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Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe, sanitary, and homelike environment for residents who resided in the facility for 3 of 3 units observed. Baseboards, walls, door trim were marred, with holes, or chipped paint, floors had debris built up, missing lights fixtures, dust build up on fixtures, and dirt on window sills. ( Memory Springs unit, [NAME] Hall, East Hall, Resident D)

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications were properly dated and labeled, failed to keep medications refrigerated until opening, and failed to destroy expired medications for 3 of 4 medication carts observed. (west hall medication cart and east halls medication carts)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that food was served at palatable temperatures for 1 of 1 trays tested for temperature. (200-hall)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure documentation was complete and accurate for 1 of 1 residents reviewed for weight loss, 3 of 3 residents reviewed for insulin administration, and 1 of 3 residents reviewed for wounds. (Resident 9, Resident 28, Resident 5, Resident 14, and Resident 36)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who desired to self-administer their medications were evaluated for capability to self-administer medications for 1 of 1 residents observed with medications in their room. (Resident 11)

Inspectors wroteBased on record review and interview, the facility failed to ensure as needed (PRN) orders for psychotropic drugs, that were ordered beyond 14 days, included an evaluation of need for the medication after 14 days and indicated a specific duration of use for 1 of 1 residents reviewed for non-pressure related wounds. (Resident 36)

Inspectors wroteBased on record review and interview, the facility failed to ensure accuracy of assessments for 2 of 5 residents reviewed for unnecessary medications. (Resident 53 and Resident 12)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure oxygen services were provided according to physician orders for 2 of 2 residents reviewed for respiratory care. Oxygen tubing not date. (Resident 11, Resident 14)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were administered according to physician's orders and professional standard for 3 of 7 residents observed during medication pass. Three medication errors were observed during 39 opportunities for error in medication administration. This resulted in a 10.34% error rate. (Resident 66, Resident 57, and Resident 5)

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure a resident was free from significant medication errors for 1 of 2 residents observed for insulin administration (Resident 57). Resident 57 received the wrong insulin.

Inspectors wroteBased on observation, record review, and interview, the facility failed to implement proper use of Enhanced Barrier Precautions (EBP) and use of gloves for a random observation of wound care. (Resident 39)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure there was not an emergency call light in 6 of 6 public restrooms that could be utiized by residents in 2 of 2 observations. (Back Hallway, East Hallway) Findings Include: On 1/14/26 at 2:30 P.M., the woman's public restroom in the back hallway was observed to have no key or emergency call system. On 1/15/26 at 8:3 A.M., the public restrooms on back hall and east hall public were observed to have no key or emergency call bell systems. During an interview on 1/16/26 at 10:38 A.M., the administrator was not aware of the need to have an emergency call light or key for a public bathroom if could be accessed. She had been told different things. On 1/16/26 at 1:45 P.M., a policy for the call system was asked for and not received. 3.1-19(u)(2)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drug records were in order and an account of all drugs were maintained for 2 of 2 nursing units reviewed. The narcotic drug count was not accurate. (East Unit, [NAME] Unit)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure physician orders were followed for 1 of 3 residents reviewed for wounds. Wound treatments were not signed as completed on the Electronic Medical Administration Record (EMAR).

Inspectors wroteBased on observation, interview and record review, the facility failed to notify the physician and resident representative of a change in condition for 1 of 3 residents reviewed for skin/wounds. A treatment order was not obtained for a pressure injury, a resident representative was not notified of a pressure wound or facial bruising. (Resident B)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were administered according to physician's orders and professional standard for 4 of 4 residents observed during medication pass. (Resident 10, Resident 39, Resident 42, Resident 30) Five medication errors were observed during 31 opportunities for error in medication administration. This resulted in a 16.13 error rate.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications were properly dated and labeled, failed to keep medications refrigerated until opening, and failed to destroy expired medications for 2 of 2 medication carts observed. (100 hall west medication cart and 200 hall east medication cart)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that food was served at palatable temperatures for 1 of 1 trays tested for temperature. (200-hall)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was correctly prepared for 4 of 4 residents who received puree altered diets.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was prepared under sanitary conditions during 3 of 3 kitchen observations and 1 of 1 dining observations. Staff did not wear hairnets, and gloves were not changed before touching food items. (Dietary Manager, [NAME] 5, [NAME] 14, Activities Department Staff)

Inspectors wrote2. On 10/17/24 at 12:08 P.M., Resident 16's clinical record was reviewed. Resident 16 was admitted on [DATE]. Diagnoses included, but were not limited to, chronic obstructive pulmonary disease and diabetes mellitus. The most recent Quarterly MDS (Minimum Data Set) assessment, dated 8/19/24, indicated Resident 16 was cognitively intact, required partial assistance from staff for toileting and bathing, and was completely dependent on staff for transfers. Current physician orders included, but were not limited to: Basaglar (insulin medication) Inject 10 unit subcutaneously every morning and at bedtime for diabetes, Start date 4/9/24 On the following dates subcutaneous insulin administration was documented by QMA 10 on the electronic medication administration record during the last 30 day period: 9/20/24 8:00 A.M. 9/27/24 8:00 A.M. 10/2/24 8:00 A.M. 10/3/24 8:00 A.M. 10/16/24 8:00 A.M. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure physician consultation was provided before treatment alterations occurred to modify medications prior to administration for 1 of 1 residents reviewed for crushed medications received. (Resident 47)

Inspectors wroteBased on record review and interview, the facility failed to ensure residents' MDS (Minimum Data Set) Assessment's were completed within 14 days of admission for 1 resident reviewed for accidents and 1 resident reviewed for advanced directives. (Resident 259 and Resident 261)

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the MDS (Minimum Data Set) Assessments were completed accurately for 1 of 2 residents reviewed for falls, 1 of 2 residents for nutrition, 1 of 5 residents reviewed for unnecessary medications. (Resident 50, Resident 30)

Inspectors wroteBased on interview and record review, the facility failed to develop care plans for 1 of 1 residents reviewed for communication. A care plan was not developed for residents with English as a second language. (Resident 50)

Inspectors wroteBased on record review and interview the facility, failed to ensure that documentation of interventions were not revised for 1 of 2 residents reviewed for falls and revise a residents care plan after they returned to facility from a hospital admission with a urinary tract infection and sepsis for 1 of 1 resident reviewed for urinary tract infections. (Resident 36, Resident 50).

Inspectors wroteBased on interview and record review, the facility failed to ensure practitioner's diagnostic practices met professional standard of care for 1 of 1 resident diagnosed with scizoaffective disorder and bipolar disorder after admission. (Resident 47)

Inspectors wroteBased on clinical record review and interview, the facility failed to ensure care consistent with professional standards of practice were received to prevent pressure ulcers from progressing by administering treatments as physician ordered and treatments were administered by qualified personnel for 1 of 2 residents reviewed for wounds. (Resident 16)

Inspectors wroteBased on record review and interview, the facility failed to ensure diet recommendations were followed in 1 of 3 residents reviewed for nutrition. (Resident 34)

Inspectors wroteBased on record review and interview, the facility failed to ensure a pharmacy recommendation was followed for 1 of 5 residents reviewed for unnecessary medications (Resident 47).

Inspectors wroteBased on observation, record review, and interview, the facility failed to implement infection prevention measures by following physician orders for enhanced barrier precautions for 1 of 1 residents observed for wound care. (Resident 6)

Inspectors wroteBased on interview and record review, the facility failed to develop care plans for 1 of 3 residents reviewed for wounds. A care plan was not developed after a resident returned from the hospital with a new diagnosis and new medication order. (Resident M)

Inspectors wroteBased on interview and record review, the facility failed to ensure physician orders were followed for 1 of 3 residents reviewed for medications. A resident's blood pressure parameters were not followed for giving a medication. (Resident B)

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure safety or supervision of a resident for 1 of 1 residents reviewed for falls resulting in major injury. This deficient practice resulted in a fall with a fractures requiring hospitalization. (Resident 43)

Inspectors wroteBased on observation, interviews and record review the facility failed to store, prepare and serve food in accordance with professional standards for food service for 1 of 2 kitchen observations. Food was served on dishes that were not thoroughly sanitized, emergency use of paper goods was delayed for 55 of 55 residents served meals in the facility. The facility failed to ensure that the temperature of unit refrigerators were with acceptable range in 3 of 3 refrigerators observed. ( Kitchen, East Hall Nourishment Pantry)

Inspectors wroteBased on record review and interview, the facility failed to schedule care plan conferences and revise care plans for 12 of 12 residents reviewed. (Resident 14, Resident 16, Resident 20, Resident 22, Resident 24, Resident 25, Resident 30, Resident 36, Resident 38, Resident 39, Resident 43, and Resident 47).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that all drugs and biologicals used in the facility were stored under proper temperature controls for 1 of 2 medication storage refrigerators reviewed during the survey, and that medications refused by a resident were disposed of properly (Resident 16, [NAME] hall, East Hall).

Inspectors wroteBased on observation and interview, the facility failed to ensure a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 4 of 6 resident rooms, 1 of 2 medication storage rooms, 1 of 1 pantries, and 4 of 4 units reviewed for environment. Floors were sticky and dirty, there were holes in the walls, sticky substances were on surfaces, drawers were missing, dressers were in disrepair, and clutter was present (2 east halls, 1 west hall, 1 locked unit, west medication room, east pantry, and room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]).

Inspectors wroteBased on interview and record review, the facility failed to attempt to obtain labs, indicate clinical signs of a UTI (urinary tract infection), or ensure the proper antibiotic was prescribed prior to administering an antibiotic for behaviors for 1 of 1 residents reviewed for current antibiotic use. (Resident 47)

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 of 1 residents reviewed for respiratory care (Resident 38).

Inspectors wroteBased on interview and record review, the facility failed to ensure that staff received sufficient training to ensure resident safety and reduce the number of adverse events or other resident complications for 1 of 1 residents reviewed who use the mechanical lift. (Resident 37)

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the complete and accurate staffing records were posted for 6 of 6 days reviewed during the survey (8/21/23, 8/22/23, 8/23/23, 8/24/23, 8/25/23, 8/28/23).