West Valley Post Acute

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 3) was treated with respect and when staff did not wear the facility-issued identification badge. This deficient practice had the potential to compromise the resident's sense of safety and security. During a review of Resident 3's admission Record, the admission Record indicated that Resident 3 was initially admitted to the facility on [DATE] with diagnoses including cerebral edema (swelling of the brain), malignant neoplasm (a tumor that can invade surrounding normal tissue and/or spread to other parts of the body) of the brain, and malignant neoplasm of the bone. During a review of Resident 3's Minimum Data Set (MDS- a resident assessment tool) dated 5/9/2026, the MDS Entry Tracking Record indicated Resident 3 was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure History and Physical (H&P- contains relevant information about the resident's past medical history, current medical concerns, including review of any pre-existing medical conditions, past hospitalizations and surgeries, allergies, medications being taken, family medical history, physical examination and assessment of mental status) Examinations were completed by the physician for two of three sampled residents (Resident 1 and Resident 2). This deficient practice had the potential to result in incomplete clinical information, inconsistent care coordination, and compromised continuity of care, placing Resident 1 and Resident 2 at risk for unmet care needs and inadequate treatment planning. a. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify a resident's physician regarding an elevated blood sugar (the concentration of sugar in the blood) greater than 300 milligrams per deciliter (mg/dl - a unit of measurement, normal ranges: between 79 mg/dl and 99 mg/dl before meals) per the physician order for one of four sampled residents (Resident 1). This deficient practice had the potential to result in worsening symptoms of hyperglycemia (high values of sugar in the blood) and negatively affect the delivery of care and services to Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to notify the physician when the following medications: methimazole (used to treat hyperthyroidism [a condition that a thyroid gland produces and releases too much thyroid hormone], albuterol sulfate (used to prevent and treat wheezing, difficulty breathing, chest tightness, and coughing caused by lung diseases), and ipratropium bromide (a medication that helps breathe easier) were unavailable for administration to one for four sampled residents (Resident 1). This deficient practice resulted in Resident 1's physician being unaware Resident 1's medications were not available for administration and placed the resident at risk for health complications.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from physical abuse for two of two sampled Residents (Resident 1 and Resident 2) when on 10/30/2025, Resident 1 hit Resident 2 in the face using a right closed fist and Resident 2 hit Resident 1's face with the wheelchair footrest. The facility failed to:1. Ensure the facility's policy and procedure (P&P) titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, reviewed 5/28/2025, was followed which indicated residents have the right to be free from abuse. The resident abuse, neglect, and exploitation prevention program consists of a facility-wide commitment. to protect residents from abuse, neglect, exploitation or misappropriation of property, anyone including, but not necessarily limited to other residents and any other individuals. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive person-centered care plan (a written course of action that helps a resident achieve outcomes that improve their quality of life) for one of two sampled residents (Resident 2), who was identified to have behavioral triggers (something that causes the brain to react in a certain way, leading to a behavior). This deficient practice had the potential to result in the resident's behavioral needs not being properly addressed. Cross reference F600.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care in a manner that maintained a resident's dignity by failing to provide privacy during indwelling urinary catheter (a flexible tube inserted into the bladder [organ that stores urine] and left in place to continuously drain urine) care for two of five sampled residents (Resident 44 and 15). This deficient practice had the potential to negatively affect the residents' psychosocial (refers to the interplay between psychological factors [thoughts, feelings, behaviors] and social factors [relationships, environment, culture]) wellbeing and loss of dignity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to:1. Notify residents of the location of results of the most recent survey (means the Statement of Deficiencies [Form CMS-2567] generated by the most recent standard survey and any deficiencies resulting from any subsequent complaint investigation(s) for five (Resident 20, Resident 33, Resident 34, Resident 42, and Resident 88) who attended the resident council meeting.2. Post in a place readily accessible (is a place [such as a lobby or other area frequented by most residents, visitors or other individuals] where individuals wishing to examine survey results do not have to ask to see them) to residents and family members and legal representatives of residents, the results of the most recent survey of the facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a copy of the resident's Advance Directive (AD- a legal document indicating resident preference on end-of-life treatment decisions) was kept in the resident's medical chart and easily retrievable for two of three sampled residents (Resident 3 and 35) reviewed under the Advanced Directive care area. This deficient practice had the potential to create confusion which could lead to conflict with the resident`s wishes regarding their health care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the confidential personal information of residents were protected by failing to ensure documents containing protected health information ([PHI]- any health information that can be used to identify a specific individual which must remain confidential to prevent harmful consequences) were not shredded prior to disposing in the waste container. This failure had the potential to violate 100 of 101 residents' rights for privacy and confidentiality of personal and medical records.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a document that summarizes a resident's needs, goals, and care/treatment) for three of four sampled residents (Resident 114, 11, and 12) by failing to: 1. Develop a care plan addressing Resident 114 and 11's use of antibiotic (medication that fights bacterial infections). 2. Implement and follow Resident 12's care plan addressing Resident 12's elevated blood sugar. These deficient practices had the potential to result in failure to deliver the necessary care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services to improve or maintain range of motion ([ROM] full movement potential of a joint) and mobility (ability to move) for three of four sampled residents (Resident 105, 55, and 56) with positioning, mobility, and restorative nursing ([RNA] nursing aide program that helps residents to maintain their function and joint mobility) concerns by failing to: 1. Objectively measure Resident 105's ROM in both legs during the Physical Therapy ([PT] profession aimed in the restoration, maintenance, and promotion of optimal physical function) Evaluations, dated 3/2/2025 and 7/22/2025. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the urinary catheter tubing (a hollow tube inserted into the bladder to drain or collect urine) was positioned free flowing, without dependent loops (a sagging or U shaped section of the drainage tubing that dips below the level of the drainage bag) or kinks (twist) and did not backflow to the urine drainage port (a component of a urinary catheter that allows urine to flow from the bladder into the collection bag) for two of two sampled residents reviewed under the urinary catheter care area (Resident 44 and Resident 15). This deficient practice had the potential to negatively affect Resident 44 and Resident 15 from receiving the proper care necessary to prevent UTI's (urinary tract infection - an infection in the bladder/urinary tract).

Inspectors wroteBased on interview, and record review, the facility failed to provide nutritional care and services consistent with the resident's nutritional assessment and care plan for one of three sampled residents (Resident 8) reviewed under the nutritional care area by: 1. Failing to obtain the resident's weight on readmission from the General Acute Care Hospital (GACH, or simply hospital).2. Failing to obtain weekly weights This deficient practice had the potential to result in further weight loss for Resident 8 after their return from the GACH on 7/23/2025.

Inspectors wroteBased on interview and record review the facility failed to: 1. Account for one (1) dose of Controlled Substances (also known as Controlled Drug and Controlled Medications [CS, CD, CM]- medications which have a potential for abuse and may also lead to physical or psychological dependence) for Resident 2 in one (1) of two (2) inspected medication carts (Medication Cart 3.) 2. Account for one (1) dose of CS for Resident 102 in one (1) of two (2) inspected medication carts (Medication Cart 2.) 3. Reconcile (the process of comparing transactions and activity to supporting documentation) and account for four (4) medication emergency kits (eKITs) containing CSs for August 2025, in one (1) of one (1) inspected Medication Rooms (Medication room [ROOM NUMBER].) As a result, control and accountability of CSs did not follow state and federal regulations and facility policy and procedures. 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five (5) percent (%). Four (4) medication errors out of 28 total opportunities contributed to an overall medication error rate of 14.29% affecting three (3) of four (4) residents observed for medication administration (Resident 4, 49 and 99.) The medication errors were as follows:1. Resident 4 did not receive polyethylene glycol (a medication used for bowel management) as ordered by Resident 4's physician. 2. Resident 49 received Spiriva (a medication used to treat chronic obstructive pulmonary disease [COPD - a disease causing shortness of breath) at a different dose than ordered by Resident 49's physician. 3. Resident 49 was to be administered expired umeclidinium (a medication used to treat COPD) oral inhalation powder. 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free of any significant medication errors (means the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order, manufacturer's specifications, and accepted professional standards) by: 1. administering three (3) doses of expired Umeclidinium-Vilanterol (a medication used for chronic obstructive pulmonary disease [COPD - a disease causing shortness of breath)]) Ellipa (medication delivery device) inhalation powder by Licensed Vocational Nurse (LVN) 7 and Registered Nurse (RN) 2 between 8/9/2025 and 8/11/2025 to Resident 63 in one (1) of two (2) inspected medication carts (Medication Cart 3,) not in accordance with standards of practice. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to remove and discard from use: 1. one (1) open, expired insulin (a medication used to control high blood sugar levels) Lantus (brand name insulin for glargine, a long-acting insulin) Solostar (a type of insulin injection device) pen stored at room temperature for Resident 11, in accordance with manufacturer's requirements and facility policy and procedures, in one (1) of two (2) inspected medications carts (Medication cart 3.) 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the menu and did not meet nutritional needs of residents when:a. [NAME] 1 used perforated spoon (a large spoon with slots or holes for draining liquids) when portioning carrots and broccoli.b. [NAME] 2 mashed the sweet potato fries in the number 8 scoops (1/2 cup, [c, household measurement) to fill it in causing more than 1/2 c of sweet potato fries per serving. This failure had the potential to decrease nutrient and fiber intake and increase nutrient intake of calories and carbohydrates resulting in unplanned weight loss, unplanned weight gain and ineffective diet therapy to 74 of 101 residents on regular texture (texture of food with no restrictions and modifications) diet and consistent carbohydrate (CCHO, diet consisting of the same amount of carbohydrate each meal), getting food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare food by methods that conserve temperature when the puree corn salad was at 58 F ( F, a degree of temperature), sweet potato fries and sweet tater tots were at 79 F at the beginning of trayline. This deficient practice placed 95 of 101 facility residents on regular (texture of food with no modifications and restrictions) and modified texture diet at risk of unplanned weight loss, a consequence of poor food intake, getting food from the kitchen. Based on observation, interview, and record review, the facility failed to prepare food by methods that conserve temperature when the puree corn salad was at 58 F ( F, a degree of temperature), sweet potato fries and sweet tater tots were at 79 F at the beginning of trayline. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare foods in a form designed to meet individual needs when residents on puree diet/level four (4) received puree bread and puree beef were flat, and it did not hold its shape on the plate. This deficient practice had the potential to cause difficulty in eating, coughing, choking (to keep from breathing the normal way) and decrease of food intake resulting in weight loss for 18 of 101 residents on puree/level 4 diet.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: 1. Kitchen equipment and kitchen areas were not free from dust, dirt, food debris.a. Reach in freezer bottom shelves had boxes particles dirt debris and the gasket was torn and had dirt buildup.b. The walk-in refrigerator floor had sticky food spills and had dirt.c. The walk-in freezer floor had ice and dirt debris.d. Ice machine vent had dust build up and its internal parts had white dirt debris coming out when wiped with a paper towel.2. Ten dented cans were stored with non-dented cans. 3. Kitchen utensils and equipment were not smooth and free from chips, cracks and scratches.a. Fifty cracked, and chipped trays were used for lunch service.b. [NAME] chopping board with scratches and black stains.4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose garbage and refuse properly when one (1) of three (3) dumpsters (a movable waste container designed to be brought and taken away by a special collection vehicle, or to a bin that a specially designed garbage truck lifts) were not covered while not actively being used and there were trashes, empty cups, paper towel and salsa spills on the floor. This failure had potential to attract birds, flies, insects, pests and possibly spread infection to 100 of 101 facility residents.

Inspectors wroteBased on interview and record review, the facility failed to maintain timely and accurate resident medical records in accordance with accepted professional standards by failing to: 1. Complete timely documentation of a resident's urinary catheter care (flexible tube passed into the bladder to drain urine) for one of two sampled residents (Resident 15) reviewed under the urinary catheter care area.2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure a resident's nasal cannula (device used to deliver supplemental oxygen placed directly on a resident's nostrils) oxygen tubing was dated for one of one sampled resident (Resident 125) reviewed under the respiratory care area. This deficient practice had the potential to result in contamination of the resident's care equipment and risk of transmission of bacteria that can lead to infection. 2. Ensure a resident's urinary catheter (a flexible tube inserted into the bladder to drain urine) system was labeled for one of two sampled residents (Resident 15) reviewed under the catheter care area. This deficient practice placed Resident 15 at risk for infections and prolonged use of an old urinary catheter. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a call light (a device used by a patient to signal his or her need for assistance from a professional staff) was within reach for one of three sampled residents (Resident 83) investigated under the environment facility task. This deficient practice had the potential to result in Resident 83 not being able to call for facility staff assistance and delay in the provision of necessary care and services that can negatively affect the residents' comfort and well-being.

Inspectors wroteBased on interview and record review the facility failed to notify the resident's physician of a change of condition (COC, decline or improvement in a resident's status that will not resolve itself without intervention) in accordance with physician's orders for one of two residents (Resident 12) reviewed who were prescribed insulin (hormone that regulates blood sugar levels) by failing to: 1. Notify the physician when Resident 12's blood sugar was over 300. 2. Notify the physician when Resident 12' blood sugar was over 400 and change in condition form was not filled out. This had the potential for Resident 12 to suffer complications from elevated blood glucose such as infection and diabetic coma (a complication of diabetes where a person loses consciousness due to extremely high blood sugar levels).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a qualified staff member adjusted the left extension knee splint (brace designed to help maintain or improve the range of motion at the knee joint) for one of three residents (Resident 105) with positioning and range of motion ([ROM] full movement potential of a joint) concerns in accordance with professional standards and the facility's job descriptions. This failure placed Resident 105 at an increased risk for developing injury, skin breakdown (tissue damage caused by friction [surfaces rubbing against each other], shear [strain produced by pressure], moisture, or pressure), and further ROM limitations on the left knee.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Medication Regimen Review (MRR - review of a resident's drug therapy to assure appropriateness of medication usage completed each month by the consultant pharmacist) was acted upon for one (Resident 12) of six residents investigated for unnecessary medications, by failing to act upon the facility consultant pharmacist's recommendation to provide a location of application for Diclofenac Gel (a nonsteroidal anti-inflammatory drug [NSAID] used topically for pain relief and inflammation). This had the potential for licensed nurses not to know the location of Resident 12's pain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately assess range of motion ([ROM] full movement potential of a joint) limitations in both legs for one of three sampled residents (Resident 55) with positioning and mobility (ability to move) concerns on four Minimum Data Set ([MDS] a federally mandated resident assessment tool) assessments, dated 10/31/2024, 1/31/2025, 4/30/2025, and 7/30/2025. This failure had the potential to affect the provision of Resident 55's care and provided inaccurate information to the Federal database.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide at least 80 square feet (sq. ft. - unit of measurement) per resident in multiple resident bedrooms for the four out of 38 resident rooms (Rooms 1, 2, 3, 5, 7, 9, 15, 17, 19, 21, 23, 25, 26, 28, 30, 31, 36, 37, 39, 41, 42, 43, 44, 45, 46, 47 and 48). This deficient practice had the potential to result in inadequate useable living space for all the residents and inadequate working space for the health caregivers.

Inspectors wroteBased on interview and record review, the facility failed to implement its policy and procedure (P&P) on abuse for an allegation of financial abuse for one of three sampled residents (Resident 1) by failing to: 1. Conduct a thorough investigation of the alleged financial abuse. 2. Ensure the facility's Social Services Director (SSD) reported a suspicion of financial abuse to the Abuse Coordinator on 6/26/2025. 3. Complete and submit a written five (5) day follow-up investigation report indicating the results of the investigation for the allegation of financial abuse that occurred on 6/26/2025. This deficient practice had the potential to place Resident 1 at risk for further financial exploitation and resulted in a delay in investigation of a suspicion of financial abuse.

Inspectors wroteBased on interview and record review, the facility failed to implement policies and procedures (P&P) for ensuring the reporting of a reasonable suspicion of a crime in accordance with Section 1150B of the Act by failing to report an allegation of financial abuse for one of three sampled residents (Resident 1) to the State Survey Agency (SSA) within the required timeframe. This deficient practice had the potential to place Resident 1 at risk for further financial exploitation and resulted in a delay in investigation of a suspicion of financial abuse.

Inspectors wroteBased on interview and record review, the facility to ensure two of five sampled residents (Resident 1 and Resident 2) received care and services in accordance with professional standards of practice by: 1. Failing to administer Resident 1's acetaminophen (a medication used to relieve mild to moderate pain) as prescribed by the physician. This deficient practice had the potential for Resident 1 to experience untreated pain. 2. Failing to ensure licensed nurses attempted and documented nonpharmacological interventions (treatments or strategies that do not involve the use of medications) prior to administering as needed (PRN) hydrocodone-acetaminophen (medication used to treat severe pain) to Resident 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide reasonable accommodation of resident needs and preferences by failing to ensure the call light (an alerting device for nurses or other nursing personnel to assist a resident when in need) was within reach for one of five sampled residents (Resident 3). This deficient practice had the potential to result in a delay of care and services and possible injury to residents when unable to obtain the needed care and services.

Inspectors wroteBased on interview and record review, the facility failed to implement its policy and procedure (P&P) on care planning- interdisciplinary (a group of professionals from different fields who work together to achieve a shared goal for the resident) team by failing to ensure the required interdisciplinary team members, including a physician, a registered nurse (RN), and a certified nurse assistant (CNA), were in attendance during a scheduled care plan meeting for one of five sampled residents (Resident 1). This deficient practice had the potential to affect residents' care coordination, potentially leading to unmet needs and avoidable declines in condition.

Inspectors wroteBased on interview and record review, the facility failed to provide the needed care and services that were resident-centered for one of five sampled residents (Resident 4) by the facility failing to accurately transcribe Resident 4's Lenalidomide (a medication used to treat multiple myeloma [a type of blood cancer that originates in plasma cells - a type of white blood cells that produce antibodies {a protein produced by the immune system to identify and neutralize foreign substances like bacteria and viruses}]) order. This deficient practice resulted in Resident 4 not receiving Resident 4's prescribed medication as ordered and placed Resident 4 at risk for worsening medical condition and compromised immune system that may lead to infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's attending physician documented and completed a resident's History and Physical (H&P- a formal assessment by a healthcare provider that involves a resident interview, physical exam, and documentation of findings) within 72 hours following a resident's admission for two of three sampled residents (Resident 1 and Resident 2). This deficient practice had the potential for inconsistent care coordination due to incomplete medical records for Resident 1 and Resident 2.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled residents (Resident 4) was free from significant medication error by failing to ensure Resident 4's Lenalidomide (a medication used to treat multiple myeloma [a type of blood cancer that originates in plasma cells - a type of white blood cells that produce antibodies {a protein produced by the immune system to identify and neutralize foreign substances like bacteria and viruses}]) was administered as ordered. This deficient practice resulted in Resident 4 receiving one dose of a 21-day cycle medication.

Inspectors wroteBased on interview and record review, the facility failed to implement the facility's policy by failing to investigate a report regarding a resident's missing bilateral (affecting both sides) hearing aids one of four sampled residents (Resident 1). This deficient practice had the potential for a delay in resident's right to retain and use personal property (bilateral hearing aids).

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure the designated Administrator (DADM) held a current and active license from the State to serve in the capacity of a nursing home administrator (NHA) 2. Implement its policy and procedures (P&P) for ensuring the background check of the DADM was initiated and completed prior to employment. This deficient practice resulted in DADM operating the facility with an inactive NHA licensed that could potentially negatively affect the facility's functions.

Inspectors wroteBased on interview and record review, the facility failed to ensure a copy of a resident's Advance Directive (a written statement of a person's wishes regarding medical treatment) was kept in the resident's chart and easily retrievable for three of four sampled residents (Resident 83, 49, 18). This deficient practice has the potential to create confusion which could lead to conflict with the resident's wishes regarding his/her health care.

Inspectors wrote2. During a review of Resident 13's admission Record, the admission Record indicated Resident 13 was initially admitted on [DATE] with diagnoses including type 2 diabetes mellitus (DM II - a long-term condition in which the body has trouble controlling blood sugar and using it for energy). During a review of Resident 13's MDS dated [DATE], the MDS indicated Resident 13 had intact cognition. The MDS indicated that Resident 13 required substantial assistance from staff with activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store food in accordance with professional standards by not labeling food stored with a use by date. These deficient practices had the potential for 98 of 100 residents who receive food from the facility kitchen to be at risk for food borne illness (illness caused by food contamination with bacteria, viruses, parasites, or toxins).

Inspectors wroteBased on interview and record review, the facility failed to obtain consents and inform the resident in advance of the risks and benefits of the psychotropic (medications capable of affecting the mind, emotions, and behavior) medications for one of three sampled residents (Resident 13). This deficient practice violated Resident 13's right to know about and make decisions about their medical care.

Inspectors wroteBased on interview, and record review, the facility failed to develop a comprehensive person-centered care plan (a plan for an individual's specific health needs and desired health outcomes) for one of two sampled residents (Resident 18) by failing to develop a comprehensive person-centered Care Plan for the activity needs (any activities that are intended to improve a resident's quality of life and promote their physical, cognitive, and emotional health) of Resident 18. This deficient practice had the potential for Resident 18 to not receive the necessary care and services to address and allow Resident 18 to participate in activities.

Inspectors wroteBased on interview, and record review, the facility failed to immediately (no later than 21 days after admission) develop a comprehensive person-centered care plan (a plan for an individual's specific health needs and desired health outcomes) for one of two sampled residents (Resident 91). Resident 91 received a physician order for the use of Apixaban (a type of anticoagulant [blood thinning] medication) on 6/23/24, a care plan for anticoagulants was not developed until 7/22/24. This deficient practice had the potential for Resident 91 to not receive the necessary care and services to address and prevent complications of anticoagulant therapy for Resident 91 such as excessive bleeding.

Inspectors wroteBased on interview and record review, the facility failed to reassess one of 19 sampled resident's (Resident 156) pain level (the amount of pain a resident is experiencing), 30 minutes to one (1) hour after the administration of oxycodone (medication used to treat pain). This deficient practice increased the risk of Resident 156 having untreated and prolonged unrelieved pain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 32) received needed dental services. This deficient practice placed Resident 32 at increased risk for deterioration of oral hygiene and gum disease (bacteria attacks the gums, causing swelling and bleeding)

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare pureed (consists of food that have been blended into smooth, soft consistency) egg noodles according to the facility recipe on 9/4/2024 for 14 of 100 residents who are on a pureed diet. This deficient practice had a potential for residents who are on pureed diet not to eat the served food and could potentially lead to weight loss.

Inspectors wroteBased on interview and record review, the facility failed to transmit a resident's Discharge Minimum Data Set (MDS, a standardized assessment and care screening tool) within 14 days after the Discharge MDS completion date for one of 48 sampled residents (Resident 27). This deficient practice had the potential to delay care and services for the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that 27 of 49 resident rooms (room [ROOM NUMBER], 2, 3, 5, 7, 9, 15, 17, 19, 21, 23, 25, 26, 28, 30, 31, 36, 37, 39, 41, 42, 43, 44, 45, 46, 47, and 48) met the square footage requirement of 80 square feet (sq. ft. - unit of measurement) per resident in multiple resident rooms. The room size for these rooms had the potential to have inadequate space for resident care and mobility.

Inspectors wroteBased on observation and interview, the facility failed to ensure one of three sampled residents (Resident 1) was provided a clean and homelike environment when on 8/28/2024, observed the floor of Resident 1's room soiled with multiple plastic wrappers, two plastic containers, one plastic spoon, several pieces of paper and a soiled washcloth on the floor around Resident 1's bed. This deficient practice had the potential to negatively impact Resident 1's quality of life, had the potential to result in the spread of infection; and increased the risk of accidents or injuries to residents, staff, and visitors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control practices by: 1. Failing to ensure one of five sampled staff (Housekeeping 1 [HK 1]) performed hand hygiene (HH - cleaning hands by either washing with soap and water, or by using a hand sanitizing [removing germs] gel) after exiting Resident 4's room which was placed on novel respiratory precautions (NRP - precautions should be used for residents known or suspected to be infected with { Coronavirus Disease 2019 [COVID-19 - a highly contagious respiratory illness in humans capable of producing severe symptoms]}). 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that one of three sampled residents (Resident 1), who had a diagnosis of paroxysmal atrial fibrillation (A-fib: an irregular, often rapid heart rate that commonly causes poor blood flow) and was prescribed Coumadin (also known as Warfarin- a medication used to prevent blood clots [gel-like clumps of blood] from developing), was provided with the needed laboratory services when on 5/16/2024, a physician order for the laboratory draw of Prothrombin Time with an International Normalized Ratio (PT/ INR- a laboratory test that takes a measurement of the time taken for blood to clot; lab results are needed for the attending physician to determine what dose of Coumadin a resident should take) was not done for Resident 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive person-centered care plan (a plan for a resident ' s specific health needs and desired health outcomes) for three of three sampled residents (Resident 2, 7 and 8) by: 1. Failing to ensure a care plan was developed for Resident 2 ' s use of Warfarin (a medication used to treat and prevent blood clots [gel-like clumps of blood]). 2. Failing to ensure a care plan was developed for Resident 7 ' s use of Digoxin (medication use to treat congestive heart failure [CHF- A weakened heart condition that causes fluid buildup in the feet, arms, lungs, and other organs]). 3. [...]

Inspectors wroteBased on interview and record review the facility failed to provide reasonable accommodation of resident needs and preferences by failing to ensure the call light (an alerting device for nurses or other nursing personnel to assist a resident when in need) was within reach for one of three sampled residents (Resident 1). This deficient practice had the potential to result in a delay of care and services and possible injury to residents when unable to obtain the needed care and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure laboratory orders were obtained for the use of Phenytoin Sodium (Dilantin- a medication used to treat seizures [a sudden, uncontrolled burst of electrical activity in the brain which can cause changes in behavior, movements, feelings and levels of consciousness]) for one of three sampled residents (Resident 8) in order to determine if the dose of the Phenytoin Sodium is within therapeutic drug levels (measures the amount of certain medicines in your blood, to determine if the dose of the medication is within expected range). This deficient practice placed Resident 8 at risk of not receiving appropriate care and services and had the potential to result in having nontherapeutic laboratory levels which may cause seizure activity.

Inspectors wroteBased on interview and record review the facility failed to ensure that one of three sampled residents (Resident 1) was free of unnecessary medication, when on 2/2/2024, Registered Nurse 1 (RN 1) obtained a physician's order for Norco (a medication used to relieve moderate to severe pain) without performing a complete pain assessment. This deficient practice resulted in Resident 1 receiving an unnecessary dose of Norco on 2/2/2024 and placed Resident 1 at risk for side effects (unwanted, undesirable effects resulting from a medication) such as confusion, sleepiness, difficulty in breathing, dizziness, and drowsiness.

Inspectors wroteBased on interview and record review, the facility failed to protect a resident's right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) for one of four sampled residents (Resident 1) when on 12/25/2023, Resident 3 witnessed Resident 2 shoved (to push with force) and hit Resident 1's head and shoulder area. This deficient practice resulted in Resident 1 being subjected to physical abuse by Resident 2 while under the care of the facility. Based on the reasonable person concept (hypothetical [suggested], average person's reaction to the actual circumstances) due to Resident 1's moderately impaired cognition (ability of think and make decisions), an individual subjected to physical abuse has lifetime physical pain and psychological (mental or emotional) effects including feelings of embarrassment and humiliation.

Inspectors wroteBased on interview and record review, the facility failed to implement its policy and procedures (P&P) for ensuring the reporting of a reasonable suspicion of a crime in accordance with Section 1150B of the Act by failing to report the initial report of the physical abuse allegation within two (2) hours of the incident for one of four sampled residents (Resident 1). This deficient practice had the potential to result in delay of necessary actions to oversee the protection of the residents in the facility by the State Survey Agency (SSA).

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure the Dehydration (lack of sufficient water in a person's body) Risk Assessment was accurately completed for two of three sampled residents (Resident 1 and Resident 2). 2. ensure the Registered Dietitian (RD) conducted a nutritional assessment for two of three sampled residents (Resident 1 and Resident 2) upon admission, as per the facility's policy and procedure (P&P) titled Nutritional Assessment. These deficient practices had the potential to place Resident 1 and Resident 2 at risk for dehydration and placed both residents (Resident 1 and Resident 2) at risk for medical complications related to inadequate nutrition.

Inspectors wroteBased on interview and record review, the facility failed to notify the responsible party (RP) of a change in condition (COC - when there is a sudden change from a resident's health) timely for one of three sampled residents (Resident 1) when on 10/26/2022, Resident 1 was exposed to Coronavirus Disease 2019 (COVID-19 - a highly contagious respiratory illness in humans capable of producing severe symptoms). This deficient practice had the potential outcome to have had a negative effect on Resident 1's treatment if any decisions were needed at the time of the change of condition.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a written course of action that helps a resident achieve outcomes that improve their quality of life) for one of three sampled residents (Resident 1), who was identified at risk for dehydration (lack of sufficient water in a person's body). This deficient practice had the potential to negatively affect the delivery of care and services to Resident 1.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the peripheral (the arms, hands, legs, and feet) intravenous (IV-into the vein) catheter (a thin plastic tube inserted into a vein using a needle) policy was implemented to provide safe care to prevent complications for one of three sampled residents (Resident 2). This deficient practice had the potential to place Resident 2 at risk for developing complications such as inflammation of the vein and infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure effective pain management was done by failing to: 1. Administer pain medication for the appropriate pain scale as indicated by the physician's orders for four of four sampled residents (Resident 66, 62, 81, and 68). 2. Document pain assessments on the Medication Administration Record (MAR) for two of two sampled residents (Resident 66 and 62). These deficient practices may lead to inaccurate pain assessment and inadequate management of residents' pain.

Inspectors wroteBased on interview and record review, the facility failed to provide dementia (brain disease causing memory problems) training and verify staff competency upon staff orientation for five out of five sampled newly hired staff (Certified Nursing Assistant 4 [CNA 4], Certified Nursing Assistant 5 [CNA 5], Licensed Vocational Nurse [LVN 9], Licensed Vocational Nurse [LVN 10], and Registered Nurse [RN 4]), investigated under the facility task of sufficient and competent nurse staffing. This deficient practice had the potential to place elderly residents with dementia at risk for harm due to lack of sufficient and competent staff training.

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Ensure the Controlled Drug Record (CDR- accountability record of medications that are considered to have a strong potential for abuse) coincided with the Medication Administration Records (MAR) for two of two sampled residents (Residents 66 and 62). This deficient practice resulted in inaccurate reconciliation of the controlled medication and placed the facility at potential for inability to readily identify loss and drug diversion (illegal distribution of abuse of prescription drugs or their use for unintended purposes) of controlled medications. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe storage and handling of medications for two of four medication carts (Med Cart 1 and Med Cart 3), one of two medication storage (Med Storage 1), and safe provision of pharmaceutical services for three of three sampled residents (Resident 76, 28, and 100) by: 1. Failing to ensure Med Cart 1's blood sugar strips was opened with an opened date. 2. Failing to ensure Med Cart 3 contained: - Resident 31 and Resident 4's ipratropium/albuterol (used to control and prevent symptoms [wheezing and shortness of breath] caused by ongoing lung disease) foil pouch was dated with an opened date. - Resident 41's Percocet (used to treat moderate to severe pain) bubble pack (container) slot #1 with a cracked seal was disposed accordingly. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the proper storage, preparation and distribution of food was done under sanitary conditions for 112 of 116 residents of the facility by: 1. Failing to properly label one box of orange juice, one box of apple juice, one box of nectar water, five containers of an apple sauce-like substance, one container of cooked pasta, and one prepared salad. 2. Failing to ensure there was an air gap (the physical separation of the potable and non-potable water supply systems by an air space) between the ice machine drainage pipe and the drain. 3. Failing to ensure the quaternary ammonium sanitizing solution (ammonium solution used for sanitizing surfaces) log was completed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control policy and procedure by failing to: 1. Ensure Resident 250's nasal cannula (thin, flexible tube containing two open prongs used to deliver oxygen) tubing was labeled with the date and kept off the floor. 2. Ensure staff doffed (took off) their personal protective equipment (PPE - specialized clothing, like glove, gown, mask, or eye protection, used to protect from exposure to potentially infectious materials to avoid injury or disease) properly as evidenced by Restorative Nursing Assistant 1 (RNA 1) removing her gown over her contaminated gloves when doffing in Resident 65's room. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an interdisciplinary team meeting (IDT- communication among healthcare team members) was conducted prior to Resident 23's self-administering medication for nasacort (used to treat inflammation caused by allergies such as runny nose and congestion), for one of one resident. This deficient practice had the potential to result in inappropriate use and unsafe resident self-administration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 26 sampled residents (Resident 52) was provided with a call light (device used to notify staff when assistance is needed). This deficient practice resulted in Resident 52 not being able to summon health care workers for assistance when needed.

Inspectors wroteBased on interview and record review, the facility failed to ensure documented evidence that Resident 94's advance directive (written instruction, such as a living will or durable power of attorney, of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them) was discussed, for one of eight sampled residents (Resident 94). This deficient practice violated the resident's right to be fully informed of the option to formulate their advance directive.

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet professional standards of quality when the physician was not notified of Resident 28's missing lidocaine patch (a prescription topical analgesic used to treat the symptoms of nerve pain, and temporary pain relief) before Licensed Vocational Nurse (LVN 7) reapplied another one per facility's policy and procedure, for one of three sample residents (Resident 28). This deficient practice has the potential to result in an overdosage of Lidocaine to Resident 28 with symptoms that may include slow heartbeat, seizure (convulsions), loss of consciousness, or confusion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Resident 24 and 250) investigated under the Oxygen Care Area Task were provided safe oxygen administration by: 1. Failing to ensure Residents 24 and 250 had an oxygen treatment ordered by the physician. This deficient practice had the potential to receive an unnecessary medication. 2. Failing to ensure Resident 24 had a signage for oxygen in use while oxygen was in in the room. This deficient practice had potential for Resident 24 at increased risk of accident such as risk for fire hazard.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Medication Regimen Review (MRR - a review of a resident's drug therapy to assure appropriateness of medication usage) was acted upon for two of six sampled residents investigated under the care area of unnecessary medications (Resident 200 and 89) by: 1. For Resident 200, the facility's consultant pharmacist failed to identify Resident 200's Xanax (medication used to treat anxiety [intense, excessive, and persistent worry and fear about everyday situations]) as needed (PRN) order did not have a duration and stop date. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that one of five sampled residents (Residents 81) was free of unnecessary medication by failing to ensure the dabigatran etexilate mesylate (Pradaxa, an anticoagulant [a class of drugs used to treat or prevent the formation of blood clots]) was prescribed with an adequate indication. This deficient practice had the potential to result in the resident receiving unnecessary medication resulting in adverse effects (any unexpected or dangerous reaction to a drug) such as bleeding.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of six residents (Resident 200) reviewed for unnecessary medications, were free from unnecessary psychotropic medications (medications capable of affecting the mind, emotions, and behavior) by failing to ensure Resident 200's physician order for Xanax (medication used to treat anxiety [intense, excessive, and persistent worry and fear about everyday situations]) as needed (PRN) had a duration (length of time of treatment). This deficient practice had the potential to result in adverse reaction (any unexpected or dangerous reaction to a drug) or impairment in the resident's mental or physical condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure call light system was in working condition for one of one sampled resident (Resident 400). This deficient practice had the potential to result in delay in response to the resident's requests and needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS - a comprehensive standardized assessment and screening tool) was completed within the required time frame for one out of two sampled residents (Resident 2) investigated addressing resident assessments. This deficient practice had the potential to negatively affect the provision of necessary care and services for Resident 2.

Inspectors wroteBased on interview and record review, the facility failed to ensure an accurate assessment was conducted for Resident 101's discharge status in the Minimum Data Set (MDS - a resident assessment and care screening tool), for one of three sampled residents under the investigative area of closed record review. This failure had the potential to negatively affect Resident 101's plan of care and delivery of necessary care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that 27 of 49 resident rooms (room [ROOM NUMBER], 2, 3, 4, 5, 6, 20, 21, 22, 23, 24, 25, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, and 42) met the square footage requirement of 80 square feet (sq ft. - unit of measurement) per resident in multiple resident rooms. The room size for these rooms had the potential to have inadequate space for resident care and mobility.