Vista Hills Health Care Center

Inspectors wroteBased on interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights , that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for 1 of 4 residents reviewed for care plans. (Resident #1). The facility failed to ensure Resident #1's care plan addressed wound care. This failure had the potential to affect residents by placing them at risk for unmet care needs.

Inspectors wroteBased on interviews, observation, and record review, the facility failed to designate a registered nurse to serve as the director of nursing on a full-time basis. The facility failed to ensure they employed a full time or interim DON from 03/04/2026 through 03/17/2026, and 04/01/2026 to 04/19/2026. This failure could place all residents at risk of not receiving necessary care and services.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the resident's right to personal privacy during medical treatment and personal care was provided for 2 of 8 residents (Resident #1 and Resident #2) reviewed for privacy. -The facility failed on 04/29/2026 to provide glucose reading for Resident #1 and Resident #2 in a private setting.-The facility failed on 04/29/2026 to provide insulin injection for Resident #1 in a private setting. These deficient practices could affect residents by contributing to poor self-esteem, dignity issues, diminished quality of life, and leaking of protected health information.

Inspectors wroteBased on observations, interviews, 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 for 3 (Resident #33, Resident #43 and Resident #68) of 16 residents observed for oxygen management. The facility failed to clean the oxygen concentrator air filter for Resident # 33, and Resident # 43 while the oxygen was in use, concentrators was observed with air filters with dust, and lint collected on them on 02/09/2026. The facility failed to ensure Resident #68's dirty nasal cannula was replaced when it was observed on the floor on 02/09/26 and CNA F used a wipe to clean the nasal cannula. This failure could place residents on oxygen therapy at risk of receiving incorrect or inadequate oxygen support and decline in health. [...]

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) to meet the needs of each resident for 2 of 16 residents (Resident #12 and Resident #17 ) reviewed for pharmacy services. The facility failed to ensure skin ointment was not left at bedside and within reach of Resident #12 and Resident #17 and other residents on(02/09/2026) . The facility failed to maintain their treatment cart free from the Antimicrobial soap's red fluid spillage and red-dried drippings observed on the Antimicrobial soap on 02/11/26. This failure could place residents at risk of inaccurate drug administration and not having appropriate therapeutic effects.

Inspectors wroteBased on observations and interviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for sanitation and food storage.-The facility failed to keep the deep fryer free of food particles, grease accumulation, and burnt oil, and the stove wall next to the fryer was not free of oil splatter and food particles.-The facility failed to keep the oven door free of grime and oil spatter.-The facility failed to keep the refrigerator clean.-The facility failed to dispose of moldy vegetables.-The facility failed to store frozen vegetables in a sealed bag inside the freezer to prevent food contamination and freezer burn. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 of 8 residents (Residents #12) reviewed for dignity. -The facility failed to assist Resident #12 to dress with personal clothing instead of a hospital gown. -The facility failed on 02/09/2026 to ensure Resident #12's door was closed to provide privacy while resident's lower extremities were exposed. The deficient practice could affect residents by contributing to poor self-esteem, dignity issues and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents were provided services with reasonable accommodation of needs and preferences for 1 of 10 residents (Resident #68) reviewed for call lights. The facility failed to ensure Resident #68's call light was within reach on 02/09/2026. This failure placed residents at risk of having their needs unmet when they were unable to contact staff.

Inspectors wroteBased on interviews and record reviews, the facility failed to develop and implement written policies and procedures to prohibit and prevent abuse, neglect and exploitation of residents and misappropriation of residents' property for 1 out of 8 residents (Residents #15) reviewed for abuse and neglect. The facility failed to implement their abuse policy when they failed to report, unknown charges made to Resident #15's bank card in the amount of 700 dollars while the resident resided at the facility. This failure could place residents at risk for exploitation, misappropriation, abuse, and neglect by not immediately following the facility policies and procedures of recognizing, reporting, investigating, allegations of exploitation, misappropriation, abuse and neglect.

Inspectors wroteBased on interview and record review the facility failed to ensure alleged violations involving neglect or mistreatment, including misappropriation were reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 of 8residents (Resident #15) reviewed for reporting. [...]

Inspectors wroteBased on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 6 residents (Residents #10) reviewed for care plans. The facility failed to have a comprehensive person-centered care plan for Resident #10 to address prescribed active Medications for pain, Tramadol 50 MG Take 1 tablet by mouth every 8 hours as needed pain, and Anxiety, Alprazolam 0.5 MG Take 1 tablet by mouth at bedtime. This failure could place residents at risk of not receiving care and services to meet individualized medical and nursing needs. [...]

Inspectors wroteBased on observations, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for one of eight residents ( Resident #58) reviewed for ADL care. The facility failed to ensure Resident #58's fingernails was clean and free from debris on 02/09/26. This failure could place residents who required assistance with ADL's at risk for unmet care needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 3 residents reviewed for repositioning. The facility failed to ensure adequate supervision and safe handling techniques were provided during routine repositioning to prevent injury for Resident #1 who sustained a spiral fracture of the distal right femur while being repositioned in bed by a CNA C.This failure could place residents at risk for injuries. The noncompliance was identified as PNC-IJ. The facility had corrected the noncompliance before the survey began.

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for 1 (Resident #1) of 1 reviewed for quality of care. The facility failed to ensure staff acted in a timely manner to transfer Resident #1 to a hospital after radiologist confirmed a spiral femur fracture on 05/29/2025 at 11:51 PM and delayed response until 05/30/2025 at 06:32 AM. This failure resulted in the resident receiving delay in emergency care services for a fractured femur and placed the resident at risk of further harm and injury.

Inspectors wroteBased on interview and record review the facility failed to consult with the resident's physician when there was a significant change in the resident's physical status for one (Resident #1 ) of 4 residents reviewed for physician notification. -The facility failed to immediately consult with physician and/or Nurse Practitioner when the facility did not have 4 doses of the prescribed Entresto Oral Tablet on hand to administer to Resident #1 according to physician's orders. This failure could place residents at risk of delayed medical treatment. Findings Included: Review of the admission Record dated 04/20/25 revealed an [AGE] year old female that was admitted on [DATE]. [...]

Inspectors wroteBased on 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) to meet the needs of each resident for 1 (Resident #1) of 4 residents reviewed for pharmacy services in that: -The facility failed to administer Entresto Oral Tablet to Resident #1 as ordered. This failure placed residents at risk of inadequate therapeutic outcomes and a decline in health due to not receiving medication as ordered.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who are incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 (Resident #8) of 3 residents reviewed for catheter care. The facility failed to ensure Residents #8s catheter leg strap was in place to secure the catheter. This failure could place residents with foley catheters at risk of catheter pulling causing pain.

Inspectors wroteBased on interviews and record review, the facility failed to consider the views of the residents and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility. The facility failed to demonstrate their responses and rational's for such response for 1 of 1 resident council. The facility failed to ensure concerns expressed in the resident council meetings for (the past 7 months) were reported to the administrator and designated department heads. This failure could lead to residents feeling unheard and unvalued in their place of residence.

Inspectors wroteBased on interview, and record review the facility failed to treat residents with respect, dignity and care for each resident in a manner that promotes maintenance or enhancement of his or her quality of life for 5 of 13 residents in the confidential group interview. The facility failed to provide privacy by conducting care plan meetings in resident rooms. These failures could place residents at risk of decreased feelings of self-worth and decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure the prompt resolution of all grievances to include all written grievance decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns, a statement as to whether the grievance was confirmed, any corrective action or to be taken by the facility as a result of the grievance, and the date when the decision was issued for 5 of 13 confidential residents reviewed for resident rights. 1. - The Activities Director failed to initiate grievance reports on behalf of the residents regarding grievances and concerns voiced during the Resident Council Meetings. 2. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 (Resident #27) of 18 residents reviewed for assistance with ADLs. The facility failed to ensure Resident #27, who required assistance with ADLs, did not have long and dirty fingernails. This failure could affect residents who were dependent on assistance with ADLs and could result in poor care, lack of dignity, infection, and skin tears due to long nails.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide proper treatment and care to maintain mobility and good foot health in accordance with professional standards of practice, including to prevent complications from the resident's medical conditions and if necessary, assist the resident in making appointments with a qualified person, and arranging for transportation to and from such appointments for 1 of 18 residents (Resident #27) reviewed for foot care. The facility failed to provide access to podiatrist for Resident #27. This failure placed residents at risk of poor foot hygiene and decline in residents' physical condition.

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 biological's) to meet the needs of each resident for 3 (ADON L, RN A, and LVN C) of 4 licensed staff. The facility failed to ensure ADON L, RN A, and LVN C, signed off on the Controlled Drugs-Count Record after verifying all controlled substances in the medication cart were accounted for with the on-coming nurse at the change of shift. These failures could place residents at risk for not receiving the intended therapeutic response of prescribed medications and drug diversion of controlled substances.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide safe and secure storage of medications for 3 of 3 medication carts (halls E, B and C), 1 of 1 medication rooms checked for medication storage. 1. -The facility failed to ensure medications were stored according to routes of administration. 2. -The facility failed to ensure opened bottles of Acidophilus Probiotic Dietary Supplement were refrigerated after opening in 2 of 3 medication carts 3. -The facility failed to ensure medication cart drawers were clean and free of trash. These failures could affect residents that received medications from the facility and drug diversion. Medication Carts: Observation and interview on 11/20/24 at 3:20 PM with LVN H, on hall E revealed oral medications, and topical medications in a drawer were not stored according to routes of administration. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food that was palatable and served at an appetizing temperature for 1 of 1 diet test tray reviewed for food temperatures. 1. - The facility failed to maintain food hot on diet serve test tray. 2. - The facility failed to maintain cold foods in palatable temperatures of less than 41 degrees F. These failures could affect the residents by placing them at risk for malnutrition due to not providing appetizing temperature meal.

Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation and food storage. 1. - The facility failed to keep metal shelving in the food preparation area free of food particles. 2. - The facility failed to discard expired perishable foods stored in the refrigerator. 3. - The facility failed to store food in refrigerators and freezers in sealed containers. 4. - The facility failed to label food containers stored in the refrigerators. 5. - The facility failed to keep the tile floor in the dry food storage area free of dust, white stains and food particles. 6. - The facility failed to keep food containers in the dry storage room free of dust, food particles and sealed. 8. [...]

Inspectors wroteBased on observations, and interviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public in 1 of 1 laundry room, 2 of 2 linen closets and residents' rooms reviewed for environmental conditions. 1. - The facility failed to maintain wood linen closet shelves in clean linen closets and ensure the shelves were free from splintered edges. 2. -The facility failed to replace missing floor baseboards in the laundry room. 3. - The facility failed to maintain walls in the laundry room and ensure they remained free of holes and chipped paint. 4. -The facility failed to replace broken or missing tiles in the shower room. 5. -The facility failed to keep water drains in the shower room free of rust. This deficient practice could place residents at risk of not living in a safe, functional, sanitary, and comfortable environment.

Inspectors wroteBased on interview and record review the facility failed to ensure assessments accurately reflected the resident's status for 1 (Resident #5) of 7 residents whose records were reviewed for assessments. Resident #5 was not listed as having behaviors on her annual MDS assessment. This failure to ensure comprehensive and accurate assessments could affect residents by placing them at risk for inaccurate and incomplete MDS assessment which could result in residents not receiving correct care and services.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included 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 of 6 residents (Resident #6) reviewed for care plans. The facility failed to ensure the a care plan was developed to include Resident #6's head of bed being elevated to 30 degrees due to continuous enteral feeding . This deficient practice could place residents at risk of not receiving the necessary care or services and having personalized plans developed to address their needs.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident who was fed by enteral means received the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers for 1 of 6 residents (Resident #6) reviewed for enteral feeding . The facility failed to ensure Resident #6's head of bed was maintained at 30 degrees elevated according to physicians' orders. The failure could place residents at risk of aspiration (when food or liquid goes into the lungs or airway).

Inspectors wroteBased on observation, interview, and record review the facility failed to assure that one (Resident #5) of seven residents reviewed for enteral feeding, received appropriate treatment and services to prevent complications of enteral feeding. -The facility failed to ensure that Resident #5's feeding tube bags were labeled with name of resident, date, and time the administration began to ensure residents maintain nutritional status within optimal parameters. This failure could place residents receiving enteral feedings at risk of not being provided the correct enteral feeding and not receiving feeding care in a timely manner to prevent complications.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure that residents receive care, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 2 (Resident #2 and #5) of 7 residents reviewed for quality of care. 1. The facility failed on 02/12/2024 to ensure the pressure ulcer on Resident #2's sacrum was covered with a dressing as ordered. 2. The facility failed to ensure there were orders in place to provide treatment to Resident #2's right lateral great toe although treatment was being provided. 3. The facility failed to ensure Resident #5 had a pressure relieving mattress to prevent development of pressure ulcers. These failures could result in increased pain, infections, development of new pressure ulcers, and decline in quality of life for residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services that assured the accurate acquiring, receiving, dispensing, safe and secure storage of medications for 1 of 2 treatment carts (North Side) checked for medication storage. 1. The facility failed to ensure Santyl Ointments stored in treatment cart had a prescription label. 2. The facility failed to store prescribed and over the counter external ointments separately and labeled with resident's name. 3. The facility failed to ensure oral swabs were not stored with external ointments in the treatment cart. 4. The facility failed to remove medications from treatment carts after residents were discharged from the facility. These failures could affect residents that received treatments at the facility by placing them at risk of not having prescribed medications and cross contamination.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and 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 1(North Side) of 2 treatment carts checked for cross contamination, and in one (Room F-108) of seven resident rooms checked for cross contamination. 1. The facility stored a used wound vac (a machine that removes drainage from a wound) in the treatment cart. 2. The facility had multiple self-adhesive dressing rolls that were not stored in sealed container in the treatment cart. 3. The facility failed to ensure oral swabs were not stored with external ointments in the treatment cart. 4. The facility failed to ensure used resident gowns were not placed in garbage cans. [...]

Inspectors wroteBased on observations, interview and record review, the facility failed to consult with the physician when the resident experienced a change in condition for 1 of 7 residents (Residents #4) reviewed for resident rights, in that: The facility failed to ensure the treatment nurse notified the physician when Resident #4 had a change in skin integrity. This deficient practice could place residents at risk of a delay of medical treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident to meet a resident's medical, nursing, and mental and psychosocial needs that describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for one (Resident #3) of seven residents reviewed for comprehensive person-centered care plans. The facility failed to develop and implement a care plan to address Resident #3's behavior of scratching. This failure put residents at increased risk of discomfort, impairment of skin integrity, and infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for two (Resident #4 & #3) of three residents reviewed for quality of care. The facility failed to ensure treatment nurse transcribed the physician treatment order to treat Resident #4's rash on groin area. The facility failed to identify and treat Resident #3's rash and behavior of scratching. This failure placed residents at risk for delays in treatment, developing infections and deterioration of skin condition.

Inspectors wroteBased on observations, interview and record review, the facility failed to maintain medical records that were complete and accurately documented for 1 of 7 residents (Residents #4) reviewed for resident rights. The facility failed to ensure the treatment nurse documented she notified the physician when Resident #4 had a change in skin integrity. This deficient practice could place residents at risk of a delay of medical treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nurse staffing data was posted and readily accessible to residents and visitors for 1 (02/10/2024) of 6 days reviewed for nurse staffing information. The facility failed to post the required staffing information for 02/10/2024. This failure could place residents, their families, and facility visitors at risk of not having access to information regarding staffing data and facility census.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents were free from any physical restraints imposed for the purposes of convenience and not required to treat the resident's medical symptoms for two (Resident #2 and Resident #4) of 7 residents reviewed for restraints. The facility failed to ensure a scoop mattress (a mattress with built up sides that create a barrier to help stop residents from rolling or sliding out of bed) was not used with Resident #2 and Resident #4 without any medical indication. This failure could result in residents having physical restraints used that limited their movement without being evaluated for the medical need for this.

Inspectors wroteBased on interview and record review the facility failed to provide pharmaceutical services to meet the needs for 1 (Resident #3) of 7 residents reviewed for pharmacy services. The facility did not provide Resident #3's Clozapine (used to treat severely ill patients with schizophrenia who have used other medicines that did not work well). The medication was not available as the facility pharmacy was not contacted regarding the refill of the medication. The facility did not have pharmacy recommendations for Gradual Dose Reduction forms for Resident #3, that were signed and reviewed from the physician. This failure could place residents at risk for a delay in medication administration and could place residents at risk of medical complications due to missed doses and reviewed pharmacy gradual dose reductions forms.

Inspectors wroteBased on interviews and record review the facility failed to provide or obtain laboratory services only when ordered by the physician; physician assistant; nurse practitioner or clinical nurse specialist in accordance with State Law, including scope of practice laws and promptly notify the ordering physician of the results for 1 (Resident #3) of 7 residents reviewed for labs. Resident #3's labs were not drawn monthly as ordered by the physician. This failure could place residents at risk of a delay in receiving the necessary interventions to treat their medical condition.

Inspectors wroteBased on the observations, interviews, and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for sanitation. 1. Facility Staff and Dietary Staff were not wearing hair nets or beard guards when entering or working in the kitchen. This failure could affect residents by placing them at risk of food borne illness.

Inspectors wroteBased on 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 to meet the needs of one (Resident #2) of seven residents reviewed for availability of medications. The facility failed to obtain and administer Lyrica (pain medication) nine time between 12/01/23 and 12/05/2023 as per physician's orders to Resident #2. This failure puts residents at risk of not receiving prescribed medications and experiencing pain or other symptoms of diagnosed conditions.

Inspectors wroteBased on interview and record review the facility failed to implement written policies that prohibit and abuse, neglect, and exploitation of residents and to investigate any such allegations for one (Resident #1) of 7 residents reviewed for implementation of written abuse, neglect, and exploitation policies: The facility failed to follow the facility policy on reporting allegations of all alleged violations to the Administrator, State agency and other officials in accordance with state law on and to investigate any such allegations on 12/05/23 when Resident # 1 had bruises on left groin of unknown origin. This failure could place all residents at the facility at risk for abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, are reported immediately, but no later than 2 hours after the event, if the events result in serious bodily injury, or no later than 24 hours if the events do not result in serious bodily injury, to the Administrator of the facility and to other officials (including to the State Survey Agency) in accordance with state law through established procedures for 1 (Resident #1) of 7 residents reviewed for abuse. -LVN C failed to immediately notify the Administrator on 12/05/23 Resident #1 had bruising left groin of unknown origin. - Facility failed to report an injury of unknown origin to the State Survey Agency within 24 hours of being reported to Administrator on 12/05/23. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the transfer or discharge is documented in the medical record for 1 (Resident #1) of 7 residents reviewed for clinical records. The facility failed to complete Transfer/Discharge Form on 12/12/23 when Resident #1 was sent for Evaluation to the Emergency Room. This failure could put residents at risk of arriving at the emergency room without information regarding their medical conditions or needs.

Inspectors wroteBased on interviews and record reviews, the facility failed to develop and implement comprehensive person-centered care plans that included measurable objectives and time frames, to meet a resident's medical and nursing needs, to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 3 residents (Resident #1) reviewed for care plans. The facility failed to develop a comprehensive person-centered care plan for Resident #1's interventions for falls, including a fall mat, and bed being in a low position, and for activities of daily living. This deficient practice could place residents, in the facility, at risk of not receiving the necessary care or services and not having personalized plans developed to address their needs.

Inspectors wroteBased on interview, and record review the facility failed to maintain clinical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for 1 (Resident #1) of 5 residents reviewed for accuracy and completeness. The facility failed to complete a SBAR for Resident #1's significant change in condition. The facility failed to accurately document wound description after each wound care provided to Resident #1. This failure could place residents at risk of not having accurate and complete information available to those providing their treatment and care.

Inspectors wroteBased on interview and record review the facility failed to ensure the resident/ RP has the right to be informed of, and participate in, his or her treatment for one (Resident #1) of 5 reviewed for resident rights and RP rights, in that: Resident #1's RP was not notified or provided any information on Resident #1's discovered necrotic tissue on 09/22/23. The RP was denied the opportunity to participate on Resident #1's treatment options. This failure could place residents at risk of not being aware/informed to treatment options.

Inspectors wroteBased on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for 1 of 5 (Resident #3) residents reviewed for comprehensive care plans, in that: Resident #3 care plan did not include Hospice care. This failure could place residents at risk of not receiving the appropriate care and needs not being met.

Inspectors wroteBased on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident describing the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for three residents (Resident #7, Resident #10 and Resident #89) of 27 residents reviewed for comprehensive care plans. The facility failed to ensure that Resident #7 ' s care plan accurately reflected her impaired vision or need for assistance with dining. The facility failed to ensure that Resident #10 ' s care plan accurately reflected her wandering and exit seeking behavior. The facility failed to ensure that Resident #89 ' s care plan reflected his visual impairment and resulting care needs. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for four (Residents #29, #79, #89, and #212) for 27 residents reviewed for an ongoing program to support residents in their choice of activities. - The facility failed to provide individualized activities for Residents #29 and #79 who were bedbound. -The facility failed to provide Resident #89 with individualized activities reflecting his impaired visual status or preferences. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that a resident who is incontinent of bladder received appropriate treatment and Foley care to prevent urinary tract infections for 2 (Resident #29, and Resident #79) of 4 residents reviewed for urinary incontinence, in that: The facility staff failed to provide Foley catheter care very shift as scheduled for Resident #29, and Resident #79. This deficient practice could place residents with catheters at increased risk for residents of urinary tract 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) to meet the needs of each resident and failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. The facility failed to perform controlled drug destruction with pharmacist and an allowed witness (DON, Administrator, Agent of the state board of Pharmacy) in accordance with state requirements from February 2023 until [DATE]. The facility failed to have a pharmacist available to perform controlled drug destruction from [DATE] to [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for professional standards for food service safety. - 1 bag with various vegetables found in the refrigerator opened to air and without a label of its ' contents. -2-gallon sized bottles of pancake syrup were unlabeled with the date they were opened. - 1 container of sugar unlabeled with date it was opened, as well as the label of the container ' s contents. These failures could place residents at risk of food-borne illness.

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 (Resident #29) of 9 resident reviewed for infection control, two (A Hall Linen Cart and F Hall Linen Cart) of two linen carts reviewed were not covered and sealed, and that one linen closet (D Hall Linen Closet) of one linen closet was kept closed. The facility failed to ensure that 2 linen carts were covered The facility failed to ensure that 1 linen closet was kept closed. The facility failed to provide safe, sanitary care and follow g-tube 20-22 French declogger (a device used to clear obstructions in gastrotomy tubes) packaging indication to discard after each use to prevent contamination. [...]

Inspectors wroteBased on interviews, observations, and record reviews the facility failed to promote care for residents in a manner and in an environment that maintained or enhanced dignity and respect for 2 (Resident #24 and #79) of 9 residents reviewed for care that maintained or enhanced their dignity. -The facility failed to maintain Resident #24 ' s sense of dignity by not proving change in brief in a timely manner leaving resident soiled (wet) in the lobby area with other residents. -The facility failed to maintain Resident #79's sense of dignity by leaving a portion of his left side of his body exposed during transportation to the shower. These failures could place residents who require assistance with bathing and changing their clothing at risk of decreased self-esteem affecting their dignity.

Inspectors wroteBased on interview and record review the facility failed to ensure the resident ' s right to formulate advance directives for two (Resident #62 and Resident #29) of 27 residents reviewed for enactment of advance directives. Resident #62 had both an out-of-hospital DNR order (tells health care providers not to do cardiopulmonary resuscitation) and a physician ' s order for full code (meaning if her heart stopped beating and/or she stopped breathing, all resuscitation procedures will be provided to keep her alive) in her medical record. Resident #29 had both an out-of-hospital DNR form and a physician ' s order for full code in his medical record. The failures could put residents at risk of not having their end of life wishes honored.

Inspectors wroteBased on observation, interview and record review the facility failed to conduct initially and periodically an accurate assessment of each resident's status capacity for 1 (Resident #89) of 27 residents reviewed for accurate assessment of resident ' s functional capacity. The facility failed to correctly assess and document on the MDS that Resident #89 had a severe vision impairment. This failure put residents at risk of not receiving services based on their actual functional capacity.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that a resident who is fed by enteral means receives the appropriate treatment and services for 1 of 8 residents (Resident # 207) reviewed for enteral feeding. -Resident #207 ' s ' s enteral feeding (nutrition given through a feeding tube) formula was not labeled with time of administration, date it was hung, and the rate the formula was given. This failure could place residents receiving enteral feedings at risk of malnutrition if feedings were to be given incorrectly.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice for 1 (Resident #207) of 3 residents observed for oxygen management. -Resident #207 utilized oxygen in his room and did not have an oxygen sign posted outside of the room. This failure could place residents on oxygen therapy at risk of receiving incorrect or inadequate oxygen support and decline in health.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that medical records were accurately documented for one (Resident #94) of 5 residents reviewed for accurate documentation of medical records. The facility failed to correctly document the administration of Fentanyl 50 mcg/hour patches every 72 hours to Resident #94 and instead documented that she was administered Fentanyl 25 mcg/hour patches every 72 hours. These failures could put residents at risk of incorrect records of medications administered.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide reasonable accommodation of needs for 1 of 8 residents (Resident #1) reviewed for accommodation of needs: -Residents #1's push button call system was not adequate to meet the needs of the residents who required padded call light button. -Resident #1's call system was not placed within reach of the resident. This failure could place residents at risk of not being able to have their needs met.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who was 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 6 residents (Residents #1) reviewed for assistance with ADLs in that: -Resident #1 had long fingernails that were dirty and had a black substance underneath them. This failure could place residents who required assistance with showering and maintaining good personal hygiene at risk for not receiving care and services to meet their needs and avoid ADL decline.

Inspectors wroteBased on observation interview, and record review the facility failed to ensure resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 5 (Resident #2) residents reviewed for foley catheter. -The facility failed to ensure Resident #1 had foley catheter secured on her thigh. This failure could place residents with foley catheter at risk of catheter pulling causing pain and/or infection.