Vintage Health Care Center

Inspectors wroteBased on interview and record review, the facility failed to ensure residents had the right to retain and use personal possessions for 4 (Resident #3, #5, #8 and #9) of 8 reviewed for personal property. The facility failed to allow Resident's #3, #5, #8 and #9 to exercise the right to retain and use personal possessions, including clothing. This failure could place residents at risk emotional distress, embarrassment, and lower self-esteem.

Inspectors wroteBased on observation, interview and record review the facility failed to provide housekeeping services necessary to maintain a sanitary and comfortable interior for 3 (Resident #3, #7 and #9) of 8 resident's reviewed for environment. The facility failed to ensure there was clean bed linen at the time of residents' showers. The facility failed to change and provide clean bed linen for Resident #3 and Resident #7 on shower/bath days. The facility failed to provide clean bath towels for Resident #9 on shower days. This failure could affect any resident and place them at risk for not having clean linens which could lead to a decreased quality of life.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 5 (Resident #3, # 4, #5, #6 and #7) of 8 residents reviewed for ADL care provided to dependent residents. The facility failed to ensure Resident #3, Resident #4, Resident #5, Resident #6, Resident #7 received their scheduled showers. This failure could place residents at risk of not receiving necessary services to maintain good personal hygiene, skin integrity, or decreased self-esteem.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 2 (Resident #1 and Resident #2) of 8 residents reviewed for call lights. The facility failed to ensure Resident #1 and Resident #2 had call lights within reach while in their beds on 05/27/2026. This failure could place residents at risk of being unable to obtain assistance or help when needed and in the event of an emergency.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the right for residents to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for four (Resident #4, #7, #9, and #10) of ten residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident #4, #7, #9, and #10's room were in a position that was accessible to the resident on 04/22/2026. This failure could place the residents at risk of not obtaining assistance when needed and help in the event of an emergency.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for three of twelve (Resident #1, #2, and #6) reviewed for respiratory care. The facility failed to ensure Resident #1 had his nebulizer mask bagged when not in use on 04/22/26. The facility failed to ensure Resident #2's nasal cannula was bagged when not in use on 04/22/26. The facility failed to ensure Resident #2 had physician orders for use of the oxygen concentrator. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident had the right to be treated with respect and dignity for 2 of 4 residents (Resident #3 and #6) reviewed for dignity. Med Aide G was observed standing over Resident #1 feeding her while the resident was sitting in his wheelchair and not at eye level. The facility failed to ensure Resident #6's indwelling urinary catheter bag had a dignity/privacy bag/screen on 04/22/26. These failure could place residents at risk of not feeling not treated with dignity, privacy, and respect.

Inspectors wroteBased on interviews, and record reviews the facility failed to ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 8 residents (Resident #5) reviewed for ADL care provided to dependent residents. The facility failed to ensure Resident #5 received her scheduled showers since admission on [DATE]. This failure could place residents at risk of not receiving necessary services to maintain good personal hygiene, skin integrity, or decreased self- esteem.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that residents' environment remained as free of hazards as was possible for one of six residents (Resident #4) reviewed for accident hazards. The facility failed to ensure Resident #4 had fall mat placed alongside her bed for fall prevention. This failure could place residents at risk for potential injury.

Inspectors wroteBased on observations and interviews, the facility failed to ensure the resident environment remained free of accident hazards as was possible for 1 of 1 doorway to the Clean Linen Storage on the secure unit reviewed for accidents and hazards. The facility failed to ensure residents who resided on the secure unit were safe from hazardous items when the door to the Clean Linen storage room was observed open on 2/10/2026. This failure could place residents in the secure unit at risk of harm from exposure to hazardous materials, injury from freestanding shelves and linens, or entrapment in a confined space.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation for 7 (Resident #10, Resident #12, Resident #49, Resident #56, Resident #63, Resident #64, and Resident #80) of 8 resident rooms observed and reviewed for grab/assist bars. The facility failed to have evidence of informed consent for Resident #12, Resident #49, Resident #56, Resident #63, Resident #64, and Resident #80, for grab/enabler bars (smaller bars used by the person in bed to reposition themselves) to be placed on the bed. The facility failed to have evidence of assessment for Resident #10, Resident #12, Resident #49, Resident #56, Resident #64, and Resident #80, for risk of entrapment and ability to safely use the grab/enabler bars. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services in accordance with currently accepted professional principles for three (Residents #44, #48, and #62) of twelve residents reviewed for pharmaceutical services. The facility failed to ensure MA C documented in the controlled medication logbook immediately after administering Hydrocodone to Resident #44 on 02/11/2026. The facility failed to ensure MA C documented in the controlled medication logbook immediately after administering Clonazepam to Resident #48 on 02/11/2026. The facility failed to ensure MA C documented in the controlled medication logbook immediately after administering Pregabalin to Resident #62 on 02/11/2026. This failure could place residents at risk of not receiving their medications as ordered by their physician.

Inspectors wroteBased on observation, interviews, and record reviews the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. The facility failed to ensure all food items in the facility kitchen were dated and discarded prior to their use-by date. The facility failed to ensure all canned items in the dry storage area were dated and discarded prior to their use-by date. These failures could place residents at risk for food contamination and food-borne illness.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for one (Resident #14) of sixteen residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident #14's room was in a position that was accessible to the resident on 02/10/2026. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure the residents had the right to personal privacy and confidentiality of his or her personal space for 1 of 4 residents (Resident #63) reviewed for privacy. The facility failed to ensure that the roommates of residents with AEM had signed consents in the active section of the EHR from the roommate or their RP acknowledging the AEM in the shared room since 01/28/2026. This failure could place residents at risk of having medical or personal information or conversations recorded or exposed to others, and cause residents to feel a loss of privacy, dignity, and decreased self-worth and self-esteem.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #38) of six residents reviewed for respiratory care. The facility failed to ensure Resident #38's nasal cannula was stored properly when not in use on 02/10/2026. This failure could place residents at risk for respiratory infection and not having their respiratory needs met.

Inspectors wroteBased on observation, interview and record review the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for one (Resident #31) of twelve residents reviewed for medication storage. The facility failed to ensure Resident #31 did not have a topical analgesic ointment on her bedside table on 02/10/2026. This failure could place residents at risk of not receiving the full benefit of the medications or misuse of medications that could lead to adverse reactions or overdose.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the resident's right to personal privacy and confidentiality of his or her personal and medical records for fifteen (Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, and #15) of twenty five resident reviewed for privacy and confidentiality. 1. The facility failed to ensure a list of residents who were using oxygen (Resident #1, #2, #3, #4, #5, and #6) was not left unattended on top of a nurse's cart on 11/04/2025. 2. The facility failed to ensure a list of residents who had a Foley (device used to help drain urine from bladder) (Resident #7) was not left unattended on top of a nurse's cart on 11/04/2025. 3. The facility failed to ensure a list of residents who were on dialysis (Residents #8, #9, and #10) was not left unattended on top of a nurse's cart on 11/04/2025. 4. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to, in accordance with State and Federal laws, store all drugs and biologicals in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for four (Resident #1, #2, #3, and #4) of ten residents reviewed for medication storage. 1. The facility failed to ensure zinc oxide (medicated cream used to prevent skin irritation) was not left inside the Resident #1's room on 10/08/2025. 2. The facility failed to ensure zinc oxide was not left inside the Resident #4's room on 10/08/2025. 3. The facility failed to ensure a vial of solution used for breathing treatment was not left inside Resident #2's room on 10/08/2025. 4. The facility failed to ensure a tube of topical pain reliever was not inside Resident #3's room on 10/08/2025. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that a resident who needed respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #2) of eight residents reviewed for respiratory care. The facility failed to ensure Resident #2's breathing mask (medical device used to deliver medication in a form of mist) was stored properly when not in use on 10/08/2025. This failure could place residents at risk for respiratory infection and not having their respiratory needs met.

Inspectors wroteBased on interview and record review, the facility failed to ensure the comprehensive care plan described the services furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for four (Residents #1, #2, #3, and #5) of nine residents reviewed for Comprehensive Care Plans. Based on interview and record review, the facility failed to ensure the comprehensive care plan described the services furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 4 (Residents #1. #2. #3 and #5) of nine residents reviewed for Comprehensive Care Plans.1. A. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure the resident environment remained as free of accident hazards as is possible and each resident received adequate supervision to prevent accidents for 4 (Residents #1, #2, #3 and #5) of 9 residents reviewed for accidents and hazards. Based on observations, interviews, and record review the facility failed to ensure the resident environment remained as free of accident hazards as is possible and each resident received adequate supervision to prevent accidents for 4 (Residents #1, #2, #3 and #5) of 9 residents reviewed for accidents and hazards. 1. A. [...]

Inspectors wroteBased observations, interviews, 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 (Resident #4) of eight residents observed for infection control. Based observations, interviews, 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 (Resident #4) of eight residents observed for infection control. The facility failed to ensure that CNA E changed gloves and performed hand hygiene while providing incontinent care to Resident #4. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for one (Resident #2) of five residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident #2's room was in a position that was accessible to the resident on 05/20/2025. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for two (Resident #1 and Resident #2) of four residents reviewed for respiratory care. 1. The facility failed to ensure Resident #1's humidifier bottle (a medical device designed to increase the moisture level in supplemental oxygen) had water in it on 05/20/2025. 2. The facility failed to ensure Resident #2's nasal cannula (flexible tube used to deliver oxygen to the nose through two prongs) were properly stored when not in use on 05/20/2025. These failures could place residents at risk for respiratory infection and not having their respiratory needs met.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 resident (Resident#1) of 3 residents reviewed for Care Plans. The facility failed to ensure Resident #1 was care planned for indwelling foley catheter. This failure could place residents at risk of needs not being met.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 2 (Resident #2, and Resident#3) of 8 residents reviewed for ADLs. The facility failed to ensure Resident#2 had his fingernail cleaned and trimmed. The facility failed to ensure Resident#3 had his toenails trimmed. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 resident (Resident #1) of 1 reviewed for catheter and incontinence care. The facility failed to ensure Resident#1 urine catheter bag was off the floor when she was lying in bed, and the tubing was properly strapped to her leg. These failures could place residents at risk for not receiving care appropriate to address their incontinence and could increase the risk of urinary tract infections.

Inspectors wroteBased on observations, interview, and record review, the facility failed to ensure resident received adequate monitoring, supervision, and/or assistive devices to prevent accidents for 1 of 8 residents (Resident #1) reviewed for accidents, hazards, and supervision. On 03/07/2025, the facility failed to identify potential hazards and follow internal systems in place to prevent Resident #1's elopement from the facility approximately two hours and twenty minutes after his admission. He was located approximately two hours later by local law enforcement approximately 1 mile east of the facility. A Past Non-Compliance Immediate Jeopardy (PNC IJ) was identified and presented to the Administrator on 04/17/2025 at 4:24 PM. The noncompliance began on 03/07/2025 and ended on 03/07/2025. The facility corrected the noncompliance before the investigation began . [...]

Inspectors wroteBased on interview and record review the facility failed to immediately inform the resident, consult with the resident's physician; and notify, consistent with his or her authority, the resident representative where there was a significant change in the resident's physical, mental, or psychosocial status and when there was a need to alter treatment significantly for one of two (Resident #99) post operative surgical residents reviewed for notification of changes related to post operative care. The facility failed to notify Resident #99's attending physician or surgeon after changes to her surgical incision site were repeatedly observed resulting a subsequent infection that required hospitalization and surgical intervention. An Immediate Jeopardy (IJ) situation was identified on 11/08/2024 at 12:35 PM. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive resident-centered care plan for one (Resident #99) of two residents reviewed for quality of care. 1. The facility failed to ensure physician orders for treatment, care, and monitoring of Resident #99's surgical site incision was obtained upon admission resulting a subsequent infection that required hospitalization and surgical intervention. 2. The facility failed to complete and document any skin/incision/wound assessments of Resident #99's surgical incision site resulting a subsequent infection that required hospitalization and surgical intervention. 3. The facility failed to develop a baseline care plan that addressed Resident #99's surgical care needs. [...]

Inspectors wroteBased 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 two (Resident #08, Resident #38) of four residents observed for infection control. 1. The facility failed to ensure MA X sanitized the blood pressure device between contact and care of Resident #08 and Resident #38on 11/06/2024. 2. The facility failed to ensure RN K and CNA G sanitized their hands during the distribution of lunch trays on 11/05/2024. These failures could affect resident's health and place them at risk of illness and exposure to diseases.

Inspectors wroteBased on interview and record review, the facility failed to develop a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care that was developed within 48 hours of resident's admission for one (Resident #99) of six residents reviewed for baseline care plans. The facility failed to complete a sufficient baseline care plan that identified her surgical incision site care needs for Resident #99 within 48 hours of resident's admission. This failure placed the facility care staff and Resident #99 at risk of not being informed of their initial goals and services, receiving continuity of care and communication among nursing home staff, increase resident safety and safeguard against adverse events that are most likely to occur right after admission.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents received care, consistent with professional standards of practice, to prevent pressure ulcers for one (Resident #44) of five residents reviewed for wound care treatment and services. The facility failed to ensure Resident #44 wore her heel protector on 11/05/2024 per physician order to prevent the re-development of a previous pressure ulcer. This failure could place the residents at risk for the development, re-development, or worsening of pressure wounds .

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for one (Resident #44) of five residents reviewed for accidents, hazards, and supervision. The facility failed to ensure Resident #44's fall mat was placed appropriately on the floor by her bed on 11/05/2024. This failure could place residents at risk for serious injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program to ensure the facility was free of pests in one of one kitchen (Kitchen #1 and one of one dining hall (Dining Hall #2). The facility failed to treat the gnats in the dining hall and kitchen. This failure could place residents at risk for the potential spread of infection, cross-contamination, and decreased quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents had the right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms for 2 of 3 residents (Resident #1, and #2) reviewed for restraints. The facility failed to ensure Resident #1 and Resident #2 had physician orders or a physician assessment for a scoop mattress. This failure could place residents at risk of unnecessarily inhibiting the residents' freedom of movement or activity.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 resident (Resident #3) reviewed for respiratory care. 1. The facility failed to ensure Resident #3's tubing on her oxygen concentrator was changed within the facility's policy of 7 days. 2. The facility failed to ensure the humidifier for Resident #3's oxygen concentrator was filled with distilled water. These failures could place residents at risk for respiratory infection and not having their respiratory needs met.

Inspectors wroteBased interviews and record reviews, the facility failed to maintain the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week, for 21 days of the 4-month review period, reviewed for RN coverage. The facility failed to ensure the facility maintained the services of a registered nurse for at least 8 consecutive hours a day on Saturdays and Sundays for 21 days of the four months reviewed. This failure placed residents at risk of receiving higher levels of patient care. Findings Included: Review of the facility provided time sheets for Registered Nurses (RN) for the review period from April 2023 to September 2023, the facility failed to have the required RN coverage of at least 8 consecutive hours a day, for the following dates: [...]

Inspectors wroteBased on interview and record review, the facility failed to consult with the resident's physician when there was a need to alter treatment significantly for nine (Residents #3, #54, #52, #51, #33, #27, #60, #4, #14) of 15 residents reviewed for physician notification. 1. The facility failed to notify Resident #3's Physician when their medications, Trileptal and Risperdal, were not available. 2. The facility failed to notify Resident #54 Physician when their medication, Aricept, was not available. 3. The facility failed to notify Resident #52's Physician when their medication, Lunesta, was not available. 4. The facility failed to notify Resident #51's Physician when their medication, isosorbide, was not available. 5. The facility failed to notify Resident #33's Physician when their medication, dicyclomine, was not available. 6. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to provide a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for areas in the facility for 6 of 6 rooms (Rooms # 1, 2, 4, 6, 7, and 12) observed for a safe, clean, comfortable, and homelike environment. The facility failed to ensure that resident rooms were cleaned and serviced in accordance with the facility's policy on Housekeeping Services. This deficient practice could place residents at risk of infections and living in an uncomfortable environment leading to a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate administering of all drugs and biologicals) to meet the needs of each resident for nine (Residents #3, #54, #52, #51, #33, #27, #60, #4, #14) of 15 residents reviewed for pharmacy services. 1. The facility failed to administer medications as ordered, Trileptal and Risperdal, to Resident #3. 2. The facility failed to administer medications as ordered, Aricept, to Resident #54. 3. The facility failed to administer medications as ordered, Lunesta, to Resident #52. 4. The facility failed to administer medications as ordered, isosorbide, to Resident #51. 5. The facility failed to administer medications as ordered, dicyclomine, to Resident #33. 6. The facility failed to administer medications as ordered, Depakote, to Resident #27. 7. [...]

Inspectors wroteBased on observation, interviews and record reviews the facility failed to ensure food was stored, prepared, distributed and served in accordance with professional standards for food service safety for the facility's only kitchen reviewed for kitchen sanitation. The facility failed to ensure kitchen equipment were clean and sanitary. The Facility failed to ensure prepared food was covered. The facility failed to ensure the Iced Tea dispenser, prepared for residents, was covered, and sealed from air-borne diseases once prepared. The Facility failed to ensure the Ice Scoop Holder and Ice Machine was clean and sanitary These failures could place residents at risk for cross contamination and other illnesses.

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 2 (Resident #25 and #39) of 3 residents observed for infection control. 1. The facility failed to ensure that the two prongs of Resident #39's nasal cannula (a device used to deliver supplemental oxygen to an individual. It consists of a lightweight tube on which one is connected to the oxygen source and the other end splits into two prongs and are placed in the nostrils) was not on the floor. 2. The facility failed to ensure CNA G changed her gloves and performed hand hygiene while providing incontinence care to Resident #25. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for two (Resident #39 and Resident #27) of ten residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Residents #39 and #27's rooms was in a position that was accessible to the resident. This failure could place the residents at risk of being unable to obtain assistance in the event of an emergency.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents had physician's orders for the resident's immediate care for one (Resident #27) of two residents reviewed for admission orders. The facility failed to provide physician's orders for oxygen supplement for Resident #27 at the time of admission. This failure could place the resident at risk of not receiving necessary care and services upon admission that could result to worsen condition.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for a resident for 2 of 6 residents (Resident #27and resident #39) reviewed for Care Plans. The facility failed to ensure Resident #27 and Resident #39 were care planned for oxygen administration. This failure could place residents at risk of needs not being met.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure the timeliness of each resident's person-centered, comprehensive care plan, and to ensure that the comprehensive care plan is reviewed and revised by an interdisciplinary team for 2 of 6 residents (Resident #23 and #53) reviewed for revised Care Plans. The facility failed to ensure Resident #23 and Resident #53's Do Not Resuscitate (DNR) were updated on the care plan. These failures placed residents at risk of needs not being met.

Inspectors wroteBased on interviews and record review, the facility failed to develop and implement an effective discharge planning process that focused on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions for 1 of 6 residents (Resident #63) reviewed for Discharge Planning. The facility failed to address the Resident #63's family request to discharge resident to home healthcare on or around 08/01/23. This failure could place resident at risk of not achieving maximum potential and complicate the resident's recovery.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 6 residents (Resident #63) reviewed for Pressure Ulcer Services. The facility failed to address the resident's concerns with a faulty air mattress, which went unresolved for 4 days until it was replaced on 09/11/23. This failure could place resident at risk of new pressure wounds developing, or current pressure wounds worsening.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to ensure that a resident who needed respiratory care was provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 (Resident #39) of 2 residents reviewed for respiratory care. The facility failed to ensure Resident #39's oxygen concentrator had a humidifier. This failure could place the resident at risk for nasal dryness and nasal irritation.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free of significant medication errors for one (Resident #27) of nine residents reviewed for significant medication errors. 1. The facility failed to ensure Resident #27 was free of significant medication errors. Depakote was not administerd as ordered. This failure placed residents at risk for not receiving the therapeutic effect of their medications as ordered by the physician.