Westpark Rehabilitation and Living

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 5 of 7 residents (Resident #7, #9,#11, #12 and #13) reviewed for respiratory care. The facility failed to ensure Resident #7's Nasal cannula connected to the oxygen tank was properly stored on 04/01/26. The facility failed to ensure Resident #9's suction tip was properly stored on 04/01/26. The facility failed to ensure Resident #11's Nasal cannula connected to the oxygen concentrator was properly stored on 04/01/26. The facility failed to ensure Resident #12's Nasal cannula connected to the oxygen concentrator was properly stored on 04/01/26. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to, in accordance with State and Federal laws, store all drugs and biologicals in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys 3 of 7 residents (Residents #1, #7, and #10) reviewed for hazards. The facility failed to ensure Resident #1 did not have a bottle of Lumify eye drop in her room on 04/01/26 The facility failed to ensure Resident #7 did not have a pack of Alka Seltzer and saline nose spray in his room on 04/01/26 The facility failed to ensure Resident #10 did not have a jar of Vicks Vapor rub in her room on 04/01/26 These failures could place the residents at risk of accidental overdose, misuse of medications, and possible adverse reactions.

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 2 of 4 residents (Resident #1 and #5) reviewed for dignity. CNA E was observed standing over Resident #1 feeding her while the resident was lying in bed. Resident #5 was observed lying in bed and her catheter bag could be observed hanging from her bed without a privacy bag. These deficient practices could place residents at risk of not feeling as if they were being treated with dignity, privacy, and respect.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth 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 a resident for 1 of 6 residents (Resident #1 ) reviewed for care plans. The facility failed to ensure Resident #1's care plan reflected an intervention which included assisted feeding. This failure could place residents at risk of their needs not being met.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that residents' environment remained free of accident hazards as was possible for 2 of 12 residents (Residents #6, and #8) reviewed for accident prevention. The facility failed to ensure Resident #6's fall mat was placed alongside her bed while she was lying in it on [DATE]. The facility failed to ensure Resident #8 did not have a can of Lysol Spray in his room on [DATE]. These failures could prevent residents from having an environment that was free from hazards.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure resident received services in the facility with reasonable accommodation of resident needs for 2 of (Resident #1 and Resident #2) 7 resident rooms reviewed for reasonable accommodations. The facility failed to ensure the call light was accessible to Resident #1 and Resident #2 when lying in bed. This failure could place residents at risk of being unable to have a means of directly contacting caregivers. Findings Included: Record review of Resident #1's face sheet, dated 03/18/26, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents had the right to a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for 11 of 20 resident rooms (room [ROOM NUMBER], #2, #3, #4, #5, #6, #7, #8, #9, #10, and #11) and 2 of 2 shower rooms observed for cleanliness. The facility failed to ensure Rooms #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, and #11 were thoroughly cleaned and sanitized. The facility failed to ensure two of two shower rooms were thoroughly cleaned and sanitized. This facility failure could place residents at risk of living in an unclean and unsanitary environment, leading to a decreased quality of life.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for six (Residents #16, #26, #59, #85, #107, and #72) of sixteen residents reviewed for respiratory care.1. The facility failed to ensure Resident #16 's nasal cannula was stored properly when not in use on 02/04/2026.2. The facility failed to ensure Resident #26's breathing mask was properly stored when not in use on 02/04/2026. 3. The facility failed to ensure Resident #59's breathing mask was properly stored when not in use on 02/04/2026. 4. The facility failed to ensure Resident #85 's nasal cannula was stored properly when not in use on 02/04/2026.5. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free of significant medication errors for one (Resident #51) of six residents reviewed for significant medication errors. The facility failed to ensure Resident #51's propranolol (blood pressure medication) was administered as ordered on 02/05/2026. This failure could place residents at risk for not receiving the therapeutic effect of their medications as ordered by the physician.

Inspectors wroteBased on observation, interview and record review the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for ten (Resident #10, #18, #21, #31, #53, #73, #98, #102, #103, and #68) of twenty-eight residents reviewed for medication storage. 1. The facility failed to ensure Resident #10 did not have an anti-fungal cream on top of her bedside table on 02/04/2026.2. The facility failed to ensure Resident #102's zinc oxide was not left inside the resident's room on 02/04/2026.3. The facility failed to ensure Resident #103's zinc oxide was not left inside the resident's room on 02/04/2026.4. The facility failed to ensure Resident #21 did not have containers of zinc oxide on the resident's shelf on 02/04/2026.5. [...]

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 for the facility's for one of one kitchen reviewed for food and nutrition services. The Dietary Manager failed to wear a beard cover in the kitchen while prepared food was present. The facility failed to ensure dietary staff properly labeled and dated stored food received by vendors. The facility failed to ensure stored food in the freezer was concealed from air-borne contaminants. The facility failed to ensure the tea dispenser was covered. The facility failed to ensure the following were thoroughly cleaned and/or sanitized: [...]

Inspectors wroteBased 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 three (Residents #10, #150 and #60) of fifteen residents reviewed for infection control. 1. The facility failed to ensure CNA K wore a gown while changing Resident #10's linen, who was on enhanced barrier precautions due to having a g-tube, on 02/03/2026. 2. The facility failed to ensure RN E wore a gown when disconnecting Resident #150's antibiotic via PICC line, who was on enhanced barrier protection, on 02/05/2026.3. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for two direct care staff (RN D and MA G) and one (Crash Cart) of four carts reviewed for other environmental conditions.1. The facility failed to ensure that the drawers of the crash cart was not easily opened when not in use on 02/05/2026.2. The facility failed to ensure that RN D did not leave a container of germicidal wipes on top of the treatment cart at the wander unit unattended on 02/05/2026. 3. The facility failed to ensure MA G did not leave a container of germicidal wipes on top of her cart unattended on 02/05/2026. These failures could prevent the residents from having an environment that was safe for the residents, staff, and public.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for one (Resident #6) of fourteen residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident #6's room was in a position that was accessible to the resident on 02/04/2026. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.

Inspectors wroteBased on interview and record review the facility failed to notify the State Mental Health Authority to inform them of a significant change in mental condition for two (Residents #2 and #3) of eight residents reviewed for Preadmissions Screening and Annual Resident Review (PASRR).1. The facility failed to notify the SMHA to ensure Resident #2 received a new PASRR level 1 screening following identification of his diagnosis of major depressive disorder on 06/20/2017, delusional disorder on 04/15/2021, and dementia on 01/08/2023.2. The facility failed to notify the SMHA to ensure Resident #3 received a new PASRR level 1 screening following identification of his diagnoses of bipolar disorder, major depressive disorder, and generalized anxiety disorder on 11/14/2023. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth 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 a resident for 2 of 12 residents (Resident #22 and #36 ) reviewed for care plan. The facility failed to ensure Resident #22's care plan reflected a plan of care for the cancer lesion on her forehead. The facility failed to ensure Resident #36's Comprehensive Care Plan reflected the resident had a midline intravenous catheter for antibiotic administration. These failures could place residents at risk of their needs not being met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 8 residents (Resident #114) reviewed for ADL care. The facility failed to ensure Resident #114 received any scheduled showers for January 2026 and no indication of refusal. This failure could place residents at risk of not receiving necessary services to maintain good personal hygiene, skin integrity, or decreased self- esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents' environment remained free of accident hazards as was possible for 1 of 6 residents (Resident #114) reviewed for hazards. The facility failed to ensure Resident #114 did not have a bottle of rubbing alcohol in his room on 02/04/26. This failure could prevent the residents from having an environment that was free from hazards.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles for two (Resident #16 and Resident #32) of sixteen residents and one (Nurse's Cart) of two carts reviewed for pharmaceutical services. 1. The facility failed to dispose of an over-the-counter gas relief dated 12/2025.2. The facility failed to dispose of Resident #16's expired Linzess capsules dated 12/2025.3. The facility failed to dispose of Resident #32's expired Clonidine tablets with discard after date of 04/30/2024. These failures could place residents at risk of not receiving the medication's full therapeutic benefits and possible adverse reactions when taken.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow policies and procedures to ensure that each resident or the resident's representative had the opportunity to refuse immunization for 1 of 6 residents (Resident #33) reviewed for vaccinations. The facility failed to ensure Resident #33 did not receive the influenza vaccination on 10/17/25. This failure could place residents at risk of having an adverse reaction and suffering harm.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to develop a complete care plan that meets all of a resident's needs, with timeframes and actions that can be measured for one of three residents (Resident #2) reviewed for Care Plans. The facility failed to ensure Resident #2's usage of a Nebulizer device was care planned. This failure could place the resident at risk of not receiving the necessary care and services required.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure each resident is being watched and has assistance devices, when needed, to prevent accidents for one (Resident #1) of five residents reviewed for accident prevention. The facility failed to ensure Residents #1 had physician orders for the scoop mattress on his bed. The facility failed to ensure Resident #1's fall mat was properly positioned while he was in bed. These failures could prevent the resident from having an environment that was free and clear of accidents and hazards.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one of three residents (Resident #2) reviewed for respiratory care. The facility failed to ensure Resident #2's nebulizer mask was properly stored in a bag when not in use on 09/24/25. This failure could place the residents at risk for respiratory infection and not having their respiratory needs met.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for two of ten residents (Resident #1 and Resident #2) reviewed for reasonable accommodation of needs. 1. The facility failed to ensure the call light system in Resident #1's room was in a position that was accessible to the resident on 08/21/2025.2. The facility failed to ensure the call light system in Resident #2's room was in a position that was accessible to the resident on 08/21/2025. These failures could place residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.

Inspectors wroteBased on observation, interviews, and record review the facility failed to ensure all drugs and biologicals were stored securely for one (treatment cart #1) of 1 treatment carts reviewed for storage of medications. The facility failed to ensure treatment cart #1 was locked while unattended. This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm or drug diversions.

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 two (Residents #1 and #2) of eight residents reviewed for medications and pharmacy services. 1. The facility failed to obtain hospital discharge orders and administer Resident #1's seizure medication after his admission to the facility on Friday-03/21/25, resulting in him missing the medication on the evening of 03/21/25 and the morning of 03/22/25. 2. The facility failed to administer Resident #2's long and short acting inhalers related to her COPD after her admission to the facility on Friday-03/21/25 and on Saturday 03/22/25, in accordance with the admission orders. [...]

Inspectors wroteBased on observations, interview, and record review, the facility failed to protect a resident's right to be free from abuse for 1 (Residents #7) of 6 residents reviewed for resident abuse. The facility failed to ensure Resident #7 was free from physical abuse from LVN B during an incident on 01/04/2025 that subsequently required surgery on 01/09/2025. A Past Non Compliance Immediate Jeopardy (PNC IJ) was identified and presented to the Administrator on 02/19/2025 at 11:37 AM. The noncompliance began on 01/04/2025 and ended on 01/06/2025. The facility corrected the noncompliance before the investigation began. These failures placed residents at risk for serious injuries, abuse, and serious harm. Findings Included: Review of Resident #7's Face Sheet, dated 02/18/2025 at 1:30 PM, revealed she was a [AGE] year-old female admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for two (Resident #3 and Resident #4) of ten residents reviewed for Reasonable Accommodation of Needs. The facility failed to ensure the call light system in Resident #3 and Resident #4's rooms were in a position that was accessible to the residents on 02/18/2025. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident was incontinent of bladder received services and assistance to prevent urinary tract infections for one (Resident #2) of one resident reviewed for Urinary Incontinence. The facility failed to prevent Resident #2's indwelling urinary Foley catheter (device that drains urine from the urinary bladder) device from contact with the floor on 02/18/2025. This failure could place the resident with indwelling urinary catheter devices at risk for the development of urinary tract infections.

Inspectors wroteBased on observation, interview,' and record review the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #1) of five residents reviewed for Respiratory Care. The facility failed to ensure Resident #1's face mask for his nebulizer was properly stored when not in use on 02/18/2025. This failure could place residents at risk for respiratory infection and not having their respiratory needs met.

Inspectors wroteBased 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 one (Resident #5) of ten residents reviewed for Infection Control. The facility failed to ensure CNA G and COTA G changed their gloves and performed hand hygiene while providing incontinent care to Resident #5 on 02/18/2025. These failures could place residents at risk of cross-contamination and development of infections.

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 for one (Resident #1) of 5 residents reviewed for Dignity. The facility failed to treat Resident #1 with dignity and promote enhancement of her quality of life when the resident was not provided a privacy bag for her catheter bag. This failure placed residents at risk of not having their right to a dignified existence maintained and a decline in their quality of life.

Inspectors wroteBased on observations, interviews, and record review the facility failed to provide a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for 7 (room [ROOM NUMBER], #2, #3, #4, #5, #6, and #7) of 10 resident rooms and the hallway floors reviewed for cleanliness and sanitization. The facility failed to ensure that Resident room [ROOM NUMBER], #2, #3, #4, #5, #6, and #7 were thoroughly cleaned and sanitized. The facility failed to ensure that the facility hallway floors were cleaned. These deficient practices could place residents at risk of living in an unclean and unsanitary environment which could lead to a decreased quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 3 of twelve residents (Resident #35, Resident #55 and Resident #45) reviewed for Respiratory Care. 1. The facility failed to ensure Resident #35's nasal cannula for her oxygen concentrator was properly stored. 2. The facility failed to ensure Resident #55's face mask for his nebulizer was properly stored when not in use. 3. The facility failed to ensure Resident #45's nasal cannula (flexible tube used to deliver oxygen to the nose through two prongs) at the back of the wheelchair was properly stored. [...]

Inspectors wroteBased on observation, interviews, and record reviews the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for the facility's only kitchen, reviewed for food storage, labeling, dating, and kitchen sanitation. 1. The facility failed to ensure the ice chest, located on the 400-hall, was cleaned. 2. The facility failed to ensure the food stored in the refrigerator and freezer were labeled with the stored date. 3. The facility failed to ensure that the sugar and flour bins were cleaned. 4. The facility failed to ensure the ice scoop in the facility kitchen was cleaned. 5. The facility failed to ensure the kitchen cooking equipment was cleaned. 6. The facility failed to ensure the tea dispenser had the top placed back once the tea had brewed. [...]

Inspectors wroteBased 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 two of eight residents (Resident #6 and Resident #41) reviewed for Infection Control. 1. The facility failed to ensure CNA C changed her gloves and performed hand hygiene while providing incontinent care to Resident #6 on 11/19/2024. 2. The facility failed to ensure CNA B changed her gloves and performed hand hygiene while providing incontinent care to Resident #41 on 11/20/2024. 3. The facility failed to ensure CNA C would not place the pericare cleanser that would be used for incontinent care inside her pocket before using it on 11/19/2024. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for one (Resident #35) of sixteen residents reviewed for Reasonable Accommodation of Needs. The facility failed to ensure Resident #35 call light was answered within a reasonable time on 11/20/2024. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide the right to personal privacy which includes accommodations during personal care for one (Resident #1) of fourteen residents reviewed for Privacy. The facility failed to ensure LVN A closed Resident #1's door while checking the resident's blood sugar and while administering insulin on 11/20/2024. This failure could place the residents at risk of not having their personal privacy maintained during medical treatment.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure each resident received an accurate assessment, reflective of the resident's status for one (Resident #45) of eight residents reviewed for Accuracy of Assessments. The facility failed to ensure Resident #45's Quarterly MDS Assessment, dated 11/10/2024, accurately reflected that Resident #45 was on oxygen therapy. This failure could place residents at risk for not receiving care and services to meet their needs, diminished function of health, and regressions in their overall health.

Inspectors wroteBased on observations, interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as was possible for 1 of 3 residents (Resident #66) reviewed for accident hazards. The facility failed to obtain physician orders or a physician assessment, as of 11/19/24, for Resident #66 for the usage of a scoop mattress prior to installing the mattress to assist in fall prevention. This failure could place residents at risk of accidents and hazards.

Inspectors wroteBased observation, interview and record review the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infection and to restore continence to the extent possible for one of two residents (Resident #6) reviewed for Incontinent Care. The facility failed to ensure CNA C did not use the same wipes used to clean Resident #6's groin (junction between the central part of the body and the thighs) to clean the resident's front part on 11/19/2024. This failure could place residents at risk of cross-contamination and development of urinary tract infections.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident who was fed by enteral means received appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding which included but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers for one of two resident (Resident #39) reviewed for feeding tube. 1. The facility failed to ensure LVN A used a new syringe during Resident #39's medication administration via g-tube (a tube inserted through the abdomen that delivers nutrition directly to the stomach) on 11/20/2024. 2. The facility failed to ensure LVN A put on Resident #39's abdominal binder on 11/20/2024 as per order. These failures could place residents at risk of infection and accidental pulling of the gastronomy tube.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 11 residents (Resident #1) reviewed for abuse and/or neglect. The facility failed to protect Resident #1, who was not verbal, from sexual abuse when a confidential interviewee provided video footage of the resident trying to cover her breasts and vaginal area with her hands while CNA A was undressing her and when CNA A had her hands between Resident #1's legs and moved her hand in a fast motion inside the vaginal area for eight (8) minutes and two seconds (.02) after changing her. An IJ was identified on 08/07/24. The IJ template was provided to the facility on [DATE] at 1:30 p.m. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents, for 1 of 11 residents (Resident #1) reviewed for abuse. The facility failed to implement policy that prohibited abuse of Resident #1 was sexually abused when a confidential interviewee provided video footage of CNA A undressing Resident #1 as Resident #1used her crossed arms to cover her breast and CNA A inserted her hands between the legs of Resident #1, moved her hands in a fast motion inside the vaginal area for eight (8) minutes and 2 (.02) seconds after the resident's clothes were taken off. An IJ was identified on 08/07/24. The IJ template was provided to the facility on [DATE] at 1:30 p.m. [...]

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 for one (Resident #1) of three residents reviewed for care plans. The facility failed to ensure two staff performed incontinence care per the care plan for Resident #1. This failure could place residents at risk for not receiving care consistent with their care plan.

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 infection for one (Resident #1) of two residents observed for incontinence care. CNA A failed to perform hand hygiene and clean Resident #1's mattress during incontinence care. This failure could place residents at risk for infection during incontinence care.

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, mental and psychosocial needs that are identified in the comprehensive assessment for 4 of 10 residents (Residents # 37, #30, #21, #47) reviewed for care plans. The facility failed to address Residents #37, #30, #21 and #47's elected code status on their comprehensive person-centered care plan. This failure could affect residents and could result in resident's needs not being met.

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 safety in the facility's only kitchen. 1. The facility failed to ensure Dietary Aide G's hair restraint was worn properly and the Dietary Manager wore a beard restraint. 2. The facility failed to ensure stove top (range/griddle) and ovens were cleaned in accordance with professional standards. These failures could place all residents, who receive food from the kitchen, at risk for food contamination and food-borne illness.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pharmaceutical services, which included procedures that assured accurate acquiring, receiving, dispensing and administering of all drugs and biologicals to meet the needs of each resident, for 1 of 16 residents (Resident #15) reviewed for pharmacy services. The facility failed reorder the pain medication oxycodone in time causing Resident #15 to missed three doses on 10/17/23. This failure could place residents at risk for not receiving the therapeutic benefits of the prescribed medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure any drug regimen irregularities reported by the Pharmacist Consultant were acted upon, for 1 of 5 residents (Resident #1) reviewed for unnecessary medications, psychotropic medications, and medication regimen review. The facility's Pharmacist Consultant recommended Resident #15's Lexapro 10 mg be discontinued. The physician agreed but the medication continued to be administered to the resident. This failure could place residents on psychoactive medications at risk for possible adverse side effects, adverse consequences, and decreased quality of life.

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 one of three residents (Resident #27) reviewed for infection control, in that: 1. RN A failed to perform hand hygiene prior to entering room [ROOM NUMBER] to obtain blood pressure. 2. RN A failed to clean the blood pressure wrist cuff after checking vitals of Resident #27 and then placing the contaminated wrist cuff in the top drawer of the medication cart. 3. [...]

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 1 of 2 Medication Carts (400 Hall Medication Cart) reviewed for pharmacy services. The facility failed to ensure 400 Hall Medication Cart did not include medication for a deceased resident, Resident #1. This failure could place residents at risk of not receiving the correct medication, adverse reactions to medications, and worsening of symptoms of diseases. Findings Include: An observation on [DATE] at 7:52 AM, revealed there was medication on the 400 Hall Medication Cart for Resident #1. Record review of Resident #1's electronic record revealed the resident passed away on [DATE]. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for one of three (400 Hall Medication Cart) treatment carts reviewed for medication storage. The facility failed to ensure the 400 Hall Medication Cart was locked when unattended. This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm or drug diversion.

Inspectors wroteBased on observation, interview, and record review the facility failed to coordinate an assessment with the Preadmission Screening and Resident Review program (PASRR) under Medicaid to the maximum extent practicable to avoid duplicative testing and effort for one (Resident #1) of one resident reviewed for PASRR services. The facility failed to submit Resident #1's PASRR Comprehensive Service Plan (PCSP) form in the LTC Online Portal for Resident #1 by the specific deadline. This failure could place residents with a positive PASRR evaluation at risk of not receiving specialized PASRR services which could contribute to a decline in physical, mental, psychosocial well-being and quality of life.