Rivercrest Post Acute

Based on observation, interview and record review it was determined the facility failed to ensure residents received treatment and care for a catheter for 1 of 1 sampled resident (#25) reviewed for urinary catheter. This placed residents at risk for urinary tract infections. Findings include: Resident 25 admitted to the facility in 12/2025 with diagnoses including osteomyelitis (bone infection) and neurogenic bladder (loss of bladder control). A 12/15/25 Nursing admission Assessment revealed Resident 25 admitted to the facility with a catheter in place.A 12/22/25 admission MDS revealed Resident 25 had an indwelling catheter in place. A review of Resident 25's physician orders revealed no orders related to the care of her/his indwelling catheter until 2/9/26.On 2/9/26 at 1:53 PM Resident 25 was observed with a catheter. Resident 25 stated she/he felt the facility did not provide required care for the catheter. On 2/10/26 at 2:54 PM Staff 19 (RN) stated physician orders were required to direct the nursing staff to provide care for catheters, including when to flush and change them.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to ensure residents were free from unnecessary antiplatelet medications for 1 of 1 sampled resident (#28) reviewed for dialysis. This placed residents at risk for adverse side effects. Findings include:Resident 28 was admitted to the facility on [DATE] with diagnoses including end-stage renal disease (ESRD) and acute embolism and thrombosis of deep veins in lower extremity (a blood clot forms inside a blood vessel then breaks off and travels through the bloodstream until it lodges in a narrower vessel).A review of the 1/24/26 Hospital Transfer orders revealed Resident 28 was to start Eliquis (an anticoagulant) on 1/24/26. Resident 28 was to then start Plavix (an antiplatelet) on 3/6/26. Special instructions stated to not take Plavix while on Eliquis.A review of the January 2026 MAR revealed Resident 28 started Eliquis on 1/24/26 per physician orders and continued receiving Eliquis through 2/9/26. The MAR also revealed on 1/28/26 an order…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review it was determined the facility failed to store resident food in a sanitary manner for 1 of 1 resident refrigerator reviewed for food safety. This placed residents at risk for contamination and at risk for foodborne illness. Findings include:A review of the 9/1/24 Resident Food from Outside Source facility policy revealed the following:-Refrigerated food items from an outside source are stored in a container with the date it was received, name of product type, and resident name/room number.-Refrigerated products are discarded on the following schedule: homemade items, restaurant leftovers, take out items, milk, cottage cheese and similar type items are discarded on day three. During a review of the resident refrigerator located in the dining room on 2/12/26 at 3:50 PM, the following was found:-One clear plastic container that contained what appeared to be sliced peppers that were brown in color. It was labeled with a resident's name and dated 1/6/26 (stored 37 days).-A clump of thick brown creamy substance located on the ceiling of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interviews, and record review it was determined the facility failed to follow transmission-based precautions for 1 of 1 facility reviewed for infection control. This placed residents at risk for infection. Findings include:Resident 25 was admitted to the facility in 12/2025 with diagnoses including diabetes.On 2/9/26 at 11:47 AM Resident 25 was observed to have a urinary catheter in place, and Staff 20 (CNA) was observed transferring Resident 25 into her/his wheelchair without a gown on.On 2/9/26 at 12:02 PM, Staff 20 stated Resident 25 was on enhanced barrier precautions, and she should have worn a gown when transferring Resident 25 out of bed.On 2/11/25 at 1:19 PM Staff 4 (LPN Infection Preventionist/Assistant Director of Nursing) stated Resident 25 was on enhanced barrier precautions due to having a urinary catheter and wounds. Staff 4 stated when residents were on enhanced barrier precautions, staff were expected to wear gloves and a gown when providing direct patient care such as transferring residents out of bed.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to follow physician orders for 2 of 6 sampled residents (#s 2 and 22) reviewed for medication. This placed residents at risk for adverse side effects. Findings include:1. Resident 2 admitted to the facility in 2025 with diagnoses including depression and adjustment disorder.The 1/29/25 Care Plan indicated Resident 2 experienced pain due to a recent surgery and motor vehicle accident with multiple fractures. Interventions included to administer medications as ordered.A 4/8/25 physician order indicate Resident 2 was to receive oxycodone 5 mg every four hours as needed for pain and 10 mg every four hours as needed for pain. The medication was not to exceed more than 40 mg daily.A 4/24/25 progress note indicated Staff 5 (LPN) signed out a dose of oxycodone and noted Resident 2 received 50 mg of Oxycodone on 4/23/25. The medication was to not exceed 40 mg per day. Resident 2 was notified and the on call provider was notified. Resident 2 was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review it was determined the facility failed to ensure falls were evaluated to ensure resident safety and to ensure care plan interventions were followed for 2 of 4 sampled residents (#s 3 and 7) reviewed for accidents. This placed residents at risk for continued accidents. Findings include: 1. Resident 3 admitted to the facility in 11/2024, with diagnoses including heart failure. A 12/1/24 at 02:26 AM Progress Note indicated Resident 3 slid out of bed, landed on the floor and got a skin tear on her/his leg. The same progress note indicated Resident 3 was sent out to the hospital per her/his request, not due to injury. The resident did not return to the facility. The progress note did indicate if Resident 3's fall was witness or unwitnessed. Record review found no documented evidence to show the resident's fall was evaluated to ensure resident safety and care plan interventions were followed. On 4/18/25 at 10:15 AM, Staff 2 (DNS) and Staff 3 (RN consultant) confirmed that a thorough and complete analysis was not done for Resident 3's fall incident. 2.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review it was determined the facility failed to ensure staff followed contact precautions for 1 of 3 sampled residents (#1) reviewed for infection control. This placed residents at risk for cross contaminations. Findings include: Resident 1 was admitted to the facility on 5/2024, with diagnoses including a stage 4 and stage 3 pressure ulcer. On 4/17/25 at 9:09 AM, Staff 4 (LPN) and Staff 5 (CNA) performed a dressing change for Resident 1. Staff 4 removed the old dressing and carefully cleaned Resident 1's wound. Staff then re-dressed the wound per physician order. Staff 4 did not change her gloves between handling soiled dressings and clean dressings. On 4/17/25 at 9:18 AM, Staff 4 (LPN) removed her PPE gown improperly. Staff 4 came into contact with the exterior side of the gown when it was removed. On 4/17/25 at 9:21 AM, Staff 4 (LPN) confirmed she was aware she should have changed her gloves between dirty and clean portions of the procedure. Staff 4 stated she understood the contamination risk related to how a PPE gown should be removed.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review it was determined the facility failed to have the Medical Director attend the Quality Assessment and Assurance and Quality Assurance Performance Improvement (QAA/QAPI) committee meetings. This placed residents at risk for unidentified needs. Findings include: Documentation of QAA/QAPI meeting minutes were requested from 4/2024 through 9/2024 which revealed Staff 23 (Former Medical Director) did not attend any of the QAA/QAPI meetings. On 10/8/24 at 9:59 AM, and on 10/11/24 at 1:51 PM, Staff 1 (Administrator) stated Staff 23 the Former Medical Director refused to attend the QAA/QAPI meetings in person or via skype.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview it was determined the facility failed to ensure carpet, flooring and doors were in good repair 1 of 1 facility and 3 of 19 resident rooms reviewed for homelike environment. This placed residents at risk for injury from damaged surfaces and lack of a homelike environment. Findings include: Multiple observations between 10/7/24 and 10/11/24 revealed hall carpet throughout the facility was heavily stained and worn. Observations on 10/9/24 at 9:36 AM revealed a metal floor latch socket was missing below the fire doors between rooms [ROOM NUMBERS]. This created a hole in the flooring 2.5 inches long, 1.5 inches wide and an inch deep; large enough for canes and walkers to catch on. On 10/10/24 at 10:50 AM the floor covering surrounding the base of the toilet between rooms [ROOM NUMBERS] was observed to be damaged with exposed under floor. The exposed surface was rough, brownish-gray and was not a cleanable surface. The rest of the bathroom floor was worn and had patches of gray…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it was determined the facility failed to promote self determination for 1 of 3 sampled residents (#5) reviewed for choices. This placed residents at risk for lack of honoring choices and room preferences. Findings include: 1. Resident 5 was admitted to the facility on 9/2020 with diagnoses including anxiety and schizoaffective (a condition that is marked by depression and mania) disorder. The Quarterly MDS dated [DATE], revealed Resident 5 had a BIMS score of 15, which indicated the resident was cognitively intact. Random observations from 10/7/24 through 10/10/24 revealed her/his room was cluttered with multiple items on the bedside table, bed, dresser and on the floor. Resident 5 was observed using a front wheel walker, frequently going out to smoke or walking up and down the halls. On 10/7/24 at 10:44 AM, Resident 5 and Staff 8 (LPN) were present for an interview. Resident 5 stated she/he was told by management she/he would have to move out of her/his room,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review it was determined the facility failed to ensure residents were informed in writing of changes in financial coverage for 1 of 3 sampled residents (#3) reviewed for advance beneficiary notification. This placed residents at risk for unknown financial liabilities and lack of knowledge regarding the right to appeal the decision. Findings include: Resident 3 admitted to the facility in 5/2024 with diagnoses including lower extremity paraplegia (the inability to move lower extremities). A review of Resident 3's electronic health record revealed she/he was discharged from Medicare Part A services on 8/9/24 with 37 skilled days remaining. The resident remained in the facility. No evidence was found in the resident's record to indicate she/he received a Notice of Medicare Non-coverage form (NOMNC) or a Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN). In an interview on 10/9/2024 at 3:16 PM Staff 4 (Social Services Coordinator) stated she was unable to locate a NOMNC or a SNF ABN for Resident 3. In an interview on 10/11/24 at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review it was determined the facility failed to ensure personal privacy was honored for 1 of 1 resident (#187) reviewed for privacy. This placed residents at risk for breaches of confidentiality. Findings include: Resident 187 admitted to the facility in 9/2024 with diagnoses including intracranial (inside the skull) abscess. On 10/10/24 from 1:00 PM through 2:00 PM, Resident 187 was observed meeting with Staff 27 (Physician's Assistant) in a corner of the main dining room. The survey team was meeting in the activity room adjacent to the main dining room and the two rooms were separated by a curtain. The survey team was able to hear the medical conversation. The resident and Staff 27 were discussing private health information including diagnoses, symptoms, medications and prognosis. Resident 187 was overheard telling Staff 27 about her/his discomfort with the lack of privacy associated with sharing a room with three roommates and stated she/he wanted to leave the facility due to the lack of privacy. In an interview on 10/11/24 at 9:28 AM…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review it was determined the facility failed to develop a comprehensive person centered care plan for 1 of 3 recently admitted residents (#85) reviewed for incontinence and respiratory care. This placed residents at risk for unmet needs. Findings include: Resident 85 was admitted in 9/2024 with diagnoses including diabetes, chronic obstructive pulmonary disease, history of lung cancer, heart failure and generalized weakness. Resident 85's admission MDS and CAAs dated 9/24/24 identified the resident was frequently incontinent of urine related to weakness and the use of diuretic medication, and the resident required staff assistance with toileting. Current Physician orders for Resident 85 included an order for a 2000 ml per day fluid restriction. Resident 85's care plan dated 9/21/24 identified bladder incontinence related to the use of diuretic medication, impaired mobility and the need for extensive assistance with transfers. Interventions directed staff to check and change frequently throughout the shift and PRN. The care plan did not include…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review it was determined the facility failed to ensure residents received appropriate ADL assistance for 1 of 3 sampled residents (#136) reviewed for activities of daily living. This placed residents at risk for lack of grooming and personal hygiene. Findings include: Resident 136 was admitted to the facility in 10/2024 with diagnoses including stroke. A review of Resident 136's Baseline Care plan dated 10/5/24 revealed the resident required substantial/maximal assistance from one person for showers. A review of Resident 136's 10/2024 shower task form revealed the resident received a bed bath on 10/6/24. An observation and interview on 10/7/24 at 2:36 PM revealed Resident 136 was in bed and her/his hair was greasy. Resident 136 stated she/he received one bed bath since admission, but her/his hair was not washed, which would have been nice. Random observations from 10/8/24 through 10/9/24 revealed Resident 136 was in her/his bed or up in her/his wheelchair, and the resident's hair was greasy. On 10/9/24 at 11:56 AM Resident 136 stated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to ensure residents received support to maintain continence for 1 of 2 residents (#85) reviewed for incontinence. This placed residents at increased risk for skin breakdown and loss of dignity. Findings include: Resident 85 was admitted in 9/2024 with diagnoses including chronic obstructive pulmonary disease, heart failure and generalized weakness. Resident 85's admission MDS dated [DATE] identified the resident was frequently incontinent of urine and the resident required staff assistance with toileting. The 9/24/24 Urinary Incontinence CAA identified the type of incontinence as a mixture of urge, related to use of diuretic medication and functional, due to weakness and impaired mobility. According to the CAA as the resident regained strength, it was anticipated the resident would be more able to self-toilet and avoid incontinence issues. Resident 85's care plan dated 9/21/24 indicated the presence of moisture associated skin breakdown…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review it was determined the facility failed to follow physician's orders for continuous oxygen use for 1 of 1 (#85) sampled resident reviewed for respiratory care. This place residents at risk for complications related to chronic respiratory disease. Findings include: Resident 85 was admitted to the facility in 9/2024 for rehabilitation with diagnoses including chronic obstructive pulmonary disease (COPD), obstructive sleep apnea and heart failure. Resident 85's physician orders dated 9/17/24 and Comprehensive Care Plan dated 9/21/24 directed staff to administer continuous humidified oxygen at 6 liters per minute via nasal cannula to keep oxygen saturation (percentage of oxygen in the resident blood) between 89 and 92%. Review of a published cylinder duration chart for medical oxygen indicated an E-cylinder, if full, would last 1.7 hours at a flow rate of 6 liters per minute. This information was not part of the resident's plan of care. On 10/7/24 at 1:23 PM Resident 85 was observed to transfer from a wheelchair to bed. The resident had a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview it was determined the facility failed to ensure medication storage areas were free of expired medication and biologicals for 1 of 1 medication storage room and 1 of 3 treatment carts reviewed for medication storage. This placed residents at risk for diminished treatment efficacy. Findings include: On [DATE] at 11:08 AM observations within the medication storage room refrigerator revealed a vial of tuberculin used for tuberculosis screening labeled as opened on [DATE]. Staff 2 (DNS) confirmed the tuberculin was to be discarded 30 days after opening. A bottle of acidophilus with an expiration date of 8/2024 was located in the door compartment of the refrigerator. Staff 2 confirmed it was expired. Observations of one of three facility treatment carts on [DATE] at 11:20 AM revealed a vial of Bacitracin (antibacterial) ointment with an expiration date of 8/2024. Staff 2 (DNS) confirmed the used tube of Bacitracin was expired.

Based on interview and record review it was determined the facility failed to ensure CNA staff annual performance reviews were completed for 3 of 5 sampled CNA staff (#s 8, 11 and 12) reviewed for sufficient and competent nurse staffing. This placed residents at risk for a lack of competent staff. Findings include: A review of personnel records on 7/13/23 indicated the following employees had not received their annual performance evaluations: -Staff 8 (CNA), hire date 4/9/22: no annual performance reviews were provided. -Staff 11 (CNA), hire date 10/2/01: last performance review was completed on 2/20/20. -Staff 12 (CNA), hire date 2/27/17: last performance review was completed on 12/10/20. On 7/13/23 at 10:56 AM PM Staff 13 (Human Resource Director) confirmed annual performance reviews were not completed for the identified staff.

Based on interview and record review it was determined the facility failed to ensure CNA staff received 12 hours of in-service training annually for 4 of 5 randomly selected staff members (#s 8, 9, 10 and 12) reviewed for evidence of in-service training. This placed residents at risk for lack of quality care. Findings include: On 7/13/23 at 9:48 AM Staff 1 (Administrator) stated in-service trainings were provided according the facility's training calendar, monthly staff meetings and via online courses. On 7/14/23 at 10:59 Staff 1 provided the following annual CNA training hours for the past year: -Staff 8 received five hours of annual in-service training; -Staff 9 received six hours of annual in-service training; -Staff 10 received six hours of annual in-service training and -Staff 12 received nine hours of annual in-service training. On 7/14/23 at 10:59 AM Staff 1 stated she expected CNA staff to receive at least 12 hours of in-service training annually.

Based on interview and record review it was determined the facility failed to follow physician's orders for 1 of 5 sampled residents (#17) reviewed for unnecessary medications. This placed residents at risk for adverse medical consequences. Findings include: 1. Resident 17 was admitted to the facility in 2022 with diagnoses including Parkinson's Disease (a disorder that affects movement), end-stage renal disease with dialysis, astherosclerotic heart disease (disease of the heart's major blood vessels) and depression. a. A 5/1/23 physician order indicated Resident 17 was prescribed carbidopa-levodopa (Parkinson's medication) three times a day. A review of Resident 17's 6/1/23 through 7/11/23 MAR indicated the resident's carbidopa-levodopa was not given according to physician orders on the following days: -6/3 mid day and evening doses; -6/5 morning and mid day doses; -6/6 mid day dose; -6/8 morning, mid day and evening doses; -6/9 evening dose; -6/10 morning dose; -6/12 morning and mid day doses; -6/13 morning and mid day doses; -6/15 morning and mid day doses; -6/16 mid day dose;…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review it was determined the facility failed to follow physician orders for oxygen therapy for 1 of 1 sampled resident (#17) reviewed for oxygen. This placed residents at risk for unmet respiratory needs. Findings include: The facility's Respiratory Treatment Policy and Procedure last revised 6/22/22 indicated the following: -When residents had continuous oxygen therapy, the licensed nurse was responsible for checking residents oxygen therapy each shift and validating the regulator was set for the appropriate liter flow. Resident 17 was admitted to the facility in 2022 with diagnoses including end-stage renal disease, chronic respiratory failure and heart failure. Resident 17's 5/1/23 physician order indicated she/he required continuous oxygen at four liters per minute when resting, with activity and when sleeping. On 7/11/23 at 2:30 PM and 7/12/23 at 12:09 PM Resident 17 was observed with oxygen administration being provided via nasal cannula between 1.5 and two liters per minute. A review of Resident 17's 7/2023 health care record…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review it was determined the facility failed to store drugs and biologicals in locked compartments for 1 of 2 medication carts observed during this survey. This placed residents at risk for medication diversion and accidents. Findings include: The facility's Medication Administration Policy indicated: Unlock medication cart: Cart may remain unlocked only when in direct line of sight and control by the nurse or medication aide who is administering the medications. On 7/11/23 at 1:11 PM a medication cart was observed to be unlocked near the nurses' station. The nurse was not in view of the cart. Staff 5 (LPN) verified the cart was unlocked. On 7/11/23 at 2:10 PM a medication cart was observed to be unlocked near the nurses' station. The nurse was not in view of the cart. Staff 6 (LPN) verified the cart was unlocked. On 7/12/23 at 2:58 PM Staff 1 (Administrator) stated it was her expectation the carts remained locked when staff were not using them.

Based on interview and record review it was determined the facility failed to ensure physician's visit notes were in the resident's clinical record for 1 of 5 sampled residents (#2) reviewed for unnecessary medications. This placed residents at risk for inaccurate or incomplete records. Findings include: Resident 2 was re-admitted to the facility in 2023 with diagnoses including disorder of the colon. A review of Resident 2's clinical record revealed no routine regulatory physician's visits from 1/1/23 through 7/14/23 were documented in the resident's record. On 7/14/23 at 9:51 AM Staff 2 (DNS) verified there were no regulatory physician's visit notes in Resident 2's clinical record. Staff 2 stated she was trying to obtain copies of the notes from the physician's office.