Advanced Rehab Center of Tustin

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to develop a plan of care to reflect the individual care needs for one of three sampled residents (Resident 1). * The facility failed to ensure Resident 1's comprehensive care plan included speech therapy service, goals, and interventions. This failure posed the risk of the resident not receiving the appropriate treatment, services, and individualized care.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the personal belongings for one of six sampled residents (Resident 2) were kept safe from loss or theft. * The facility failed to update Resident 2's personal inventory to include Resident 2's Apple iPad. Additionally, the facility failed to ensure the CNA reported the missing Apple iPad according to the facility's policy. These failures resulted in the loss of Resident 2's iPad and had the potential to negatively impact the resident's well being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure assistance in the formulation of an advance directive for four of six final sampled residents (Residents 10, 89, 93, and 118) reviewed for advance directive. * The facility failed to ensure assistance in the formulation of an advance directive was offered for Residents 10, 89, and 118. * The facility failed to follow up on advance directive status after providing educational materials to the resident's representative for Resident 93. These failures had the potential for the residents' healthcare decision and treatment preferences to be unknown, undocumented, and not honored.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to meet the resident care needs for four of 20 final sampled residents (Residents 4, 83, 123, and 147). * The facility failed to routinely monitor Resident 4 for bleeding and urinary changes per the resident's care plan and clinical history. * The facility failed to rotate the insulin injection sites for Resident 83. In addition, the facility failed to follow the physician's order for hydralazine (a medication used to treat high blood pressure). * The facility failed to consistently complete the Change of Condition assessment for Resident 123 despite having multiple episodes of refusing blood sugar checks. * The facility failed to notify the physician when Resident 147 had episodes of seizures. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure five of nine final sampled residents (Resident 8, 19, 93, 118, and 143) reviewed for accidents remained free from accident hazards. * The facility failed to provide Resident 93 with a WanderGuard (type of wander management system) and failed to monitor the functionality of the WanderGuard as per the physician's order. In addition, the facility failed to ensure Resident 93's elopement assessment was accurate and failed to provide the receptionist an updated list of the residents at risk for elopement. * The facility failed to consistently monitor Resident 8 and 19's bed and chair alarms as per the physician's order. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the respiratory care and services were provided in accordance with professional standards for two of two final sampled residents (Residents 83 and 118) reviewed for respiratory care. * The facility failed to ensure Resident 83's nasal cannula (flexible tube to deliver oxygen into the nose) was labeled and stored in a bag when not in use. In addition, the facility failed to provide oxygen as ordered by the physician. * The facility failed to ensure Resident 118's nebulizer mask, canister, and tubing were labeled and stored in a setup bag. These failures had the potential to result in inadequate respiratory care and increased infection control risks for the residents.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure safe medication storage in two of three medication carts (Medication Carts A and B) inspected. * The facility failed to ensure an expired glucagon emergency kit (containing one vial glucagon for injection: 1 mg glucagon and 49 mg of lactose (natural sugar), one syringe of diluent for glucagon: 12 mg/ml glycerin, water for injection, and hydrochloric acid) was not stored in Medication Cart A * The facility failed to ensure internal and external medications were stored separately. A Tear Plus (eye lubricant) eye drop medication and a bottle of Tylenol (analgesic) were stored together in Medication Cart A. * The facility failed to ensure the medication label on the bubble pack of the gabapentin (nerve pain medication) was accurate and reflected the physician's order. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure complete and accurate medical records for four of 20 final sampled residents (Residents 7, 32, 92, and 143).* Resident 92's initial H&P examination was not completed.* Resident 143's shift pain monitoring did not match the resident's highest pain levels documented when PRN pain medications were administered.* Resident 7 and 143's post-fall neurological assessments had missing dates, and multiple illegible or overwritten time entries.* Resident 32's POLST was incomplete and did not show the resident had an advance directive, despite an advance directive being present in the medical record. These failures resulted in medical records that contained incomplete or inaccurate information, which could negatively affect continuity of care and clinical decision making.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the Infection Control Prevention and Control Program was established, maintained, and implemented according to accepted standards of practice to prevent the development and transmission of communicable diseases and infections. * The facility failed to maintain an accurate infection control surveillance program for November 2025 through March 2026. The facility conducted surveillance only on the residents who exhibited signs and symptoms of infection and were prescribed antimicrobial medications. [...]

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to implement their antibiotic stewardship program. * The facility failed to conduct an assessment for the McGeer's criteria to determine the true infection for two of 20 final sampled residents (Residents 8 and 148) and fourteen nonsampled residents (Residents 11, 27, 40, 44, 59, 85, 88, 90, 158, 159, 161, 163, 164, and 165). This failure had the potential for inaccurate identification of true infections and potentially inhibited the residents' physicians from discontinuing unnecessary antimicrobials.

Inspectors wroteBased on interview, facility document review, and facility P&P review, the facility failed to ensure three of three staff (LVNs 1 and 4, and CNA 7) reviewed for COVID-19 vaccinations were educated and offered the COVID-19 vaccination. * The facility failed to offer the educational materials of the risks and benefits for the COVID-19 vaccines and offer the COVID-19 vaccine to LVNs 1 and 4, and CNA 7. These failures put the residents at risk for increased risk of infection and transmission of COVID-19.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure resident care was provided in a manner that maintained and enhanced dignity for one of 20 final sample residents (Resident 19). * The facility failed to ensure CNA 2 sat next to Resident 19 while assisting the resident to eat. This failure had the potential to negatively impact Resident 19's sense of dignity, self-worth, and well-being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure two of five sampled residents for unnecessary medications (Residents 19 and 148) and two of 20 final sampled residents (Residents 8 and 93) reviewed for informed consents were provided the right to self-determination regarding the use of the psychotropic medications and treatments. * The facility failed to ensure the informed consents for buspirone (antianxiety) and Seroquel (antipsychotic) medications were accurate for Resident 93. * The facility failed to ensure the informed consent for buspirone medication included the indication of use and manifested behavior, and the informed consent for fluoxetine (antidepressant) medication was verified by two licensed nurses for Resident 148. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medications were safely administered for one of 91 residents (Resident 59). * Resident 59 had Vitamin A and D (skin protectant) ointment at bedside. However, Resident 59 did not have a physician's order to keep the medication at the bedside. This failure had the potential for the resident to administer the medication inaccurately, develop adverse reactions, and negatively affect the resident's well-being.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide a reasonable accommodation to meet the needs of one of 90 residents (Resident 136) observed for call light accessibility. * The facility failed to ensure Resident 136's call light was within the resident's reach. This failure had the potential to negatively impact the resident's psychosocial well-being and may cause delays in receiving necessary care.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to timely notify the resident's physician for changes in condition for one of one final sampled resident (Resident 4) reviewed for change of condition. * The facility failed to timely follow-up on and notify Resident 4's physician regarding the resident's urinary changes. This failure resulted in a delay in obtaining and implementing physician interventions.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of five final sampled residents (Resident 148) reviewed for unnecessary medication was free from unnecessary psychotropic medications. * The facility failed to ensure Resident 148 was monitored for the side effects related to the use of lorazepam (antianxiety), buspirone (antianxiety), fluoxetine (antidepressant) and mirtazapine (antidepressant). In addition, the monthly behavior summary for mirtazapine medication did not match the documentation of the episodes when Resident 148 ate less than 50%. These failures had the potential to result in unrecognized adverse medication effects, delayed or inadequate clinical intervention, and inaccurate clinical decision-making regarding the continued use of the psychotropic medications for Resident 148.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure accurate and timely PASARR Level I screenings for two of two final sampled residents (Residents 10 and 32) reviewed for PASARR. * The facility failed to ensure PASARR level I screening was completed when Resident 10 entered the facility as an exception (an exempted acute care hospital discharge) and stayed more than 30 days. * The facility failed to ensure the accuracy of the PASARR Level 1 screening for Resident 32. These failures posed the risk for Residents 10 and 32 of not properly screened for serious mental illness, intellectual disability, or related conditions, potentially resulting in inadequate levels of service, incomplete assessments, and lack of appropriate interventions and evaluations.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to develop a comprehensive, person-centered plan of care to reflect the individual care needs for two of 20 final sampled residents (Residents 143 and 148). * The facility failed to address Resident 143's use of the hydroxyzine HCl medication for anxiety in the care plan. * The facility failed to develop a care plan problem and interventions to address the use of the buspirone medication (antianxiety) for Resident 148. These failures had the potential to result in inconsistent, incomplete, and non individualized care for the residents.

Inspectors wroteBased on interview and medical record review, the facility failed to provide necessary treatment and follow-up care to maintain the vision needs for one of one final sampled resident (Resident 123) reviewed for vision and hearing. * The facility failed to ensure Resident 123's follow-up eye specialize appointment was scheduled. This failure posed a risk of the resident not receiving appropriate care for the resident's vision needs.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to properly maintain and assess the IV access for one of one final sampled resident (Resident 148) reviewed for IV catheter care. * The facility failed to ensure Resident 148's PICC line was monitored accurately, and the physician was notified when there was a change in the external catheter length measurement as per the physician's order. In addition, the facility failed to measure and document Resident 148's arm circumference after the initial assessment on 4/2/26. These failures had the potential to delay the identification of PICC related complications and place the resident at increased risk for harm.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure appropriate pain management for two of five final sampled residents (Residents 83 and 148) reviewed for pain management. * The facility failed to provide nonpharmacological interventions for pain management to Resident 83 prior to administering the pain medication. * The facility failed to provide nonpharmacological interventions for pain management to Resident 148 prior to administering the pain medication. In addition, the Norco (narcotic pain medication) medication was administered to Resident 148 when the documented pain level was 0/10 (on the pain scale of 0 to 10 with 0 = no pain and 10 = worst). These failures had the potential to result in ineffective pain management and/or expose the residents to unnecessary medication use and associated adverse effects.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure necessary pharmaceutical services were provided to maintain safe and appropriate medication administration for one nonsampled resident (Resident 99) and one of three medication carts (Medication Cart A) inspected. * The facility failed to ensure LVN 4 checked Resident 99's respiratory rate prior to administering the gabapentin (nerve pain medication), as prescribed by the physician. This failure placed the resident at risk for potential side effects or complications. * The facility failed to document when the glucagon emergency kit (used to treat sever, life threatening low blood sugar) was opened and failed to replace it within 72 hours as required by the facility's P&P. [...]

Inspectors wroteBased on interview, medical record review, and facility document review, the facility failed to ensure the irregularities in a resident's drug regimen were identified and reported for one of one final sampled resident (Resident 123) reviewed for insulin (hormone produced by the body to regulate blood sugar) use. * The facility's pharmacy review binder did not contain pharmacy recommendations addressing Resident 123's repeated refusal of insulin injections and related blood sugar checks. This failure posed the risk of Resident 123 not receiving appropriate care and monitoring for diabetes management.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure one of five sampled residents (Resident 148) reviewed for unnecessary medications was free from unnecessary medications. * The facility failed to ensure Resident 148's heart rate was checked prior to administering the amiodarone (antiarrhythmic medication), as prescribed by the physician. This failure increased the risk of medication related adverse effects and had the potential to negatively impact the resident's health and well being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the laboratory testing was completed as ordered by the physician for one of five sampled residents (Resident 83) reviewed for unnecessary medication. [...]

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure the menus were followed for 25 of 91 residents receiving mechanically altered diets. * The facility failed to follow the menu for the residents receiving mechanically altered diets when the residents did not receive the correct meal portion sizes as specified in the menu and spreadsheet. These failures posed the risk that residents' nutritional needs would not be met, potentially leading to unintentional weight loss and further medical complications.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure food for the residents on textured-modified diet was prepared in accordance with accepted standards for four of 91 residents received IDDSI Level 5 diets. * The facility failed to follow the guidelines for the IDDSI Level 5 Minced and Moist diet when the minced and moist foods were not served in the correct consistency. This failure had the potential to increase the risk of choking, aspiration, and inadequate nutrition for residents requiring a modified texture diet.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure one of 20 final sampled residents (Resident 107) food preferences were honored. * The facility failed to ensure Resident 107's eggs were prepared to her stated preference, resulting in her receiving and eating eggs that were too runny and not consistent with her preference. This failure had the potential to negatively affect the resident's dining experience and overall satisfaction with care.

Inspectors wroteBased on observation and interview, the facility failed to ensure the food safety and sanitation guidelines were followed. * The facility failed to ensure a floor drain in the kitchen was clean. This failure had the potential to compromise kitchen sanitation and cause foodborne illnesses to the medically vulnerable residents population who consumed food prepared in the kitchen.

Inspectors wroteBased on interview and facility document review, the facility failed to ensure the Facility Assessment was complete and accurate. * The facility failed to ensure the Facility Assessment included input from residents and resident representatives. In addition, the Facility Assessment inaccurately indicated the facility employed a Social Services Director and only one treatment nurse. These failures posed the risk that the facility may not have identified or planned for the necessary resources to meet residents' needs.

Inspectors wroteBased on observation and interview, the facility failed to ensure for a safe and comfortable environment for two of 43 resident rooms (Rooms A and B). * The facility failed to ensure the room temperature was maintained in comfortable level for Rooms A and B, when the residents residing in the rooms complained of the room temperature being too cold. The temperature was 71 degree Fahrenheit. This failure posed the risk of the residents not being able to sleep comfortably.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to protect the residents' identifiable information. * The facility's Survey Inspection Results binder for public viewing included two Confidential Resident Rosters (a list which identified the names of the residents by their identifiers given for surveys to protect the residents' identities). This failure resulted in confidential residents' information being accessible to the public.

Inspectors wroteBased on interview and medical record review, the facility failed to timely complete the admission MDS assessments for two of 20 final sampled residents (Residents 92 and 143). - Resident 92's admission MDS assessment was late and incomplete.- Resident 143's admission MDS assessment was completed late. These failures had the potential to delay the establishment of a standardized, holistic baseline assessment of the residents' functional capabilities and health needs upon admission, as well as delay required submission of an assessment data to CMS.

Inspectors wroteBased on interview and facility document review, the facility failed to ensure three of four CNA employee personnel files contained annual performance evaluations. * CNA 3, 4, and 5's employee personnel files failed to contain the staff's annual performance evaluations. These failures posed a risk that the CNAs may not receive appropriate in service education or performance based feedback necessary to ensure quality resident care.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure an allegation of abuse was immediately reported to the CDPH, L&C Program, Ombudsman Office, and local law enforcement agency for one of four sampled residents (Resident 1). * Resident 1 alleged CNA 1 shook the resident's shower chair, pulled and yanked their hands, and kicked them. This failure had the potential for Resident 1 to be vulnerable to further abuse and emotional distress.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure one of five sampled residents (Resident 1) was provided quality care. * The facility failed to conduct a skin assessment following a newly observed skin impairment for Resident 1. In addition, the facility failed to document and monitor Resident 1's bilateral lower extremities wounds. These failures had the potential for delay in providing the necessary care and services to Resident 1.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the Braden scale assessment was performed for one of the three sampled residents (Resident 1) reviewed for the pressure injury. This failure had the potential to result in a delay in interventions being put in place to prevent further decline.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to develop the comprehensive plans of care to reflect the individual care needs for two of five sampled residents (Residents 1 and 5). * The facility failed to develop a care plan to address Resident 1's laceration to the right temporal area. * The facility failed to develop a care plan to address Resident 5's skin tear to the left forearm. These failures had the potential risk of not providing appropriate, consistent, and individualized care to these residents.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the medical record was accurate for one of three sampled residents (Resident 4). This failure posed the risk for Resident 4 not to receive the accurate and necessary care.

Inspectors wroteBased on interview, medical record review, facility record review, and facility P&P review, the facility failed to protect the resident's rights to be free from the physical abuse by a resident for one of five sampled residents (Resident 1). * Resident 1 was hit on the nose by another resident (Resident 2), which resulted in Resident 1 having a nasal fracture (broken nose). This failure had the potential to negatively impact Resident 1's well-being.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of two sampled residents (Resident 2) who was receiving aripiprazole (antipsychotic-class of medications that treat mental illness) was monitored for its side effects. This failure had the potential for increased risk of medication adverse reactions to be undetected.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed ensure timely reporting of a staff to resident abuse allegation for one of eight sampled residents (Resident 1). * CNA 3 allegedly sat next to Resident 1, put his hand on the resident's shoulder and made the resident feel uncomfortable. This failure had the potential for abuse to go unreported at a facility with a highly vulnerable resident population and posed the risk of continued abuse of the residents.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were coordinated to meet the resident's needs when discharged from the facility for one of two sampled residents (Resident 4). This failure resulted in Resident 4 not having appropriate care at home, which had the potential to negatively affect Resident 1's health.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen. * The facility failed to ensure proper labeling and dating of foods in the kitchen and failed to ensure the expired food items in the kitchen were discarded. * The facility failed to ensure the kitchen equipment were in good condition. * The facility failed to ensure proper labeling and dating of foods in the refrigerator used for the residents' food brought in by visitors and failed to ensure the expired foods were discarded. * The facility failed to ensure the microwave used to warm up the residents' food brought in from the outside was maintained in sanitary condition and free of food residue. [...]

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to implement the infection control practices designed to provide a safe and sanitary environment and help prevent the development and transmission of diseases and infections. * The facility failed to ensure the facility's monthly Infection Prevention and Control Surveillance Log was accurate. * The facility failed to ensure the laundry staff did not reuse the dirty gowns. * The facility failed to ensure there were no facility staff's personal belongings in the extra clean linen cart. * The facility failed to ensure Resident 36 was placed on contact isolation precautions while the clostridum difficile (bacteria that causes diarrhea and inflammation of the colon) test was pending. In addition, Resident 36's shared toilet was observed with brown stains. [...]

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent the development of new pressure ulcers (areas of damaged skin caused by staying in one position for a long time which reduces blood flow to the area and causes the skin to die and develop a sore) and promote healing of existing pressure ulcer for one of one final sampled resident (Resident 72) reviewed for pressure ulcers. * The facility failed to ensure the LAL mattress unit was not on the static setting(in static mode, the mattress provides a firm surface that makes it easier to transfer or reposition) when care or repositioning was not being rendered. This failure posed the potential risk for Resident 72 to not benefit from the therapy provided by the LAL mattress.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary care and services to prevent accidents for one of 20 final sample residents (Resident 421) and four nonsampled residents (Resident 120, 424, 425, and 771). * The facility failed to ensure the safe smoking practices were followed for three residents (Residents 421, 424, and 425) who smoked in the facility as evidenced by: - The residents were not accurately and thoroughly assessed to determine if they could safely store their own cigarettes or lighters. - The residents who were assessed as requiring supervision while smoking or those with a history of non-compliance with the facility's smoking P&P were permitted to keep the cigarettes, lighters, and other smoking articles/materials in their possession. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to maintain the IV accesses for two of 20 final sampled residents (Residents 421 and 671), and two nonsampled residents (Residents 422 and 423). * The facility failed to ensure the PICC line external catheter baseline measurements were obtained and documented for Residents 421 and 423. * The facility failed to ensure Residents 422 and 671's PIV sites were labeled with the date, time, and licensed nurse's initials. These failures had the potential to delay the identification of intravenous catheter related complications for the residents.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 20 final sampled residents (Resident 58) and three nonsampled residents (Residents 92, 106, and 423) were provided with the appropriate respiratory care when: * The facility failed to ensure Resident 58's oxygen tubing was labeled, dated, and not on the floor. In addition, there was no physician's order obtained and a care plan developed for the use of oxygen. There was no posted signage for the oxygen use in the doorway as per the facility's P&P. * The facility failed to ensure Resident 92's oxygen tubing and mask were labeled and dated. In addition, there was no posted signage for the oxygen use in the doorway as per the facility's P&P. * The facility failed to ensure Resident 106's nebulizer tubing was dated and placed inside a clear plastic bag when not in use. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the appropriate pain management for two of three final sampled resident (Residents 8 and 94) reviewed for pain management. * The facility failed to administer the pain medication according to the physician's order for Resident 8 and develop a care plan to address Resident 8's pain and use of the Norco (narcotic) pain medication. * The facility failed to accurately document the monitoring of pain for Resident 94 and administer the pain medication according to the physician's order. In addition, the facility failed to ensure the non-pharmacological pain interventions were provided prior to the administration of the pain medication and develop a care plan to address Resident 94's pain and the use of the Norco pain medication. [...]

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary pharmaceutical services for four of 20 sampled residents (Residents 3, 36, 43, and 47) and one nonsampled residents (Resident 113). * The facility failed to ensure the Controlled Drug Record matched the MAR for Residents 3 and 371's hydrocodone-acetaminophen (narcotic pain medication) administration. In addition, the facility failed to document the residents' pain assessment before and after the administration of the hydrocodone-acetaminophen medication. This failure posed the risk of diversion of the controlled medication. * Resident 43's insulin (used to lower blood sugar level) injection sites were not rotated. This failure had the potential for the resident to suffer from unnecessary side effects. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure three of five final sampled residents (Residents 3, 10, and 61) reviewed for unnecessary medications were free from unnecessary psychotropic drugs. * Resident 61 was prescribed lorazepam (antianxiety medication) PRN for anxiety starting on 1/27/25. There was no documented diagnosis of anxiety prior to Resident 61 starting the PRN lorazepam medication. Resident 61 did not have an informed consent signed by the resident or responsible party prior to starting the lorazepam medication. Resident 61's physician's orders for the PRN lorazepam medication on 1/27/25, did not have a manifested behavior or stop date for the PRN medication. [...]

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the medications were stored appropriately as evidenced by: * Resident 371's pack of hydrocodone-acetaminophen tablets was stored inside IV cart after the resident discharged . * Four Calmoseptine ointments (a multipurpose, over-the-counter ointment containing menthol and zinc oxide, used to treat and prevent minor skin irritations like diaper rash, burns, cuts, scrapes, and skin irritation from moisture or irritants) without expiration date were stored inside the treatment cart. * Two bins used to dispose medications were unlocked with insulin pens inside. * A bottle of Pro-stat Advanced Wound Care (supplement) was observed with sticky brown residue on and around the cap and bottle. [...]

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the menus were followed for 20 of 93 residents who received food prepared in the kitchen as evidenced by: * 19 residents who were on a CCHO diet were served the canned fruit instead of the diet gelatin with whip topping as shown on the posted menu. * Resident 87 was not served the gelatin with whipped topping as per the menu. These failures had the potential for the residents to not receive an adequate nutrition and appropriate servings to meet the residents' individual needs.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure the residents received food with preserved nutritive content and palatibility as evidenced by: * The pureed carrots were cooked and held in a hot oven for more than two hours prior to the meal service. This failure had the potential to not meet the nutritional needs for the residents consuming food prepared in the kitchen. * The facility failed to ensure the facility food was palatable when one of 93 final sampled residents (Resident 94) and one nonsampled resident (Resident 57) who received food prepared in the facility kitchen were not satisfied with the facility food. This failure had the potential for the 4 residents to have decreased intake which could lead to unplanned weight loss and other medically related concerns.

Inspectors wroteBased on observation, interview, facility document review and facility P&P review, the facility failed to ensure the residents on mechanically altered diets received food in a form that met their individual needs. * One of 11 residents (final sampled resident, Resident 3) who had physician's orders for a regular pureed diet received a regular dysphagia mechanical soft diet. * The pureed BBQ chicken was observed with small chunks of chicken. These failures posed the risk for complications such as choking for the 11 residents who were on pureed diets.

Inspectors wroteBased on interview, facility document review, and facility P&P review, the facility failed to ensure the education on safe food handling of outside food was provided to the staff, residents, and visitors. This failure had the potential to cause foodborne illnesses to the medically vulnerable resident population who consumed food brought from the outside sources.

Inspectors wroteBased on interview and facility document review, the facility failed to ensure the Facility Assessment addressed or included the following: 1. Active involvement of required individuals in developing the Facility Assessment; 2. Resources necessary to care for residents including weekends; 3. A plan to maximize recruitment and retention of direct care staff; and 4. A contingency plan for staffing needs. This failure had the potential to not meet the residents' care needs if the assessed population's needs and resources were not comprehensively identified and addressed.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to implement the antibiotic stewardship program. * The facility failed to ensure if the McGeer's criteria for true infection was completed and accurate for one of 20 final sampled residents (Resident 61) . This failure had the potential for inaccurately identifying true infections and potentially inhibiting residents from receiving the appropriate treatment and care.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the reasonable accommodations to meet the needs of one of 20 final sampled residents (Resident 107). * The facility failed to ensure the call light for Resident 107 was within the resident's reach. This failure had the potential to negatively impact the resident's well-being.

Inspectors wroteBased on interview, medical record review, and facility document review, the facility failed to provide the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) Form CMS-10055 and Notice of Medicare Non-Coverage (NOMNC) for one of three nonsampled residents (Resident 51) reviewed for beneficiary notices. This failure had the potential to not allow the resident or their representative to make informed decisions regarding their Medicare services.

Inspectors wroteBased on interview and medical record review, the facility failed to transmit the MDS timely for one of 20 final sampled residents (Resident 61) and two nonsampled residents (Residents 97 and 103). This failure had the potential for not having current information in the residents' medical records.

Inspectors wroteBased on interview and facility document review, the facility failed to ensure the documentation on the Quality Control Log was accurate for one of four medication carts. This failure had the potential for not knowing if the documented blood sugars for the residents were accurate.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the preparation for a safe and orderly discharge for one of two sampled residents (Resident 1). * Resident 1 was transferred to an acute care hospital without the hospital being notified and without the medical records being sent. * Resident 1 was transferred to an acute care hospital without the transferring nurse providing any report to the nurse at the receiving facility. * Resident 1's personal and demographic information, H&P examination, medication list, physician's orders, and POLST were not provided to Acute Care Hospital 1. These failures posed the resident at risk for not meeting the resident's medical needs when the receiving facility did not receive the needed documents for the transfer with the necessary medical information.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the mailedpackage was unopened and delivered for one of two sampled residents (Resident 1). This failure had the potential to violate the resident's rights to receive mail.

Inspectors wroteBased on interview and medical record review, the facility failed to send a copy of the notice of the transfer/discharge to the representative of the Office of the State Long-Term Care Ombudsman for two of three sampled residents (Residents 1 and 2). This failure posed the risk of the Ombudsman not being aware of the circumstances of the residents' transfer/discharge should the appeal be filed or requested by the residents or their representatives regarding the transfers.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of three sampled residents (Resident 1) and/or the resident's representative was provided a written bed hold policy prior to the transfer. This failure had the potential for the resident or resident's representative to not be informed of their rights to return to the facility following a hospitalization.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the medical records for two of eight sampled residents (Residents 3 and 7) and two nonsampled residents (Residents C and D) were complete and accurate. This failure had the potential for the resident care needs not being met as the medical information was incomplete and inaccurate.

Inspectors wroteBased on observation, interview, medical record review, and the facility P&P review, the facility failed to provide the necessary care and services to maintain the highest practicable well-being for one of five sampled residents (Resident 1). * The facility failed to show documented evidence the physician was notified of Resident 1's missed dialysis appointments on 9/10 and 9/11/24. * The facility failed to follow through on Resident 1's Dialysis Unit Communication form to notify the attending physician for Resident 1's complaints of blood in her bowel movements. * The facility failed to follow through with the attending physician for Resident 1's change in condition regarding the right ear redness. These failures had the potential to negatively affect the resident's health and well-being.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to protect the residents' (Residents 2 and 4) rights to be free from the sexual abuse by another resident (Resident 3). * The facility failed to monitor and provide Resident 3 with the 1:1 (one staff to one resident) supervision as per the care plan after an incident of Resident 3 grabbing Resident 2's breasts on 9/6/24, resulting in Resident 3 continuing to fondle Resident 4's breasts during the activities in the dining room on 9/8/24. This failure resulted in Resident 3 continuing to sexually abuse other residents.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to implement the P&P to ensure the reporting of a reasonable suspicion of a crime in accordance with section 1150B for one of four sampled residents (Resident 4) as evidenced by: * The facility failed to ensure Resident 4's sexual abuse allegation by Resident 3 was reported timely to the CDPH L&C Program and local law enforcement agency. This failure had the potential for abuse and injury of unknown origin allegations to go unreported and uninvestigated timely.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary care and services to maintain the highest practicable well-being for three of four sampled residents (Residents 1, 2, and 4). * The facility failed to ensure the nursing staff reported and documented the unwitnessed fall for Resident 1 on 8/28/24. Furthermore, the 72-hours neurological and post fall risk assessments were not completed following Resident 1's unwitnessed fall. * The facility failed to monitor the psychosocial harm for Residents 2 and 4 post abuse allegations. This failure had the potential to negatively affect the residents' health and well-being.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to prevent or minimize injuries of a fall for one of four sampled residents (Resident 1). * Resident 1 had a history of falls; however, the floor mats were not provided as per the resident care plan and the fall risk assessment was inaccurate. This failure had the potential to place the resident at risk for further serious injury.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to offer or provide the adequate and appropriate pain management for one of four sampled residents (Resident 1). * The facility failed to offer and provide Resident 1 pain medication when Resident 1 complained of pain on 8/28/24. This failure had the potential to negatively affect Resident 1's well-being.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the care plan was implemented related to informing all staff caring for Resident 1 of the special feeding needs for Resident 1. This failure had the potential for Resident 1 not receiving care and services to meet the care needs.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to implement their P&P for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act when the facility failed to report an allegation of resident-to-resident altercation to the law enforcement agency, CDPH L&C Program, and Ombudsman office for three of six sampled residents (Residents 1, 2 and 3). This failure had the potential to put the residents at risk for further abuse.

Inspectors wroteBased on interview, medical record review, and facility P& P review, the facility failed to ensure one of three sampled residents (Resident 3) was free from the unnecessary psychotropic (any drug that affects brain activity) medications. * The facility failed to obtain the informed consent from Resident 3 for the use of Ativan (its generic name, lorazepam, anti-anxiety medication). * The facility failed to ensure Resident 3's informed consent for the use of Seroquel (antipsychotic medication) was signed and dated by the physician. * The facility failed to ensure the monitoring for Resident 3's behaviors of agitation and restlessness for the use of PRN Ativan medication and the inability to sleep for the use of PRN Restoril (medication used to aid with sleep) medication were completed. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of three residents (Resident 2) was free from the significant medication errors when Resident 2 was not given the medications as ordered by the physician on multiple occasions. In addition, the facility failed to notify the resident's physician. These failures had the potential to cause significant adverse effects to the residents.

Inspectors wroteBased on interview and medical record review, the facility failed to follow the physician's orders for one of three sampled residents (Resident 3). * The facility failed to carry out the physician's order for Resident 3's STAT psychiatric consultation order until nine days later. This failure had the potential for the delay of necessary treatment and services and can negatively impact the resident's health conditions.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to notify the physician of changes for one of seven sampled residents (Resident 1). * Resident 1's physician was not notified when Resident 1's inhaler ran out and Resident 1 had increased anxiety. This failure had the potential for the resident not to get the necessary care and services as the physician was not notified of changes.

Inspectors wroteBased on interview, observation, medical record review, and facility P&P review, the facility failed to implement their P&P for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act when the report of an abuse allegation was not reported to the State Agency, Ombudsman, and local law enforcement for one of seven sampled residents (Resident 2). This failure had the potential for delay of investigation.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to timely investigate an abuse allegation for one of seven sampled residents (Resident 2). This failure had the potential for not protecting the resident from abuse.

Inspectors wroteBased on interview, observation, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided for two of seven sampled residents (Residents 1 and 3). In addition, the facility failed to ensure the facility's Emergency Procedure - Cardiopulmonary Resuscitation P&P was current. * The Daily Skilled Nursing Notes were not completed for Resident 1 who received skilled services. * Resident 3's psychiatry (a branch of medicine dealing with mental illness) consult was not completed timely. These failures had the potential to negatively impact the resident's quality of care due to incomplete medical records, delay of care and the facility P&P not being followed.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to implement the safety interventions and provided supervision to 21 of 27 sampled residents (Residents 4, 5, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26) who smoked. This failure had the potential for the residents to be at risk for injury while smoking.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of seven sampled residents (Resident 1) received the respiratory medications as per the physician's orders. This failure had the potential for the resident not having their ordered medications being available when needed.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the accurate controlled medication reconciliation for two of seven sampled residents (Residents 1 and 3). * Residents 1 and 3's Ativan (a controlled medication for anxiety) administration were not documented accurately as the controlled count sheet did not match the residents' MAR. This failure had the potential for drug diversion.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to maintain the infection control practices to help prevent the development and transmission of diseases and infections. * CNA 4 failed to perform hand hygiene before entering a room with Enhanced Barrier Precautions signage. This failure had the potential to increase the risk for the spread of infection.

Inspectors wroteBased on interview, medical record review and facility P&P review, the facility failed to develop a plan of care for one of seven sampled residents (Resident 1). * Resident 1's plan of care did not address the resident's need for monitoring while smoking and history of keeping medication in their nightstand. This failure had the potential for the resident not to receive the necessary care and interventions to promote resident's safety.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the medications were not left unattended. * Three medication cups containing medications were left unattended on the medication cart near the nurses' station. This failure had the potential for other residents to have access to medications.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to develop a plan of care to reflect the individual care needs for one of two sampled residents (Resident 1). * The facility failed to develop a care plan problem to address Resident 1's smoking and use of bronchodilators. This failure posed the risk of not providing appropriate, consistent, and individualized care to the resident.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the medical record was accurate and complete for one of two sampled residents (Resident 1). * The facility failed to ensure Resident 1's monitoring was documented every shift for the first 72 hours after admission. * The facility failed to ensure the documentations of the CPR performed to Resident 1 were accurate. These failures had the potential for the resident care needs not being met as the medical information was incomplete and inaccurate.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to protect the personal belongings from loss for one of two sampled residents (Resident 1). * The facility failed to complete an inventory of Resident 1's personal belongings for readmission and discharge. This failure had the potential to negatively impact the resident's well-being.

Inspectors wroteBased on interview and medical record review, the facility failed to protect one of two sampled residents (Resident 1) to be free from the verbal abuse by a facility's staff member. * Resident 1 had episodes of seeking to leave the facility and calling 911 (an emergency services). LVN 1 failed to respond appropriately by yelling at Resident 1. This failure had the potential to negatively impact Resident 1 's mental and emotional well-being.

Inspectors wroteBased on observation, interview, medical record review and facility document and P&P review, the facility failed to implement a systematic approach to ensure effective monitoring of acceptable parameters of nutritional status for one of 19 final sampled residents (Resident 6) when: 1. The severe weight loss of - 10 lbs. (7.7%) from 7/20/23 to 9/25/23, and - 14 lbs. (10.4%) from 5/28/23 to 9/25/23, was not assessed and monitored by the IDT (Interdisciplinary team - members of the care team including but not limited to: the attending physician, nurses, a member of the food and nutrition services staff, social workers, rehabilitation therapists and the resident or the resident's legal representative). 2. The interventions ordered by Physician 1 to maintain Resident 6's nutritional and hydration status were not implemented as ordered. 3. [...]

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure food safety and sanitation requirements were met in the kitchen when: * Time/Temperature Control for Safety (TCS) foods (food that required time and temperature controls to limit the growth of illness causing bacteria) were not monitored to ensure proper cool down process was followed. * The thawing process was not performed as per the facility's P&P. * Two of two ice machines were not clean. * The expired food items in the kitchen and residents' refrigerator were not discarded . * One of kitchen staff did not follow the facility's dress code during the food preparation. * The food preparation equipment were not in proper operating condition. * The kitchen utensils and dishware were not stored in a sanitary condition. * The floor of the walk-in refrigerator had missing tiles. [...]

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to implement and maintain their infection control program as evidenced by: * The facility failed to implement their infection control surveillance programs from October through November 2023. The facility failed to ensure the Infection Prevention and Control Surveillance Logs were complete and accurate to determine if the resident's infection met the McGeer's criteria for true infection. * The facility failed to ensure the staff practiced the special droplet/contact precautions when exiting Room B that had a posted signage outside the room for special droplet/contact precautions. * The facility failed to ensure Resident 993's oxygen nasal cannula tubing and nebulizer mask were stored properly, and the storage bag was not on the floor. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the reasonable accommodations to meet the needs of one of 19 final sampled residents (Resident 13) and two nonsampled residents (Residents 24 and 30). * The facility failed to ensure the call lights for Residents 24 and 30 were within the residents' reach. * The facility failed to provide Resident 13's preferred room temperature water during the medication administration. These failures had the potential to negatively impact the residents' well-being.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the physician and resident's responsible party were notified of the changes in conditions of two of 19 final sampled residents (Residents 7 and 69) as evidence by: * The facility failed to notify the physician and Resident 7's responsible party for the resident's back of the right hand skin discoloration. * The facility failed to ensure Resident 69's responsible party was notified of Resident 69's positive for C. diff and use of Vancomycin (antibiotic medication) to treat C. diff. These failures had the potential for Residents 7 and 69 not to receive the appropriate treatment to address his medical needs and to have a delay in care and treatment.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 19 final sampled residents (Resident 51) was free from the physical restraints. This failure had the potential to negatively affect Resident 51's physical and psychosocial well-being.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to develop the comprehensive plans of care to reflect the individual care needs of four of 19 final sampled residents (Residents 6, 44, 51, and 69) and one nonsampled resident (Resident 36). * The facility failed to develop a care plan problem to address Resident 69's antibiotic use, contact precaution, and infection for Clostridioides difficile (C. difficile or C. diff, a germ that causes diarrhea and inflammation of the colon). * The facility failed to develop a care plan goal and interventions to address and monitor the risk of dehydration for Resident 6. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure to provide the necessary services to attain or maintain the highest practicable well-being for two of 19 final sampled residents (Residents 6 and 7). * The facility failed to ensure the Geri-sleeves and heel protectors were applied to Resident 7 as ordered. In addition, the facility failed to identify and assess for Resident 7's back of the right hand black colored skin discoloration. These failures had the potential risk of not providing appropriate care for Resident 7. * The facility failed to obtain weekly weights and laboratory test as ordered for Resident 6. This failure had the potential to negatively impact the resident's well-being.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure two of 19 final sampled residents (Residents 28 and 87) and one nonsampled (Resident 9) remained free from accident hazards. * The facility failed to implement the care plan interventions to store Residents 9 and 28's smoking lighter by the nursing station. This failure posed the risk of fire and serious injuries to the residents who smoked and other residents who resided in the facility. * The facility failed to ensure Resident 87's side table was place in an area where it is not a safety hazard. This failure had the potential to cause injury to Resident 87 during a fall. These failures posed the risk of fire and serious injuries to the residents who smoked and to the other residents who resided in the facility.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary enteral feeding (a way of delivering nutrition directly to the stomach or small intestine) care and services were provided to two of 19 final sampled residents (Residents 40 and 51). * Resident 51's enteral feeding infusion was started prior to the time ordered by the physician. This failure had the potential to negatively affect Resident 51's physical well-being. * The facility failed to ensure Resident 40's Glucerna 1.5 (an enteral feeding formula) bottle was labeled and dated. This failure posed the risk of providing the resident with an outdated formula.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the safe respiratory care to three of 19 final sampled residents (Residents 40, 51, and 65) and two nonsampled residents (Residents 64 and 993). * The facility failed to ensure the supplies used for Resident 40's respiratory care were dated and stored in a labeled and dated plastic bag and failed to ensure Resident 40's respiratory treatment medication was not left at bedside. * The facility failed to ensure the supplies used for Resident 65's respiratory care were dated and not touching the floor. * The facility failed to follow the physician's order for oxygen administration for Resident 64 was followed and oxygen humidifier bottle was replaced when empty. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the dialysis care was provided for one of 19 final sampled residents (Resident 28). * The facility failed to ensure the physician's order for 1200 ml fluid restriction (a diet which limits the amount of daily fluid consumption) per 24 hours was followed and carried out accordingly for Resident 28. * The facility failed to ensure the water pitcher was not in Resident 28's room when on a fluid restriction as per the facility's P&P. * The facility failed to ensure the facility and dialysis center communication forms were completed for Resident 28. These failures had the potential for Resident 28 to experience medical complications.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to provide the environment free from accident hazards for one of 19 sampled residents (Resident 18). * The facility failed to obtain a physician's order and develop the comprehensive plan of care for the use bilateral ¼ side rails for Resident 18. This failure had the potential to place Resident 18 at risk for serious injury.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to develop the care plan to address one of 19 final sampled residents (Resident 51). This failure had the potential for Resident 51 to not receive the appropriate treatment and services needed for her dementia.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the pharmaceutical services met the residents' needs as evidenced by: - The routine medications were not available for two of 19 final sampled residents (Residents 13 and 40) and one nonsampled resident (Resident 994). - The licensed nurse left the medications unattended at Resident 40's bedside when performed other tasks. - The controlled medications were not accurately documented on the controlled medication record and MAR for one of 19 final sampled residents (Resident 60) and one nonsampled resident (Resident 593). These failures posed the risk for negatively affecting the residents' health and diversion of controlled medications.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the necessary care and monitoring were provided to two of 19 final sampled residents (Residents 44 and 51) regarding the use of anticoagulant medication. * Residents 44 and 51 received anticoagulant medication without monitoring of the side effects, including bleeding and bruising. This failure had the potential for poor health outcomes for these residents.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure four of the 19 final sampled residents (Residents 44, 47, 50, and 51) were free from unnecessary psychotropic medications (medication that affects the brain activity). * The facility failed to provide non-pharmacological interventions to Resident 47's episodes of persistent yelling and screaming to minimize the use of quetiapine (antipsychotic medication). * The facility failed to provide the non-pharmacological interventions to Resident 44's pain, inability to sleep, combative and aggressive behavior to minimize the use of Cymbalta, mirtazapine, and quetiapine fumarate (psychotropic medications). [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medication error rate was below 5%. The facility's mediation error rate was 27.59% during the medication administration observation as evidenced by: * LVN 11 failed to administer tiotropium bromide to Resident 13 per the physician's order because it was not available. * Resident 13 had a physician's order to administer Ventolin. However, LVN 11 did not provide instructions to Resident 13 prior to administration. Resident 13 coughed immediately after Ventolin administration. * LVN 13 failed to administer the lidocaine patch to Resident 40 per the physician's order because it was not available. [...]

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure the proper storage, labeling, and disposal medications as evidenced by: * The facility failed to ensure an outdated influenza vaccine was removed from the refrigerator in Medication room [ROOM NUMBER]. * The facility failed to ensure the expired alcohol wipes were removed from Medication Cart 1. * The facility failed to ensure three opened insulin pens in Medication Cart 3 had no open date labeled. * The facility failed to ensure the expired IV supplies were removed from Medication Cart 2. * The facility failed to ensure the medications were secured and attended by the licensed nurses. These failures had the potential to negatively impact the residents.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the kitchen staff had the appropriate skill sets to safely prepare meals served to the facility residents when: * Two of two cooks (Cooks 1 and 2) were not competent in monitoring the time and temperature for TCS (time/temperature control for safety) foods. This failure had the potential to place the 87 residents who received food prepared in the kitchen at risk for foodborne illness and to not meet their nutritional needs which could lead to nutritional related health concerns.

Inspectors wroteBased on observation, interview, facility document review and facility P&P review, the facility failed to ensure the nutritional needs were met for one of 19 final sampled residents (Resident 1) and one nonsampled resident (Resident 17) when: * Resident 1 disliked corn but was not served a substitute for the corn salad on her lunch tray. * Resident 17 disliked salad but was not served a substitute for the salad on her lunch tray. This failure posed the risk for the residents' nutritional needs to not be met.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the P&P for resident food brought by the visitors was followed. * The facility's P&P for Food for Residents from Outside Sources did not meet the current federal regulation. * The facility failed to ensure the staff were aware of the process of storing and discarding the resident food brought in by the visitors. * The facility failed to ensure the staff were educated on safe food handling practices when handling the resident food brought in by the visitors. * The facility failed to ensure the policy, guidelines, and safe food handling practices were communicated to the resident's family/visitors who brought the resident food from the outside. These failures had the potential to cause foodborne illness to the residents who received food brought by the visitors.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medical record for one of 19 final sampled residents (Resident 65) and one of the closed record sampled residents (Resident 91) were complete and accurate. * The facility failed to document Resident 65's indwelling urinary catheter care and monitoring of urine. This failure had the potential for the resident's care not being met as the clinical information were not complete. * The facility failed to ensure the accurate elopement risk assessment was conducted for Resident 91. This failure had the potential to affect the implementation of preventative elopement measures to ensure the safety of Resident 91.

Inspectors wroteBased on interview, medical record review, and facility record review, the facility failed to ensure the arbitration agreement provided to one nonsampled resident (Resident 74) was in a language that she understood. This failure had the potential to result in Resident 74 not understanding the purpose of the arbitration agreement she signed with the facility.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to monitor and address the use of antibiotic when the resident's condition did not meet the McGeer's criteria (a set of specific definitions to identify true infections in long term nursing facilities) for one of 19 final sampled residents (Resident 54). This failure had the potential for antibiotics to be used when it was not indicated and the development of antibiotic-resistant bacteria.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of 35 final sampled residents (Resident 51) and one nonsampled resident (Resident 14) were offered the influenza vaccine (a vaccine given to protect the resident from influenza disease) and pneumococcal vaccine (a vaccine given to protect the resident from pneumococcal disease) when the residents were eligible to receive, in accordance with the current CDC's guidelines and recommendations. This failure posed the risk of Resident 14 and 51 acquiring influenza and pneumonia.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the residents' entrapment assessments were complete and the measurements were recorded during the bed inspection when identifying areas of possible entrapment with the use of bed rails for all five residents with side rails. These failures had the potential to negatively impact the residents resulting in possible entrapment, serious injury, and death.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the privacy was provided for one nonsampled resident (Resident 35). * The privacy curtain was not closed when the licensed nurse checked Resident 35's blood sugar level and administered insulin. This failure had the potential to negatively affect the dignity of the resident and violate the resident's right to privacy.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the belongings for one nonsampled resident (Resident 543) were protected from theft and loss. * Resident 543's personal belongings were not labeled with the resident's name and listed in the inventory form. This failure had the potential for resident's property to get lost or stolen.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the MDS for one of 19 final sampled residents (Resident 9) was accurate. This posed the risk for the resident to not have an individualized plan of care based on the resident's specific needs.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to dispose and store trash in a sanitary manner. * Two of three dumpsters were overflowing with garbage which prevented for the lids to be fully closed. This failure posed the risk for the development of odors, attract and harborage or breeding place of insects and rodents, and a possible source of contamination of food, equipment, and utensils.