Willows Center

Inspectors wroteBased on observation and staff interview, the facility failed to provide a safe, clean, comfortable, and homelike environment for three (3) of five (5) resident rooms reviewed during the complaint survey process. The facility failed to keep the Packaged Terminal Air Conditioners (PTACs) in resident rooms [ROOM NUMBER] in good condition. Facility Census: 92. On 03/10/26 at approximately 9:15 .a.m., the State Agency (SA) observed debris in the upper vent of the PTAC unit in resident room [ROOM NUMBER]. On 03/10/26 at approximately 9:18 a.m., the SA observed debris and a black like substance in the upper vent of the PTAC unit in resident room [ROOM NUMBER]. On 03/10/26 at approximately 12:30 p.m., the SA observed debris in the upper vent of the PTAC unit in resident room [ROOM NUMBER]. During an interview on 03/10/26 at approximately 1:15 p.m. [...]

Inspectors wroteBased on observation and staff interview, the facility failed to dispose of garbage and refuse properly. One (1) of two (2) dumpsters was found to be overflowing with garbage bags, making it impossible for the dumpster lid to properly close. The other dumpster had sliding doors that were not completely closed. This was a random opportunity for discovery that has the potential to affect every resident at the facility. Facility census: 92.

Inspectors wroteBased upon record review and staff interviews the facility failed to report the results of investigations within approved time frames to the state survey agency(SSA). This was discovered during the Long term care survey process, during the review of Facility reported incidents (FRIs). This was found to be true for one (1) out of thirty (30) residents reviewed. Resident #74 and #108. Census:

Inspectors wroteBased on resident interview, staff interview, and operation policy the facility failed to take actions to thoroughly investigate an alleged violation related to, abuse, neglect, exploitation or mistreatment, including injuries of unknown source, and take corrective action following the investigation. Resident identifier #1, #108, #109, #98, #74, #105, #104, and #102. Facility census: 92.

Inspectors wroteBased on record review and staff interview, the facility failed to develop a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical and nursing needs. This was a random opportunity for discovery. Resident identifier: #38, #39. Facility census: 92.a) Resident #39 An electronic medical record review was completed on 12/18/25 at 11:00 AM. Resident #39 was admitted to the facility on [DATE]. Review of Resident #52's care plan identified the following: A Focus Area, initiated on12/08/25, which stated: Resident/Patient requires assistance/is dependent for ADL care in _______________ (specify: bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting) related to: [...]

Inspectors wroteBased on observation, record review, resident, and staff interview. The facility failed to assist dependent Residents with activities of daily living (ADL's) in accordance with the resident's assessed needs for care. This is true for three (3) of eight (8) residents reviewed for ADL's care. Resident Identifiers: #30, #49 and #72. Facility census: 92. Findings Included:a) Resident #49 On 12/15/23 at 11:28 AM Resident #49 stated that she does not get showers or baths as ordered or her preference. She stated that she is supposed to get two showers a week. She continued to state that the staff say they don't have enough staff to give her a shower. A review of Resident #49's ADL documentation found only two (2) showers on 11/21/25 and 12/09/25 also noted seven bed baths noted in 30 days. No Refusals noted. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to provide care in accordance with accepted professional standards of practice. This deficient practice had the potential to affect five (5) of 28 residents reviewed in the long-term care survey sample. For Resident #3, the facility failed to obtain vital signs as ordered by the physician. For Resident #69, the facility failed to follow physician-ordered medication parameters. For Resident #96, the facility failed to perform neurological checks after unwitnessed falls. For Residents #38 and #72, the facility failed to ensure coordination of care for residents receiving hospice services. Resident Identifiers: #3, #69, #96, and #38. Facility Census: 92.

Inspectors wroteBased on record review, resident interview, and staff interview, the facility failed to provide services to dialysis residents in accordance with professional standards of practice. There was no documentation that the resident's dialysis access site was monitored for one (1) of two (2) residents reviewed for the care area of dialysis. Resident Identifiers: #69. Facility Census: 92.

Inspectors wroteBased on observation and interview, the facility failed to ensure drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional principles. Multiple medications stored in a medication cart and the medication room were unlabeled and undated. This practice had the potential to affect more than a limited number of residents. Facility census: 92.

Inspectors wroteBased on food tray temperatures and resident interviews, the facility failed to serve food to residents that was palatable and at an appetizing temperature. Based on resident interview and staff interview, the facility failed to ensure hot foods were served hot and cold foods were served cold. This failed practice was true for four (4) of five (5) hallways tested for milk temperatures on the beverage carts and food tray temperatures for one (1) of one (1) meal trays tested throughout the survey process Facility census: 92.a) This surveyor asked the Director of Dining to temp the milk that was located on the west hall beverage cart on 12/15/25 at 12:45 PM. The temp was 54 degrees F. The Director of Dining acknowledged the temp was above the Food and Drug Administration (FDA) food code temp of 41 degrees F. [...]

Inspectors wroteBased on observations, resident interviews and staff interviews, this facility failed to ensure meal preferences were obtained, updated and followed per policy and or best practice as provided per District Manager for Food and Nutrition. This was a random finding during the Annual Long Term Care Survey Process. Facility Census 92 Resident identifiers #58, #31, #37Findings include: 12/15/2025 12:00PM , Resident #58. Resident interview The food is terrible, they have not updated any meal preferences with me, I asked the manager almost (3) three months ago to come talk with me 12/15/25 12:50PM , Resident #58, meal served, Resident meal was Turkeyburger, with lettuce, tomato and baked beans on plate, per resident This is what I ordered, I am glad ,observation: baked beans running on plate under Hamburger Bun. [...]

Inspectors wroteBased on observation and staff interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food safety. Additionally, the facility failed to follow the proper sanitation practices for the kitchen and the food preparation equipment. This practice had the potential to affect more than an isolated number of residents. Facility census: 92.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure complete and accurate medical records. This deficient practice affected three (3) of 28 residents reviewed in the long-term care survey sample. Resident identifiers: #2, #96 and #69. Facility census: 92.

Inspectors wroteBased on facility documentation and staff interviews, the facility failed to have required quarterly meetings. Additionally, the facility did not have required attendees present or sign in at the Quality Assessment and Assurance (QAA) meeting. This failed practice had the potential to affect all residents residing at the facility. Facility Census: 93.

Inspectors wroteBased on observation, record review, and staff interview, 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. The facility failed to follow accepted standards of practice related to enhanced barrier precautions. Facility staff also failed to perform hand hygiene between residents while giving the residents ice and failed to maintain the ice cart in a clean and sanitary manner. These were random opportunities for discovery that had the potential to affect more than a limited number of residents. Resident Identifiers: #5, #69, and #3. Facility Census: 92.

Inspectors wroteBased on observation and staff interview the facility failed to ensure two (2) residents received a dignified dining experience. This failed practice was a random opportunity for discovery. Resident identifiers: #95 and #3. Facility census: 92.

Inspectors wroteBased on record review and staff interview, the facility failed to provide the required Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) form to one (1) of three (3) residents reviewed for the facility's beneficiary protection notification practice during an annual survey. This failure placed the resident at risk of not being informed of her rights prior to the end of Medicare Part A covered services. Resident identifier: #72. Facility census: 92.a) Resident #72 Resident #72 reamined in the facility after 07/10/25 whcih was the last day of Medicare Skilled Coverage. The NOMNC was issued on 07/08/25 but there was no evidence that the SNF ABN was ever issued. During an interview on 12/18/25 at 11:25 AM, Bookkeeper #72 stated, I don't think so. [...]

Inspectors wroteBased on observation and staff interview, the facility failed to provide a safe, clean, comfortable, and homelike environment for one (1) of ten (10) resident rooms observed during the long-term care survey process. room [ROOM NUMBER]. Facility Census: 92.

Inspectors wroteBased on record review and staff interview, the facility failed to complete a new Pre-admission Screening and Resident Review (PASARR) for residents with a newly evident or a possible serious mental health disorder. This was true for two (2) out of three (3) sampled residents reviewed under the PASARR pathway during the Long-Term Care Survey Process. Resident identifiers: #1 and #6. Facility census: 92Findings included:a) Resident #1A record review, completed on 12/17/25 at 11:09 AM, revealed:Resident #1 was admitted to the facility on [DATE]. On 06/27/25, the resident was given a Bipolar diagnosis. The only PASARR on file was dated 05/02/25. This PASARR did not reflect the resident's Bipolar diagnosis During an interview on 12/17/25 at 11:29 AM, the Director of Social Services (DOSS) reported a new PASARR had not been completed to capture Resident #1's diagnosis of Bipolar. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to revise residents' care plans when treatment changed. This deficient practice had the potential to affect two (2) of 28 residents reviewed in the long-term care survey sample. Resident identifiers: #69 and #52. Facility census: 92.

Inspectors wrotePS & Findings [NAME] The facility failed to ensure residents received the appropriate treatment and assistive devices to maintain a resident's vision abilities for one (1) of one (1) resident reviewed for communication/sensory issues. Resident identifier: #59. Facility census:

Inspectors wroteBased on record review and staff interview, the facility failed to assess and treat pressure ulcers within accepted standards of care. This deficient practice had the potential to affect one (1) of five (5) residents reviewed for the care area of pressure ulcers. Resident Identifier: #98. Facility census: 92.

Inspectors wroteBased on record review and staff interview, the facility failed to provide care and services within accepted standards of practice for falls. The facility failed to document falls. The facility also failed to assess fall risk and failed to conduct appropriate post fall analyses to prevent further falls. This deficient practice had the potential to affect one (1) of four (4) residents reviewed for the care area of falls. Resident Identifier: #96. Facility Census: 92.

Inspectors wroteBased on medical record review and staff interview the facility failed to ensure quality and continuity of care was arranged for an provided for a resident receiving hospice services. Resident identieir: #38. Facility census: 92. a) Resident #38A record review on 12/16/25 of Resident #38's chart revealed that Resident #38 was admitted to the facility on [DATE] with a fair prognosis under skilled nursing care and then immediately ordered hospice care under (name of hospice) for the diagnosis of Terminal DX for Comfort. The facility has no record of the Hospice admission agreement or any other documentation signed by either Resident #38, their medical power of attorney (MPOA) and/or the facilities medical / social service staff, in either electronic format or in the hard copy binders for each resident. [...]

Inspectors wroteBased on record review, staff interview, and family interview the facility failed to inform the Medical power of Attorney (MPOA) of appointments for Resident #46. This failed practice was found true for (1) one of (3) three residents reviewed. Resident identifiers # 46, Facility Census 91.

Inspectors wroteBased on record review, resident representative interview, and staff interviews, the facility failed to process and investigate a reported grievance. This was true for (1) of (3 ) residents sampledResident Identifier: #46 Facility Census: 91 Findings Included:a) Per The Facility Grievance Policy, the grievance officer will oversee grievances through conclusion leading any necessary investigations by the facility, issuing written decisions to the patient, and coordinating with state and federal agencies.b) In an interview with resident # 46's MPOA on 10/28/25 at 2:20pm, she stated the facility had transported Resident # 46 to an appointment more than once without notifying her in advance of the appointments. She stated the first time was in October of 2024. On 01/09/2025 and on 01/29/25. the van driver dropped him off without making sure she was there for him. [...]

Inspectors wroteBased on observation, record review, and staff interviews, the facility failed to ensure professional care and standards of practice were followed in regards to meal time supervision for resident #4. This was true for one (1) of (3) residents reviewed. Resident Identifiers: # 4, # 61, and # 27 . Facility Census: 91Findings Included:a) Observation:-During an observation of meal pass on 10/29/25 at 12:44PM, Resident # 4 was served his meal by employee identifier # 60. [...]

Inspectors wroteBased on record review and resident and staff interview, the facility failed to include residents/resident representatives to participate in care plan meetings. The facility failed to hold regularly scheduled care plan meetings and to invite residents or their representatives to those meetings. This was true for five (5) of five (5) residents reviewed for care plan meetings. Resident identifiers: #295 #81, #15, #8, #40. Facility census: 94.

Inspectors wroteBased on observation and staff interviews, the facility failed to provide a safe, clean, comfortable, and homelike environment. A table top in the Transitional Care Unit (TCU) dining area had approximately one third of the laminate covering missing with exposed jagged edges. Resident #43's room floor needed to be cleaned. This was a random opportunity for discovery. This failed practice had the potential to affect a limited number of residents that currently reside in the facility. Resident identifier: #43 Facility Census:

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure the resident environment remained as free of accident hazards as possible, by failing to keep treatment and medication carts locked when they were out of use and out of sight of nursing staff, and by failing to remove razors with no safety caps from Resident #196's room. This was a random opportunity for discovery. This had the potential to affect more than a limited number of residents. Facility census: 94.

Inspectors wroteBased on resident interviews, staff interviews, record review, and resident council, the facility failed to ensure sufficient qualified nursing staff were always available to provide nursing and related services to meet the residents' needs safely and in a manner that promoted resident rights, physical, mental, and psychosocial well-being. Facility census: 94.

Inspectors wroteBased on record review and staff interview, the facility failed to complete a performance review for three (3) out of three (3) Nurse Aides (NA) reviewed in the sufficient and competent nurse staffing pathway during the Long-Term Care Survey Process. Employee identifiers: NA #5, #29, and #58. Facility census: 94.

Inspectors wroteBased on record review and staff interview, the facility failed to keep the daily posted nurse staffing information up-to-date and current. This was true for four (4) out of 12 sampled days during the Long-Term Care Survey Process. Facility census: 94.

Inspectors wroteBased on observation, record review and staff interview, the facility failed to ensure medications were dated upon opening in accordance with the accepted professional standards of practice. This was a random opportunity for discovery. Resident Identifiers: #9. Facility Census: 94. Findings Included: a) Undated Medications On 02/06/24 at 2:05 PM, a tour of the medication cart on the Transitional Care Unit (TCU) was completed. The tour found the following over-the-counter (OTC) medications and Resident #9's insulin were not dated upon opening: [...]

Inspectors wroteAccording to observation, staff interview, resident interview, and policy review, the facility failed to serve food at safe and palatable temperatures by serving cold food at higher temperatures than directed. This was a random opportunity for discovery. This has the potential to affect more than a limited number of residents. Facility census: 94.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to maintain safe and working equipment by failing to repair the ice machine in the facility's kitchen. This was a random opportunity for discovery. This had the potential to affect more than a limited number of residents. Facility census: 94.

Inspectors wroteBased on observation and staff interview, the facility failed to provide a dignified dining experience for Resident #43. This was a random opportunity for discovery. Resident identifier: #43. Facility Census: 94.

Inspectors wroteBased on observation, review of the facility grievance/complaint forms, Resident Council meeting minutes, Resident Council meeting and staff interview, the facility failed to consider resident group views and act upon grievances and recommendations. The facility also failed to provide these groups with responses, action, and rationale taken regarding their concerns pertaining to issues of resident care and life in the facility. This was a random opportunity for discovery. These practices had the potential to affect more than a limited number of residents which reside in the facility. Resident identifier: #16, #44, #66 and #77. Facility Census:

Inspectors wroteBased on observation and staff interview, the facility failed to maintain privacy and confidentiality of medical records for Resident #43 and #295. These were random opportunities for discovery. Resident Identifiers: #43 and #295. Facility Census: 94. Findings Included: a) Resident #43 On 02/06/24 at 9:03 AM, while observing medication administration, Licensed Practical Nurse (LPN) #31 left the computer screen unattended with Resident #43's information visible. LPN #31 stated, I thought I locked it. On 02/06/24 at 9:30 AM, the Director of Nursing (DON) was notified and confirmed the computer screen should have been locked prior to leaving the area. b) Resident #295 On 02/06/24 at 9:30 PM, a tour of the 100 hall was completed. During the tour, the medication cart was sitting by room [ROOM NUMBER] in which Resident #295 resides. [...]

Inspectors wroteBased on observations, review of the facility grievance/complaint policy, Resident Council meeting and staff interview, the facility failed to make information on how to file a grievance or complaint available to the resident. This was a random opportunity for discovery. This practice had the potential to affect more than a limited number of residents which reside in the facility. Resident identifier: #16, #44, #66 and #77. Facility Census: 94.

Inspectors wroteBased on record review and staff interview, the facility failed to notify the State Ombudsman of acute care transfers for Resident #6 and Resident #53. This is true for two (2) of four (4) residents reviewed under the care area of hospitalizations. Resident identifiers: #6 and #53. Facility census: 94.

Inspectors wroteBased on record review and staff interview, the facility failed to notify the resident and/or resident representative regarding the facility bed hold notice of policy and authorization. This is true for three (3) of four (4) residents reviewed under the care area of hospitalizations. Resident Identifiers: #6 , #53 and #10. Facility census: 94.

Inspectors wroteBased on record review and staff interview, the facility failed to coordinate with the appropriate, State-designated authority, to ensure that individuals with a mental disorder, intellectual disability or a related condition receives care and services in the most integrated setting appropriate to their needs by failing to update the Pre-admission Screening and Annual Resident Review (PASARR) for Resident #40 following a diagnosis of Major Depressive Disorder. This is true for one (1) of four (4) residents reviewed for PASARRs during the survey process. Resident Identifier: 40. Facility Census: 94.

Inspectors wroteBased on record review and staff interview, the facility failed to develop and implement a baseline care plan that included the minimum healthcare information necessary to properly care for the immediate needs of residents. This was true for two (2) of 23 residents reviewed during the Long-Term Care Survey Process. Resident identifiers: #196 and #347. Facility census:

Inspectors wroteBased on record review and staff interview, the facility failed to develop and/or implement a person-centered care plan regarding Post-Traumatic Stress Disorder (PTSD) for Resident #35. This was true for one (1) of one (1) residents reviewed under the care area of mood and behavior. Resident Identifier: #35. Facility Census: 94. Findings Included: a) Resident #35 On 02/05/24 at 11:30 AM, the facility matrix was reviewed. Resident #35 was identified with a diagnosis of PTSD. A record review was completed. A Social Services assessment dated [DATE] identified the resident was a victim of a violent assault. However, the care plan was not developed regarding the diagnosis of PTSD. On 02/07/24 at 10:00 AM, Social Services (SS) #80 was notified regarding the care plan not including the diagnosis of PTSD. On 02/07/24 at 12:00 PM, SS #80 stated, I updated the care plan to include PTSD. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to revise care plans to accurately reflect the conditions of residents. The facility failed to revise a care plan for depression for Resident #15, a COVID diagnosis for Resident #78, and tube feeding for Resident #53. This was true for three (3) of three (3) residents reviewed for care plan revision during the survey. Resident identifiers: #15, #53, #78. Facility census: 94.

Inspectors wroteBased on observation, record review, resident interview, and staff interview, the facility failed to provide Activities of Daily Living (ADL) care that is necessary to maintain good oral hygiene care. This was true for one (1) of 23 residents. Resident identifier: #44. Facility Census: 94.

Inspectors wroteBased on record review and staff interview, the facility failed to follow a physician's order regarding an enteral feeding for Resident #53. This was true for one (1) of one (1) residents reviewed under the care area of tube feeding. Resident identifier: #53. Facility census: 94.

Inspectors wroteBased on record review and staff interview, the facility failed to monitor Resident #15 for side effects of psychotherapeutic medications. This was true for one (1) of (1) residents reviewed for monitoring of side effects during the survey process. Resident identifiers: #15. Facility census: 94.

Inspectors wroteBased on observation and staff interview, the facility failed to serve food in a safe and sanitary manner by failing to ensure the food was free of contamination and hazards. This was a random opportunity for discovery. This had the potential to affect more than a limited number of residents. Facility census: 94. a) Test Trays At approximately 11:55 AM on 02/06/24, two (2) test trays containing the facilities lunch menu were delivered by Dietary Manager (DM) #123. The menu for lunch was: Hamburger on roll, lettuce and tomato garnish, grapes, french fries, or cottage cheese fruit platter and a cinnamon muffin. Upon observation of the trays, a pit of a pear was found on the cottage cheese fruit platter. Upon observation of the tray containing the hamburger, a dead insect was found on the lettuce. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to maintain a medical record that was complete and accurately documented. The facility failed to obtain a physician signature on a Physician Orders for Scope of Treatment (POST) form for Resident #48 prior to uploading it to the electronic medical record and the facility incorrectly entered a Code Order Status related to the timeframe the Resident #48 desired to have medically assisted nutrition. Additionally, the facility failed to complete a smoking assessment it its entirety for Resident #74. This deficient practice was true for two (2) of 23 resident records reviewed during the annual long-term care survey process. Resident Identifiers: #48 and #74. Facility census: 94. Findings Included: a) Resident #48 During a record review, completed on 02/05/24 at 4:49 PM, the following issues were identified: [...]

Inspectors wroteBased on observation and staff interview, the facility failed to maintain appropriate infection control standards during medication administration for Resident #15, Resident #47, Resident #43 and Resident #42. These were random opportunities for discovery. Resident Identifiers: #15, #47, #43, and #42. Facility Census: 94. Findings Included: a) Resident #15 On 02/06/24 at 8:22 AM, Licensed Practical Nurse (LPN) #31 was observed during medication administration for Resident #15. During the preparation of the medication the following pill was touched by LPN #31's bare hands: --Zoloft 50mg (milligrams) b) Resident #47 On 02/06/24 at 8:35 AM, LPN #31 was observed during medication administration for Resident #47. During the preparation of the medication the following pills were touched by LPN #31's bare hands: [...]

Inspectors wroteBased on record review and staff interview, the facility failed to offer vaccinations to Resident #4 and #6. This was true for two (2) of five (5) residents reviewed under the care area of immunizations. Resident Identifiers: #4 and #6. Facility Census: 94. Findings Included: a) Resident #4 On 02/07/24 at 1:30 PM, a record review was completed for Resident #4. The review found the pneumococcal vaccine (PCV) 20 was not offered to the resident. On 02/07/24 at 3:00 PM, the Infection Preventionist (IP) # 37 was notified and stated, I made a mistake .I should have offered it to her. b) Resident #6 On 02/07/24 at 2:15 PM, a record review was completed for Resident #6. The review found the PCV 20 vaccine was not offered to the resident. On 02/07/24 at 3:10 PM, the IP #37 was notified and stated, she went out to the hospital .I should've followed up with her son sooner. [...]

Inspectors wroteBased on observation and staff interview, the facility failed to ensure the activity director was certified as an activity professional by a recognized accrediting body. This was a random opportunity for discovery and had the potential to affect more than a limited number of residents. Facility census: 92.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice. One (1) of one (1) residents reviewed for non-pressure wounds did not receive wound treatment and care in accordance with professional standards of practice. The facility did not assess or provide treatment to the wounds according to professional standards of care Additionally, the physician-ordered medication parameters were not followed for one (1) of four (4) residents reviewed for medications. Resident identifier: #93. Facility census: 92.

Inspectors wroteBased on record review and staff interview, the facility failed to provide catheter care in accordance with professional standards of care. This failed practice had the potential to affect two (2) of four (4) residents reviewed for the care area of catheter care. Resident identifiers: #28, #93. Facility census: 92.

Inspectors wroteBased on observation, resident interview, and staff interview, the facility failed to ensure a resident had reasonable accommodation of needs by failing to ensure the resident had a bed that was long enough for his body length. This was a random opportunity for discovery. Resident Identifier: #88. Facility census: 92.

Inspectors wroteBased on record review and staff interview, the facility failed to report an alleged violation related to abuse, to all the required State authorities. This was a random opportunity for discovery. Resident identifier: #19. Facility census: 92.

Inspectors wroteBased on record review and staff interview, the facility failed to provide pressure ulcer care in accordance with professional standards of care. This failed practice had the potential to affect two (2) of four (4) residents reviewed for the care area of pressure ulcers. The failure to assess and follow the physician's orders for Resident #87's pressure ulcer caused harm to the resident. The resident developed a pressure ulcer infection, requiring intravenous antibiotics while in the faciity, and also was transferred to the hospital for suspected pressure ulcer infection and deteriorating wound. Resident identifiers: #93, #87. Facility census: 92.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure a complete and accurate medical record pertaining to a Covid-19 diagnosis. This practice affected one (1) of three (3), residents reviewed during a complaint survey. Resident identifier #2. Facility census: #93.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure a complete and accurate Minimum Data Set (MDS) assessment was completed for one (1) of 20 residents in the long-term care survey sample. Resident identifier: #91. Facility census: 93.

Inspectors wroteBased on observation, record review and staff interview the facility failed to ensure the care plan was revised and accurate in the Food and Nutrition area for Resident #53. This was true for 1 (one) of 20 (twenty) residents reviewed during the survey process. Resident Identifier #53. Facility Census 93.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. The medication cart was left unlocked when unattended. This was a random opportunity for discovery that had the potential to affect a limited number of residents. Facility census: 93.

Inspectors wroteBased on medical record review and staff interview, the facility failed to evaluate residents experiencing impaired nutrition. Two (2) of five (5) residents reviewed for the care area of nutrition were not weighed as ordered by the physician. Resident identifiers: #89 and #68. Facility census: 93.

Inspectors wroteBased on observation, medical record review and staff interview, the facility failed to deliver respiratory care services consistent with professional standards of practice. This was true for two (2) of three (3) residents reviewed in the area of respiratory care during the long term care survey process. Resident identifier: #62 and #86. Facility census:

Inspectors wroteBased on record review and staff interview, the facility failed to ensure performance reviews for Nurse Aides were conducted at least once every 12 months. This was true for one (1) of three (3) Nurse Aides reviewed for the sufficient and competent nurse staffing facility task. This deficient practice had the potential to affect a limited number of residents. Facility census: 93.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure PRN (as needed) orders for psychotropic medications were limited to 14 days, or that the rationale for extending beyond 14 days was documented along with the duration of the PRN order. This deficient practice had the potential to affect one (1) of one (1) residents reviewed for the care area of fall. Resident identifier: #26. Facility census: 93.

Inspectors wroteBased on observation and staff interview, it was found that two (2) containers of grape juice stored in the refrigerator had expired.

Inspectors wroteBased on medical record review and staff interview the facility failed to have a complete and accurate order regarding an indwelling urinary catheter. This was true for one (1) of three (3) residents reviewed for the care area of catheters. The order for a catheter for Resident #63 did not specify the size of catheter or the balloon inflation. Resident identifier: #63 Facility census: 93.