Warren Barr Lieberman

Inspectors wroteBased on record review and interview, the facility failed to return resident trust fund balances for 6 residents (R5-R10)reviewed for trust fund balances after being discharged /expired within 30 days reviewed for resident's rights in a sample of 10. On [DATE] at 12:21 PM, V7 (Business office manager/BOM) stated V7 is the person who closes residents RFMS account when a resident discharges from the facility or expires. V7 residents RFMS (Resident Fund Management Service) account should have been closed when the resident is discharged or expires and notifies cooperate Account Receivable (AR) so the residents, if expired residents appointed person or the state could have received a check of the residents closed balance from the residents RFMS account within 30 days. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain orders from the physician to have residentmedication at the bedside. The facility also failed to complete self-administration of medication assessments. This applies to 1 (R3) of3 residents (R2 and R4) reviewed for medications in a sample of 3. On 7/21/2026 at 11:12AM, During observation and resident interview with R3 for resident rights, surveyor observed in R3s room, a medication cup with multiple pills inside. On 7/21/2026 at 11:16AM, V5 entered R3s room while surveyor was in room with R3. V5 stated she was R3s nurse and left the medication cup in R3s room but is not supposed to leave the medication in R3s room. V5 stated V5 should have waited and watched R3 swallow R3s medication but did not stay in the room and assumed R3 would take R3s medicine. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that no medication should be left at resident's bedside without physician order. The facility also failed to follow its policy in resident self-administration of medication. This deficiency affects all four (R71, R103, R116 and R177) residents in the sample of 35 reviewed for Medication Safety.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure an accurate count of controlled medication in the controlled drug administration record sheet. This deficiency affects 2 of 5 medication carts reviewed for Controlled Medication count Management. The facility also failed to follow physician order in administration of medication. This deficiency affects two (R121 and R132) of three residents reviewed for administration of medication.

Inspectors wroteBased on observation, interview, and record review the facility failed to use appropriate infection control practices during resident care on contact isolation precaution and during taking resident's vital signs. The facility failed to provide disposable vitals equipment inside the room of resident with COVID infection. This deficiency affects all four (R48, R70, R187 and R427) residents in the sample of 35 reviewed for Infection Prevention and Control Program.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that the facial hair of a female resident who needs assistance with Activity of Daily Living (ADL) is shaved. This deficiency affects one (R9) of three residents in the sample of 35 reviewed for ADL care program.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure enteral feeding bag is properly labeled before administration affecting 1 of 2 residents (R111) reviewed for enteral feeding care in a total sample of 35. Findings Include: On 5/6/2025 at 11:40 AM, R111's enteral (tube) feeding (TF) infusing. TF bag labeled with 5/6/25 date and time 7:00AM. On 5/6/2025 at 11:50 AM, V19 (MDS/CP Coordinator) said TF bag should be labeled with resident's name, formula name and nurse initial. On 5/7/2025 at 9:29 AM, V2 (Director of Nursing) said TF bag should be labeled with resident name, feeding formula, rate, and start date and time. V2 also said TF bag label should be initialed by the nurse that initially hung the feeding. Review of records read: admission Record/Date: 4/27/2025, Diagnosis Information: Gastrostomy Status; Dysphagia following Cerebral Infarction; [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure Medication refrigerator with controlled medication is locked in the medication room. This deficiency affects one of three medication rooms reviewed for Safe medication storage.

Inspectors wroteBased on interview and record review, the facility failed to protect and secure the confidential personal medical records of a resident by allowing an unauthorized individual to obtain resident medical records. This failure applied to one of one (R72) residents reviewed for medical records.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to administer medications as ordered; and failed to follow policy and manufacturer's instructions for use in the administration of inhalers. There were 25 opportunities with four errors resulting in a 16% medication error rate. The errors involved two (R30 and R138) of nine residents in the sample of 74 reviewed for medication administration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control procedures were followed and implemented to prevent the spread and transmission of COVID-19 within the facility during a COVID outbreak. Facility staff failed to conduct proper hand hygiene, gowning and doffing, and proper wearing of PPE (Personal Protective Equipment) to contain the spread of infectious disease. This failure has the potential to affect all 231 residents currently residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide assistance to dependent residents requiring assistance with ADL (activities of daily living ) such as basic grooming hygiene, and toileting assistance for three (R1, R5, R6) of six residents reviewed for ADL care.

Inspectors wroteBased on observation, interview and record review, the facility failed to monitor the resident's refrigerator temperature for five (R128, R171, R184, R134, R82) of seven residents observed for food safety in a sample of 36.

Inspectors wroteBased on observation, interview and record review, the facility failed to post visual alert signs at the entrance of the facility notifying visitors entering the building about facility's COVID-19 status. They also failed to sanitize the glucometer in between resident's use and post the transmission-based precaution sign on R1's door affecting three of eight residents reviewed for infection control in a sample of 36.

Inspectors wroteBased on observation, interview and record review, the facility failed to label and store medications properly for five of five medication carts and one of three medication room refrigerators reviewed for medication storage.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide privacy during medical procedures for two (R10, R136) of four residents observed for privacy in a sample of 36.

Inspectors wroteBased on observation, interview and record review, the facility failed to administer the medication as ordered for one (R163) of eight residents observed for medication administration in a sample of 36.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure physician orders were followed for 1 of 7 residents R99, reviewed for edema, the facility also failed to implement a comprehensive person-centered care plan intervention for 1 of 1 resident R99 in a sample of 36.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that physician orders was followed regarding pressure ulcer preventive measures for one resident (R188) out of eight residents reviewed for ulcer preventive measures in the sample of 36.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure fall interventions were in place for three (R132, R141, R165) of fourteen residents reviewed for falls in a sample of 36.

Inspectors wroteBased on observations, interviews, and record review the facility failed to follow their care plan and monitor one resident (R170) of 1 resident reviewed for urinary catheters in a sample of 36. This failure resulting in one resident (R170) urinary catheter having sediments for 2 days without any interventions. Findings Include: On 01/24/23 at 12:58 PM R170's urinary catheter bag was uncovered and draining yellow urine with sediments. Observed urine with thick sediments in about 80% of tubing. On 01/25/23 at 1:46 PM with V16 (RN) observed sediments in catheter tubing. Observed the catheter is not attached/anchored to resident's leg. V16 states the catheter should be anchored to R170's leg. [...]

Inspectors wroteBased on observations and interviews the facility failed to follow federal guidelines and have nurse staffing information readily available in a readable format to residents and visitors at any given time. This failure had the potential to effect all 195 residents living in the facility.