Whispering Pines Lodge

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure personnel provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives for 1 of 2 (Resident #1) reviewed for quality of life. The facility failed to ensure LVN A performed basic life support measures per AHA, BCLS guidelines when Resident #1 was in distress and choking on 2/7/26. The facility failed to ensure RN B performed basic life support per AHA guidelines for Resident #1 on 2/7/26. The facility failed to ensure MA C performed basic life support per AHA guidelines for Resident #1 on 2/7/26. The facility failed to ensure LVN A, RN B, and MA C, CPR trainings were up to date. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide residents with the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for two of five residents (Resident #7, Anonymous Resident) reviewed for quality of life. The facility failed to report the Hall A water temperatures were cold and provided a bed bath to Resident # 7 with cold water during the winter storm. The facility failed to provide an anonymous resident with a warm, comfortable shower. This failure could place residents at risk for a decline in quality of life and health status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote care for residents in a manner and in an environment that maintained or enhanced each resident's respect and dignity for 1 of 5 residents (Resident #21) reviewed for dignity. The facility failed to provide dignity and respect by allowing Resident #21 to remain in soiled clothing for two hours and taking resident to dining hall without changing his clothes on 1/29/2026. This failure could place residents at risk of embarrassment and low self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure in accordance with state and federal laws, all drugs and biologicals were stored in locked compartments for 1 of 2 residents (Resident #14) reviewed for storage of medication. The facility failed to ensure that Resident #14's Fluticasone Propionate Nasal Spray (a synthetic corticosteroid that helps reduce inflammation in the body) were not left at her bedside. This failure could place residents at risk of not receiving medications as ordered or receiving too much medication.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 Halls (Hall #2) and 2 of 4 showers (Shower #2 and Shower # 4) reviewed for infection control. The facility failed to ensure trash was properly stored for Shower #4 on 1/29/2026 at 9:44 a.m. The facility failed to ensure trash was properly stored and removed from Hall #2 on 2/2/2026 at 9:46 a.m. The facility failed to ensure dirty linens were properly stored in Shower #2 on 1/29/2026 at 10:24 a.m. These failures could affect residents and place them at risk of unsanitary and uncomfortable environment.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for 1 of 4 Halls (Hall #2) and 2 of 4 showers (Shower #2 and Shower #4) reviewed for environment. The facility failed to ensure trash was properly stored for Shower #4 on 1/29/2026 at 9:44 a.m. The facility failed to ensure trash was properly stored and removed from Hall #2 on 2/2/2026 at 9:46 a.m. The facility failed to ensure dirty linens were properly stored in Shower #2 on 1/29/2026 at 10:24 a.m. The facility failed to ensure toilet rim was intact without cracked porcelain on the back of the toilet on 1/29/2026 at 10:38 a.m These failures could place residents at risk in an unsanitary and uncomfortable environment.

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 others for 4 of 21 residents (Resident #16, Resident #24, Resident #37 and Resident #60) reviewed for reasonable accommodations of needs. The facility failed to ensure Resident #16, Resident #24, Resident #37 and Resident #60 had a call light within reach on the memory care and secure unit. This failure could place residents at risk of possible falls, major injuries, hospitalization, and unmet needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure their activities program was directed by a qualified professional for 1 of 1 facility reviewed. The facility failed to employ a certified activities director who oversaw the activities program. This failure could place the residents at risk of not receiving a program of activities that meets their assessed activity needs.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure professional staff were licensed, certified or registered in accordance with applicable state laws for 1 (LVN A) of 4 licensed nursing staff reviewed for staff qualifications. The facility failed to ensure LVN A's license was valid in order to practice as a licensed vocational nurse from [DATE] through [DATE]. This failure could place residents at risk of receiving nursing services by an unlicensed nurse.

Inspectors wroteBased on observation, interview, and record review the facility failed to promptly resolve grievances for 1 of 6 residents (Resident #12) reviewed for grievances. The facility failed to ensure a grievance was filed when Resident #12 reported to the DON his roommate was loud, and he could not sleep. This failure could place residents at risk for grievances not being addressed or resolved promptly resulting in frustration and sleep deprivation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene were provided for 2 of 6 residents reviewed for ADLs (Resident #2 and Resident 30). The facility did not provide scheduled showers for Resident #2 on 01/05/2026. The facility failed to provide assistance for Resident # 30 with the removal of facial hair on 01/05/2026. These failures could place residents at risk of not receiving services/care and decreased quality of life. Findings Include: 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide an ongoing program of activities in accordance with the comprehensive assessment to meet the interests and the physical, mental, and psychosocial well-being for 2 of 6 residents (Resident #2 and Resident #7) reviewed for activities. The facility failed to ensure quarterly activity assessments were completed for Resident #2. The facility failed to provide consistent and scheduled in-room activities for Resident #7 to meet her needs. These failures could place residents at risk for not having activities to meet their interests or needs and a decline in their physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, record review and interview the facility failed to store all drugs and biologicals in locked compartments for 1 of 4 medication carts reviewed. (Nurse medication cart for the B Hall) LVN D failed to securely lock the nurse medication cart for the B Hall. This failure could place residents at risk of not having their medications available as prescribed or possible drug diversions.

Inspectors wroteBased on observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 22 residents (Resident #22), reviewed for infection control practices.1. The facility failed to ensure SNA B and CNA C wore a gown while providing direct care to Resident #22, who was on EBP (infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and glove use during high contact resident care activities), while performing a mechanical lift transfer and incontinent care on 1/05/2026.2. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside, for 1 of 6 residents (Resident #12) reviewed for call lights. The facility failed to ensure Resident #12's call light was functioning properly. This failure could place residents at risk of possible falls, major injuries, hospitalization, and unmet needs.

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 20 of 25 (Resident's #2, #4, #5, #6, #8, #9, #10, #12, #13, #14, #16, #17, #18, #19, #20, #21, #22, #23, #24) reviewed for abuse and neglect. 1. The facility failed to ensure LVN D did not physically abuse Resident #4 when she picked her up from her wheelchair and threw her on to the mattress on the floor on 07/17/25. Resident #4 sustained a bruise to her right elbow and redness to the mid abdomen. 2. The facility failed to ensure LVN E did not verbally abuse Resident #9 when LVN E yelled and cursed at Resident #9 when she asked for pain medication on 08/17/25. 3. The facility failed to ensure Resident #12 did not physically abuse Resident #13 when he shoved her on 08/07/25 and on 08/23/25. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure adequate supervision and assistance devices to prevent accidents for 11 out of 25 (Resident's #4, #7, #8, #10, #11, #12, #13, #14, #19, #21, and #22) residents reviewed for accidents. 1. The facility failed to ensure adequate supervision on the secured unit to prevent two resident-to-resident physical altercations between Resident #12 and Resident #13 on 08/07/25, and 08/23/25, which resulted in scratches to Resident #13's face. 2. The facility failed to ensure the secured unit was adequately supervised to prevent unwitnessed fall accidents for Resident's #8, #10, #12, #13, #14, #19, and #21. Resident #14 sustained a radius fracture and required 6 sutures to her left eye on 07/01/25. Resident #21 was sent to the ER after she hit her head and complained of pain on 07/03/25. [...]

Inspectors wroteBased on observations, interview, and record review the facility failed to have sufficient nursing staff with the appropriate competencies and skills set to provide nursing and related services to assure resident safety and attain or maintain the highest practicable, physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity, and diagnoses of the facility's resident population in accordance with the facility assessment for 19 of 25 resident's (Resident's #2, #4, #5, #6, #7, #8, #10, #12, #13, #14, #16, #17, #18, #19, #20, #21, #22, #23, #24) reviewed for sufficient staffing. 1. The facility failed to ensure sufficient facility staff were available to assist Resident #5 with positioning during a tube feeding on 08/20/25. [...]

Inspectors wroteBased on interview and record review, the facility failed to consult with the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 of 25 residents (Resident #6) reviewed for quality of care. The facility failed to notify the physician when Resident #6 experienced low blood pressure, low heart rate and/or low blood pressure with an increased heart rate on 7/16/25, 7/18/25, 7/20/25, 7/21/25, 7/23/25, 7/25/25, 7/26/25, 7/27/25, 7/28/25,7/29/25, 7/30/25, and 8/1/25. On 8/1/25, Resident #6 had low hemoglobin 5.8 and low hematocrit 21.6. Resident #6 was sent to the ER due to critical lab values. Resident #6 was admitted and diagnosed with gastrointestinal hemorrhage. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 1 of 3 residents (Resident #5) reviewed for enteral nutrition. During a tube feeding on 08/20/25, Resident #5's head and torso were leaning over the left armrest of his Geri-chair for approximately 1 hour and 30 minutes, which resulted in aspiration pneumonia. An immediate jeopardy (IJ) was identified on 09/11/25 at 12:59 PM. The IJ template was provided to the facility on [DATE] at 2:01 PM. [...]

Inspectors wroteBased on interview, and record review the facility failed to ensure that pain management was provided to that require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices of 2 of 11 residents reviewed for pain management. (Resident #6 and Resident #15) 1. The facility failed to ensure Resident #15 received her scheduled Oxycodone as ordered on [DATE], [DATE], and [DATE]. The facility failed to ensure Resident #15 received her scheduled Gabapentin as ordered on [DATE]. The facility failed to notify Resident #15's physician when doses of the Oxycodone and Gabapentin, scheduled for 3pm and 4pm, were not administered on [DATE]. The facility failed to offer Resident #15 alternative prn pain medication options on [DATE] per the facility's policy. [...]

Inspectors wroteBased on observations, 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 5 of 25 residents (Resident's #1, #2, #3, #7, and #8) reviewed for infection control practices. 1. The facility failed to ensure facility staff followed infection control protocol during a COVID-19 outbreak at the facility. 2. The facility failed to ensure Residents #1, #2, and #3 had airborne isolation precaution signage outside their room door on 09/08/25. 3. The facility failed to ensure the staff had access to face shields or goggles on the PPE isolation carts on 09/08/25 and 09/09/25. 4. [...]

Inspectors wroteBased on interview and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner that promotes maintenance or enhancement of her quality of life for 1 of 25 residents (Resident #15) reviewed for resident rights. The facility failed to ensure LVN M spoke to Resident #15 in a respectful and dignified manner on 8/21/25. This failure could place residents at risk for decreased quality of life, quality of care, and self-esteem.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident had the right to be free from misappropriation of property for 1 of 2 residents reviewed for misappropriation of property. (Resident #15) The facility failed to prevent a drug diversion (misappropriation) of Resident #15's Oxycodone 10 MG on 8/15/25. This failure could place residents at risk for decreased quality of life, unrelieved pain, misappropriation of property, and dignity.

Inspectors wroteBased on interview and record review, the facility failed to ensure all allegations of abuse and neglect had evidence that all alleged violations were thoroughly investigated and prevent further potential for 2 of 20 residents (Resident #15 and Residents #9) reviewed abuse, neglect and misappropriation. 1. The ADM and DON, failed to thoroughly investigate allegation of misappropriation of property, when LVN E documented an extra administration of Resident #15's oxycodone on 8/15/25. Resident #15 denied receiving an extra dose on 8/15/25. The ADM and DON, failed to provide evidence that Resident #15's incident on 8/15/25, with allegation of misappropriation of property, Oxycodone 10 MG, was thoroughly investigated. The facility failed to protect Resident #15 from potential further misappropriation of property after the allegation. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 8 residents (Resident #1) reviewed for adequate supervision. The facility failed to prevent Resident #1 from causing a burn proximal red area 5CM x 9CM, distal red area with blister 3CM X 8CM herself with coffee on 4/23/25 while she was in bed and not providing a lid for her cup. The facility failed to keep coffee available to residents or served to residents at a safe temperature. These failures resulted in the identification of an Immediate Jeopardy (IJ) on 07/15/25 at 12:09 PM. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 of 10 residents (Resident #1) reviewed for reasonable accommodations. The facility failed to ensure Resident #1 was allowed to use his personal motorized wheelchair during his stay at the facility. This failure could place residents at risk for a loss of independence, decreased quality of life, self-worth, and dignity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 10 residents (Resident #2) reviewed for accidents and supervision. The facility failed to ensure an oxygen cylinder found in Resident #2's room was properly stored. This deficient practice could place residents at risk of injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents could call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside for 1 of 10 residents (Resident #4) reviewed for the ability to call for staff assistance. The facility failed to ensure Resident #4 had a call light that was functional. Resident #4's call light did not turn on when the button was pressed. This failure could place residents at risk for a delay in assistance and decreased quality of life, self-worth, and dignity.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents received adequate supervision to prevent accidents for 1 of 7 residents reviewed for accidents. (Resident #1). The facility did not prevent Resident #1, who resided on the secured unit, from leaving the facility unsupervised on 03/13/2025. Resident #1 was found at a local hospital emergency room where he had been taken by local police. The facility was not aware the resident was missing for approximately 4 hours until staff went to get him for his evening meal. The noncompliance was identified as PNC (past noncompliance). The IJ began on 03/13/2025 and ended on 03/14/2025. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of potential accidents, injuries, harm, or death.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident had the right to be treated with dignity and respect and free from physical restraints for 1 of 3 residents (Resident #1) reviewed for resident rights. CNA D said she restrained Resident #1 on three occasions during the last month or so. She said about a month ago she had swaddled Resident #1 with a blanket by folding a blanket around Resident #1 to restrict her movements. CNA D said she had swaddled Resident #1 on the night of [DATE] to calm her down. On the morning of [DATE] CNA D said around 3:15 a.m. she had used a pair of leggings and tied Resident #1's legs to the bed to keep her from getting out of bed. Resident #1 was tied to the bed from 3:15 a.m. until around 8:00 a.m. on the morning of [DATE]. An IJ was identified on [DATE]. The IJ began on [DATE] and was removed on [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 2 of 5 residents (Resident #1 and Resident #2) reviewed for quality of care. 1. The facility failed to ensure, on 1/16/25, HA B did not leave a spray bottle of cleaner, unattended in the dining room on the secured unit. a. The facility failed to ensure Resident #2 did not possibly ingest an unattended spray of bottle of cleaner on 1/16/25. b. The facility failed to follow their cleaning policy, on 1/16/25, and safely store chemicals in a locked area on the secured unit. 2. [...]

Inspectors wrote4. Record review of Resident #22's face sheet dated 10/02/24 indicated she was [AGE] years old and admitted to the facility initially on 03/29/18 with diagnoses including unspecified dementia (a clinical syndrome that describes dementia without a specific diagnosis), generalized anxiety disorder (severe, ongoing anxiety that interferes with daily activities) and muscle weakness. Record review of Resident #22's quarterly MDS assessment dated [DATE] indicated she was understood and usually understood others. Resident #22 had a BIMS score of 4 which indicated she had severe cognitive impairment. The MDS indicated Resident #22 had disorganized thinking. The MDS indicated Resident #22 had diagnoses including dementia without other behavioral disturbances. The MDS indicated Resident #22 was receiving antipsychotic medications. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) Level I assessment accurately reflected the resident's status for 4 of 8 residents (Resident #15 #16, #49, and #52) reviewed for PASRR Level I screenings. 1. The facility failed to ensure the accuracy of the PASRR Level 1 screening for Resident #49. The PASRR Level 1 screening did not indicate a diagnosis of mental illness, although the diagnosis (Post Traumatic Stress Disorder, a mental health condition that can develop after a person experiences or witnesses a traumatic event with an onset date of 08/01/21) was present upon Resident #49's re-admission date on 11/16/23. 2. The facility failed to ensure the accuracy of the PASRR Level 1 screening for Resident #15. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an ongoing program of activities in accordance with the comprehensive assessment to meet the interests and the physical, mental, and psychosocial well-being for 1 of 1 memory care unit reviewed for activities. The facility failed to provide meaningful activities for dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) residents on the memory care unit on 9/30/24-10/1/ 24. This failure could place residents at risk for not having activities to meet their interests or needs and a decline in their physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an acceptable parameter of nutritional status was maintained for 3 of 3 residents (Resident # 36, #42 and #61) who was reviewed for nutritional status, in that: 1. The facility failed to ensure Resident #36, #42 and # 61 had sufficient fluid intake to maintain proper hydration and health as evidence by Resident #36 said on 10/1/2024 he had dry mouth, on 9/30/2024 Resident #42's said he had to ask for water and ice and on 10/1/2024 Resident #61 did not have any ice and water in his cup . This failure could place residents at risk for dehydration and decline in health due to insufficient fluid intake.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate administering of all drugs and biologicals, to meet the needs of 4 of 19 residents reviewed for pharmacy services. (Residents #18, Resident #23, Resident #34, and Resident #68) The facility failed to ensure Resident #18's Niacin-50 (is one of the water-soluble B vitamins), Ativan (is used to treat anxiety) 1 mg, and Nicotine Patch (helps you quit smoking by reducing cravings for nicotine. Nicotine is an addictive substance in tobacco) were available for administration on 08/20/24, 08/21/24, 08/22/24, 08/23/24, 08/24/24, and 08/25/24. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that it was free of medication error rate of 5 percent or greater. The facility had a medication error rate of 61.76%, based on 21 errors out of 34 opportunities, which involved 4 of 4 residents (Resident #15, Resident #20, Resident #53, and Resident #73) reviewed for medication administration. 1. MA O administered Buspirone 10mg (is commonly used to treat anxiety disorders), Lorazepam 1mg (treats anxiety), and Tramadol 50mg (a pain relief medication, specifically indicated for moderate-to-severe pain) at 10:49 a.m.-11:21 a.m. instead of 8:00 a.m. as ordered on 09/30/24 for Resident #53. 2. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure that residents were free of significant medication errors for 2 of 5 residents (Resident #23 and Resident #34) reviewed for pharmacy services. The facility failed to ensure Resident #23's losartan (blood pressure medication) was not administered when her blood pressure (is a measure of how forcefully your blood goes through your arteries) and heart rate (is how many times your heart beats in 60 seconds) was outside of the ordered parameters on 09/01/24, 09/02/24, 09/09/24, 09/17/24, and 09/26/24. The facility failed to ensure Resident #34's losartan (blood pressure medication) was not administered when her blood pressure was outside of the ordered parameters on 9/08/24, 9/09/24, 910/24, 9/17/24, 9/26/24, and 9/30/24. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the baseline care plan that included the instructions for resident care needed to provide effective and person-centered care was completed and provided to the resident and/or their representative for 1 of 5 residents reviewed for new admissions (Resident #34). The facility failed to provide Resident #34's RP a copy of the summary of the baseline care plan. This failure could place residents at risk of not receiving care and services to meet their needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet resident's medical, nursing, mental and psychosocial needs identified in the comprehensive assessment for 3 of 19 residents reviewed for care plans. (Resident #62, Resident #53, and Resident #34) 1. The facility failed to ensure that Resident #62's care plan dated 08/15/24 addressed her psychotropic medications that she was prescribed by the physician on 08/02/2024. 2. The facility failed to ensure Resident #34's CAA of behavioral symptoms were on the 08/27/24 care plan. 3. The facility failed to ensure Resident #34's behaviors of incontinence on her and other resident's property was on the 08/27/24 care plan. 4. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide the necessary services to maintain personal hygiene for 3 of 5 residents reviewed for ADLs (Residents #25, #42, and #61). The facility failed to provide baths as scheduled for Resident #25, #42, and #61. This failure could place residents who required assistance from staff for ADLs at risk of not receiving care and services to meet their needs which could result in poor care, risk for skin breakdown, feelings of poor self-esteem, lack of dignity, and health.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that residents who need respiratory care are provided with such care, consistent with professional standards of practices for 1 of 22 residents (Resident #49) reviewed for respiratory care. The facility failed to replace the oxygen filter that was damaged for Resident #49. This failure could place residents at risk for of respiratory infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary storage of residents' food items for 2 of 12 resident personal refrigerators reviewed for food safety (Resident #37 and Resident #38). 1. The facility failed to ensure the refrigerator for Resident #37 did not have expired protein drinks. 2. The facility failed to ensure the refrigerator for Resident #38 was cleaned and free from a brown and black substance with black dead gnats. This failure could place resident at risk for food borne illnesses.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 residents (Resident #40) reviewed for Covid-19 infection control practices. 1. The facility failed to ensure MA S wore an N95 mask when entering a Covid positive resident room. 2. The facility failed to ensure MA S changed her mask after leaving a Covid positive resident room. 3. The facility failed to ensure MA S wore proper PPE (Personal Protective Equipment) in Resident #40's room on 10/2/2024. Resident #40 was COVID-19 positive. MA S wore surgical mask only when entering and exiting Resident #40's Covid-19 positive room. [...]

Inspectors wroteBased on interview and record review, the facility failed to report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken for 2 of 11 residents (Resident #1 and Resident #2) reviewed for abuse and neglect. The facility failed to ensure the provider investigation report was turned into the state survey agency (HHSC) within 5 working days of the reported incident between Resident #1 and Resident #2. This failure could place residents at risk for abuse and neglect.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 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 3 of 23 residents (Resident # 53, Resident #25, Resident # 26) reviewed for infection control. 1. The facility failed to ensure LVN A used proper infection control measures when performing wound care for Resident #53. 2. The facility failed to ensure that personal protection equipment storage boxes at Resident # 25 and Resident # 26's rooms were free from cross contamination. These failures could place residents at risk for cross-contamination and the spread of infection.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to protect and promote the rights of the resident in an environment that promoted maintenance or enhancement of his or her quality of life for 4 of 18 residents (Resident #69, Resident # 52, Resident # 78 and Resident # 54) reviewed for resident rights. The facility failed to protect and value Resident #69, Resident # 52 and Resident #78's quality of life and provide a peaceful atmosphere when facility staff engaged in unprofessional and obscene behavior with family members of residents. The facility failed to ensure staff knocked prior to entering Resident #54's room. This failure could place residents at risk for decreased quality of life, increased anxiety, and increased stress.

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 for 6 of 10 residents (Resident # 6, Resident # 23, Resident #20, Resident #25, Resident #59, and Resident #63) reviewed for reasonable accommodations. The facility failed to ensure Resident # 6, and Resident # 23 could choose between taking a bath and having a sponge bath. The facility failed to ensure Resident #20's call light was in reach while in bed. The call light cord for Resident #20 was lying on the over the bed light and not within reach of Resident #20. The facility failed to ensure Resident #25's call light was in reach while in bed. The call light cord for Resident #25 was lying on the floor behind the dresser and not within reach of Resident #25. [...]

Inspectors wroteBased on observations, 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 3 of 12 residents (Resident # 64, Resident #6, and Resident #54) reviewed for comprehensive person-centered care plans. 1. The facility failed to develop a care plan for Resident # 64's diagnosis of post-traumatic stress disorder (PTSD). 2. The facility failed to implement the care plan intervention to document Resident #6 meal intake. 3. The facility failed to update Resident #54's from at risk for falls to actual fall on his care plan. 4. The facility failed to update Resident #54's fall care plan interventions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain bathing were provided for 2 of 12 residents reviewed for ADLs (Residents # 64 and Resident # 48). The facility did not provide 10 of 16 scheduled showers for Resident #64 in August of 2023 and 6 of 6 scheduled showers from September 1st to Septermber 13th 2023. The facility did not provide 8 of 13 scheduled showers for Resident #48 in August of 2023 and 3 of 5 scheduled showers from September 1st to September 13th 2023. These failures could place residents at risk of not receiving services/care and decreased quality of life. Findings Include: 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the activities program was directed by a qualified professional who was a qualified therapeutic recreation specialist or an activities professional who completed a training course approved by the State for 1 of 1 facility reviewed for Activity Director qualifications. The facility failed to ensure a certified Activity Directory was employed for the facility. This failure could place residents at risk of not receiving a program of activities that met their assessed activity needs.

Inspectors wroteBased on interview and record review the facility failed to ensure each resident was informed before, or at the time of admission, and periodically during the residents stay, of services available in the facility and of changes for those services, which included changes for services not covered under Medicare/Medicaid or by the facility's per diem rate for 2 of 3 residents (Residents #23 and #33) reviewed for Medicare/Medicaid coverage. The facility failed to ensure Resident #23 and #33 was given a SNF ABN (is a notice given to beneficiaries in Original Medicare to convey that Medicare is not likely to provide coverage in a specific case) when discharged from skilled services at the facility at least 2 days prior covered days being exhausted. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 1 of 2 (Resident #54) residents reviewed for non-pressure wounds. The facility failed to treat Resident #54's non-pressure wound (is characterized by inflammation of the skin, occurring with or without erosion or secondary cutaneous infection) of the left buttock after readmission for 2 days. This failure could place residents of risk for not receiving appropriate care and treatment.

Inspectors wroteBased on interview and record review the facility failed to ensure residents with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 of 4 residents (Resident #54) reviewed for pressure injury. The facility failed to treat Resident #54's unstageable sacrum pressure ulcer (is a term that refers to an ulcer that has full thickness tissue loss but is either covered by extensive necrotic tissue or by an eschar) after readmission for 2 days. This failure could place residents at risk for deterioration of wound.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents maintained acceptable parameters of nutritional status for 1 of 4 residents (Resident #54) reviewed for nutrition/weight loss. The facility failed to obtain a readmission weight after Resident #54 readmitted from the hospital on [DATE] per the facility policy. The facility failed to consistently document Resident #54's meal intakes. These failures could place residents at risk for decreased nutritional and weight status and decline in health.

Inspectors wroteBased on interview and record review, the facility failed to ensure, based on the comprehensive assessment of a resident, residents who had not used psychotropic drugs were not given these drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for 1 of 5 residents (Resident #54) reviewed for unnecessary psychotropic medications. The facility failed to ensure Resident #54's Lorazepam (anti-anxiety) had an appropriate diagnosis for use. The facility failed to limit Resident #54's Lorazepam prn medications to 14 days and the prescribing practitioner did not provide a rationale for extended use. These failures could put residents at risk of receiving unnecessary psychotropic medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biological were stored in locked compartments for 1 medication cart of 4 (Medication Aide Cart #1) reviewed for medication storage: The facility failed to ensure Medication Aide Cart #1 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 diversions.

Inspectors wroteBased observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Residents #65) of 5 residents observed for infection control. Housekeeper DD failed to doff (take off) PPE while exiting isolation room and entered Resident #65's room wearing contaminated PPE. Housekeeper DD wore soiled gloves in the hallway. These failures could place residents at risk of cross-contamination and infections leading to illness.