, 3. Resident 3's shower schedule in the electronic and physical record did not match. These deficient practices had the potential to result in confusion in the care and services for Resident 390 and placed the resident at risk for not receiving appropriate care due to inaccurate and incomplete documentation, and resulted in inaccurate medical records for Resident 3 and Resident 8, and missed showers for Resident 3.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents' needs were accommodated promptly for 2 of 25 sampled residents( Resident 190 and Resident 63) when call lights were not answered in a timely manner. This failure resulted in needs not being met promptly and had the potential to cause psychosocial and/or physical harm for Resident 190, and Resident 63.

Inspectors wroteBased on observation , interview, and record review, the facility failed to ensure a comprehensive care plan was developed and revised for 3 of 25 sampled residents (Resident 6, Resident 8, and Resident 16), when: 1. A care plan was not developed for Resident 6 and Resident 16's oxygen therapy use; and, 2. Resident 8's nutrition care plan was not revised. These failures had the potential for Resident 6, Resident 8, and Resident 16's plan of care not being followed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer parenteral fluids (fluids/medications administered through the vein, also known as IV or intravenous) within the professional standards of practice for two of five residents on IV therapy (Resident 22 and Resident 191) when: 1. Resident 22's IV tubing (plastic tubing that delivers the medication to the vein) did not have a cap (a covering device that covers the opening of the tubing and reduces the risk of infection to the resident) at the end of the tubing when the IV tubing was not in use; and, 2. Resident 191's PICC line (Peripherally Inserted Central Catheter: a long, thin tube that is inserted through a vein in the arm, neck or leg and passed through to the larger veins near the heart for long term intravenous (IV) antibiotics, nutrition, medication or blood draws) dressing was not changed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food preferences were honored for 3 of 90 residents (Resident 23, Resident 41, and Resident 344) receiving meals from the kitchen, when pasta was added to Resident 23's meal tray, salt packets were added to Resident 41's meal tray, and rice was served to Resident 344. These failures had the potential to result in unintended weight loss and other adverse health effects for Resident 23, Resident 41, and Resident 344.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their infection control policies and procedures when there was no signage posted on the door or the wall outside of Resident 64's room indicating the type of transmission-based precautions (TBP- precautions implemented based upon means of transmission to prevent or control the spread of germs) and required personal protective equipment (PPE- gowns, gloves, eye protection, facemasks or respirators used to prevent the spread of germs) needed prior to entering Resident 64's room. This failure could have resulted in the spread of infection and the need for additional medical interventions (medications/treatments) with a census of 91 residents. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure services provided to one of three sampled residents (Resident 1) met professional standards of quality, when Resident 1's insulins ( medication used to treat high blood sugar levels) were not administered timely. This failure resulted in delayed medication administration and had the potential for the medication to not be fully effective and to cause high blood sugar levels for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to notify one of 3 sampled resident's (Resident 1) emergency contact person/s of Resident 1's change in condition (COC), when Resident 1 had a low blood sugar (BS) level, fell with resulting head injury, became unresponsive, and was sent to the hospital on [DATE]. This failure resulted in Resident 1's family being uninformed and unaware of Resident 1's COC.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a reasonable accommodation of needs for 1 out of 4 sampled residents (Resident 3) when Resident 3 needed assistance and was unable to access the call light. This failure caused Resident 3's needs to be unmet and had the potential to cause physical and psychosocial harm.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 2 out of 4 sampled residents, (Resident 2 and Resident 4), were assisted with nail care as a part of their activities of daily living (ADL's, normal daily functions related to personal care needs) when staff did not trim their fingernails. These failures had the potential for Resident 2 and Resident 4 to acquire an infection or sustain injuries related to having long, jagged, and unclean nails.

Inspectors wroteBased on interview and record review the facility failed to ensure the facility's arbitration agreement (a document that designates a third party to resolve a dispute between others), that was presented to residents to sign, contained the selection of a neutral arbitrator (an impartial, or unbiased third-party decision maker, contracted with, and agreed to by both parties to resolve their dispute) and a venue (a location to carry out the arbitration proceedings that was agreed upon by both parties) that was convenient to both parties for a census of 90. This deficient practice had the potential for facility residents to be misinformed and to potentially negatively affect the ability to resolve disputes fairly.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe and comfortable homelike environment when: 1. No follow up occurred after two of three residents (Resident 73 and Resident 45) reported missing personal property; 2. One of three residents (Resident 73) inventory check list was incomplete; 3. One of thirty sampled residents (Resident 59) bedside table had a large hole in it; 4. Meals were served on trays for ten of ten residents eating in the dining room; and, 5. Towels were used as clothing protectors during mealtime for seven of ten residents eating in the dining room. These failures removed residents' rights to a dignified homelike environment, with the potential to result in psychosocial harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet the interests and support the physical, mental, and psychosocial needs for three of thirty sampled residents (Resident 75, Resident 63, and Resident 83) when in-room activities were not provided for the three residents who remained in their own rooms and were unable to attend out-of-room activities. This failure had the potential to affect the psychosocial needs and wellbeing of Resident 75, Resident 83, and Resident 63.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure a safe environment when: A smoking assessment and smoking care plan was not completed in a timely manner for 2 of 15 residents who smoked cigarettes, (Resident 81 and Resident 244). These failures had the potential to result in smoking accidents for Resident 81 and Resident 244.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure respiratory care was provided in accordance with professional standards of practice for four out of four residents sampled (Resident 17, Resident 45, Resident 59, and Resident 43) when: 1. Resident 17 and Resident 45's oxygen flow rates did not match their physician orders; 2. Resident 45's oxygen humidifier bottle (medical device used to increase moisture and decrease dryness from supplemental oxygen) was empty; 3. Resident 17's, Resident 43's, and Resident 45's nasal cannula (flexible tubing that sits inside the nostrils and delivers oxygen) was not dated; 4. No oxygen care plan was created for Resident 17; and, 5. Resident 43, Resident 59, and Resident 45's oxygen concentrator (a machine used to deliver extra oxygen to a person) filters were covered in dust/debris; [...]

Inspectors wroteBased on interview, record review, and facility policy and procedure review, the facility failed to ensure notification requirements were implemented for a census of 90, when: 1. Residents, Resident Representatives, and Staff were not notified of new cases of COVID-19; and, 2. Required elements of notification were not present in the facility policy and procedure and the notifications of COVID-19. These failures resulted in residents, Resident Representatives, and Staff not being notified in a timely manner of the current status of COVID-19 in the facility and not being fully informed due to missing elements in the notification process, placing residents, Resident Representatives, and Staff at increased risk for COVID-19.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure reasonable accommodation of needs were honored for one of thirty sampled residents (Resident 245), when Resident 245's wheelchair was not available for use due to Resident 245's wheelchair being borrowed to another resident. This failure resulted in Resident 245 not being able to get up for the lunch meal.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services which met professional standards of quality for one of 30 sampled residents (Resident 52), when Resident 52's order for thromboembolic deterrent hose (TED- stockings designed to promote circulation in the legs to prevent the formation of blood clots) was not followed. This failure placed Resident 52 at increased risk for developing blood clots.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary care and services to ensure that one of 30 sampled residents (Resident 5) functional abilities did not diminish when: 1. Resident 5 had a decline in her ability to walk, and services were not provided to determine the cause and/or to maintain her ambulation status; and, 2. Resident 5 did not receive restorative nursing assistant (RNA) services five times weekly from 3/26/23-4/13/23. This failure potentially contributed to Resident 5's decline in ambulation status.

Inspectors wroteBased on interview, clinical record review, and facility policy and procedure review, the facility failed to ensure acceptable parameters of nutritional status related to significant weight loss for one of four sampled residents, (Resident 86). This failure resulted in Resident 86's significant weight loss not being monitored effectively to prevent further weight loss, potentially affecting Resident 86's health and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure routine medications were provided for one of six sampled residents (Resident 153) observed during medication administration when, Resident 153 did not receive a prescribed medicated inhaler for two days because it was unavailable. This failure had the potential to cause worsening of respiratory symptoms for Resident 153.

Inspectors wroteBased on interview and record review, the facility failed to ensure medication irregularities were identified during the monthly drug regimen review (DRR) for one of thirty sampled residents (Resident 73) when, Resident 73 had an as needed (PRN) order for buspirone (medication used to treat anxiety) with no end date which was not identified and reported to the appropriate facility personnel. This failure had the potential for Resident 73 to continue to take a mind altering medication for a prolonged duration with risks for side-effects to occur.

Inspectors wroteBased on interview and record review the facility failed to ensure two of thirty sampled residents (Resident 73 and Resident 21) psychotropic medication (any drug that affects brain activities associated with mental processes and behavior) regimen were safely managed and monitored when; 1. Resident 73's PRN (as needed) order for buspirone (a medication to treat anxiety) was ordered for longer than 14 days and without an end date or medical doctor's review and assessment; and, 2. A gradual dose reduction (GDR; an attempt to taper or discontinue a medication) recommendation was not followed for two medications, olanzapine (a medication used to treat mental disorders) and trazadone (a medication used to treat depression), by the medical doctor (MD) for Resident 21. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication administration error rate was less than five percent (%), when two medication errors occurred out of twenty-seven opportunities during medication administration for 2 out of 6 residents observed (Resident 153 and Resident 65). As a result of these failures, the facility's medication administration error rate was 7.41%.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the proper storage of drugs and biologicals for a census of 90 when; 1. A lock was not secured on the refrigerator that contained a controlled substance (a drug or other substance that is tightly controlled by the government because it may be abused or cause addiction); 2. Keys to the locked refrigerator that contained a controlled substance was left unattended in the medication storage room; 3. The temperature of a medication storage room was not monitored; and, 4. Two blood glucose test strips (small, plastic strips used to test and measure the blood glucose (sugar) level in the body) containers were not labeled with an open date. [...]

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to prepare food appropriate to meet resident's needs when; 1. A pureed food (a pudding-like texture that is smooth, blended, or pureed) was not prepared in the correct consistency for five out of five residents receiving pureed diet, and 2. Diet orders and meal textures were not verified before service of meal trays for 22 of 25 patients on a modified diet, (Patient 86, Patient 77, Patient 75, Patient 46, Patient 79, Patient 39, Patient 34, Patient 43, Patient 149, Patient 94, Patient 11, Patient 30, Patient 396, Patient 66, Patient 394, Patient 63, Patient 3, Patient 65, Patient 38, Patient 397, Patient 195, Patient 194). [...]

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to follow proper sanitation and food handling practices for a census of 90 when: 1. Residents were not offered hand hygiene prior to meals in the dining room, 2. Staff did not perform hand hygiene prior to passing meal trays in the dining room and in the residents' rooms at Station 4 (a unit in the facility). These failures had the potential to cause an outbreak of foodborne illnesses (eating or drinking something that is contaminated with germs or chemicals that can make people sick).

Inspectors wroteBased on observation, interview, and policy review, the facility failed to maintain the garbage storage area in a sanitary condition when two out of two dumpsters stored outside the building and behind the kitchen were left open. This failure had the potential to attract pests.

Inspectors wroteBased on interview and record review, the facility failed to inform residents or their representatives of the nature and implications of any proposed binding agreement when one out of three sampled residents (Resident 55) signed the arbitration agreement (a document that designates a third party to resolve a dispute between others) in a form or manner that she did not understand. This deficient practice had the potential for Resident 55 to sign a binding agreement without ensuring a complete understanding of the document that was signed.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure appropriate infection control measures were completed for a census of 90 when: 1. A blood pressure cuff (used to measure a resident's blood pressure) was not cleaned between resident use; 2. The rubber seals on Resident 147's insulin pens (medication used to treat/prevent high blood sugars in the body) were not cleaned with an alcohol wipe prior to attaching the needles; and, 3. Hand hygiene was not completed during wound care for Resident 86. These failures had the potential to spread germs among residents, to inject germs into Resident 147's body, and had the potential to cause infection to Resident 86's wound.