Alameda Care Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: 1. Kitchen Aide (KA) 1 was not wearing hair net in the kitchen. 2. Two (2) and a half pack of cheese in refrigerator had no date. 3. Seven (7) veggie burger patties in freezer had no date. 4. The facility's Ice Scoop Cleaning Log was missing the time and staff initials from 6/12/2026 to 6/14/2026. These failures had the potential to result in harmful bacterial growth that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) in 83 of 86 residents who received food from the kitchen.

Inspectors wroteBased on interview and record review, the facility failed to complete an informed consent (a process of communication between a person and the health care provider that often leads to agreement or permission for care, treatment, or services) for psychotropic/psychotherapeutic (any drug that affects behavior, mood, thoughts, or perception) drug for one of five sampled resident (Resident 3) who was prescribed Mirtazapine (an antidepressant used to treat depression [mood disorder that causes a constant, heavy feeling of sadness and a loss of interest in things you once enjoyed]). This failure violated the resident's and/or responsible party's right to be fully informed about the care and treatments being provided, as well as the available alternative treatment options.

Inspectors wroteBased on interview and record review, the facility failed to provide written information concerning the resident`s right under state law to make decision concerning medical care and offer assistance in formulating an Advance Directive (AD - a legal document indicating resident preference on end-of-life treatment decisions) to the residents or the resident`s responsible party for two out of eight sampled residents (Resident 49 and 90) investigated during review of advance directive care area. This deficient practice had the potential for the facility to not honor the residents' medical decisions regarding end-of-life treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain privacy of confidential information for two of four sampled residents (Resident 46 and 7), when Licensed Vocational Nurse (LVN) 3 left the residents' electronic health record (EHR- a digital version of a resident's paper chart) open and unattended. This deficient practice violated Resident 7 and 46's right to privacy and confidentiality of medical records.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignity, including the right to be free from physical restraint (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the resident's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) for one of two sampled residents (Resident 51) when staff did not remove the restraint as directed by the physician's order and care plan. This failure had the potential to increase the risk of harm including decreased circulation, skin breakdown, and decline in mobility.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five (5) sampled residents (Resident 69's) diagnosis of Major Depressive Disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) was reflected in the resident's list of active diagnoses in the Minimum Data Set (MDS - a resident assessment tool). This failure resulted in Resident 69 having an inaccurate MDS assessment.

Inspectors wroteBased on interview and record review, the facility failed to follow-up with the Preadmission Screening and Resident Review (PASRR- a mandatory federal program requiring all applicants to Medicaid-certified nursing facilities to be screened for serious mental illness [SMI] or intellectual disability [ID/DD]) to obtain a PASRR Level II evaluation (an in-depth, mandatory assessment conducted when a Level I screen indicates a potential SMI, ID/DD, or related condition [RC]) for one of five sampled residents (Resident 8). This deficient practice had the potential to result in inappropriate placement and unidentified specialized services needs for Resident 8.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow facility policy for gastrostomy tube (G-Tube - a plastic tube inserted into the stomach to administer medications and food) medication administration when Licensed Vocational Nurse (LVN) 1 was observed giving a resident medications by slow push (a method to give medications by slowly depressing a syringe plunger by hand) and not by gravity (giving medications by pouring medications into a syringe, and letting gravity pull the liquid into the stomach) for one of nine residents (Resident 11) observed during the medication administration observation. This had the potential for nausea, vomiting, or cramping when given by slow push.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure Resident 46`s Depakote (also known as divalproex sodium, medication primarily used to treat certain types of seizures [epilepsy], prevent migraine headaches, and manage manic or mixed episodes associated with bipolar disorder [a mental health condition that causes extreme, cyclical shifts in mood, energy, activity levels, and concentration]) Oral Tablet Delayed Release 125 milligram (mg - a unit of measure for mass) was administered as a whole tablet and not crushed. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Consultant Pharmacist`s (CP) Medication Regimen Review (MRR - a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) recommendation to consider a dose reduction, if appropriate, for Seroquel (also known as quetiapine, a medication used to treat certain mental/mood disorders) and Lexapro (also known as escitalopram, medication used to treat depression [mood disorder that causes a persistent, heavy feeling of sadness and a loss of interest in things you usually enjoy] and anxiety [mental health condition that involves excessive fear, worry, or nervousness that interferes with daily life]) for one of five residents (Resident 13) reviewed for Unnecessary Medications. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five (5) percent (%). Four (4) medication errors out of 30 total opportunities contributed to an overall medication error rate of 13.33% affecting two of 10 residents (Resident 46 and 7) observed for medication administration. The medication errors were as follows: 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain an accurate and up-to-date Face Sheet (admission Record) for one (1) of 30 residents (Resident 3) reviewed for medical record accuracy when the facility staff did not remove an outdated diagnosis of dysphagia (difficulty swallowing) from Resident 3's Face Sheet. This failure had the potential to cause staff to implement unnecessary or inappropriate care interventions based on inaccurate clinical information.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: a. Ensure one (1) of 1 sampled resident (Resident 17) investigated under respiratory care nasal cannula (a medical device that delivers supplemental oxygen therapy to people with low oxygen levels) oxygen tubing was not touching the floor. This deficient practice had the potential to result in contamination of the resident's care equipment and risk of transmission of bacteria that can lead to infection. b. Report within 24 hours to the California Department of Public Health (CDPH) a resident with a new diagnosis of syphilis (a curable sexually transmitted infection caused by bacteria), which is a reportable disease (a disease that is to be appropriate county or health department officials) for one of three sampled (Resident 92) residents investigated for infection control. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain accurate and complete medical record for one of three sampled residents (Resident 1) by failing to:1. Ensure Licensed Vocational Nurse 1 (LVN 1) document accurately the time Family Member 1 (FM 1) was notified of Resident 1's change of condition on 2/13/2026.2. Ensure Registered Nurse 1 (RN 1) and LVN 2 document obtaining of urine sample through straight catheterization (a medical procedure, also known as intermittent or in-and-out catheterization, where a flexible tube is inserted through the urethra into the bladder to drain urine, then immediately removed) of Resident 1.3. Ensure nurses document notification of the physician of Resident 1's laboratory test result on 2/17/2026 and 2/20/2026. These failures had the potential to result in confusion in care and the medical records containing inaccurate documentation.

Inspectors wroteBased on interview and record review, the facility failed to notify the physician promptly (acting immediately, without delay, or exactly at a scheduled time) for one of three sampled residents (Resident 1) by:1. Failing to notify the physician promptly when Resident 1 had a change of condition with blood-tinged (a small amount of blood) urine on 2/13/2026, at 3 a.m.2. Failing to notify the physician promptly when the facility received Resident 1's urinalysis (urine test) result on 2/17/2026. These failures had the potential for a delay in the delivery of necessary care and services and had the potential for increased risk of infection to Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a person-centered care plan (a tool that ensures residents receive personalized, comprehensive, and goal-oriented care in a nursing home setting) for one of three sampled residents (Resident 1) who had an episode of hematuria (presence of blood in the urine) accurately. This failure had the potential for confusion and may delay in the delivery of necessary care and services to Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents received care consistent with professional standards of practice for three of five sampled residents (Residents 1, 6, and 7), by failing to:1. Ensure treatment for rashes was provided to Resident 1 as per physician order. Resident 1's Treatment Administration Record (TAR) was blank on 1/16/2026, 1/20/2026, and 1/27/2027.2. Obtain a physician order for Resident 6's treatment for rashes from 11/1/2025 to 11/13/2025.3. Ensure Dermatologist (a medical practitioner specializing in the diagnosis and treatment of skin disorders) was notified as per physician order on 5/17/2025. Resident 6 was never seen by a Dermatologist for eight months after a physician order.4. Ensure Dermatologist was notified as per physician order. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement infection control measures for six of fifteen sampled residents (Residents 1, 2, 3, 4, 5, and 6) after a scabies (a highly contagious [an illness or condition that can be easily spread from one person to another] skin infestation [the state of being invaded or overrun by pests or parasites] caused by the microscopic [too small to be seen by the naked eye] mite [relatives of spiders and ticks found in nearly all habitats] Sarcoptes scabiei [the human itch mite], which burrows [make a hole or tunnel], into the skin to lay eggs causing intense itching especially at night and a pimple-like rash) outbreak (occurs when there is a sudden, unexpected increase in the number of people getting sick with a specific illness in a particular place) was identified in the facility on 1/27/2026, by failing to:1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a person-centered care plan (a tool that ensures residents receive personalized, comprehensive, and goal-oriented care in a nursing home setting) for two of three sampled residents (Residents 1 and 2) by:1. Failing to develop a care plan for Resident 2's behavior of spitting.2. Failing to develop a care plan on Resident 1's use of wedge pillow (a firm, triangle-shaped foam cushion used to prop up parts of the body at an angle while sleeping, resting, or sitting in bed).3. Failing to develop a care plan for Resident 1's refusal of repositioning. These failures had the potential for delays in the delivery of necessary care and services to Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident received care consistent with professional standards of practice to prevent pressure ulcers (localized damage to the skin and/or underlying tissue usually over a bony prominence) for one of three sampled residents (Resident 1), by:1. Failing to provide wound care treatments as per physician order on 8/3/2025, 11/25/2025, 12/24/2025, 1/20/2026 and 1/27/2026.2. Failing to perform head to toe skin assessment before Resident 1's transfer to General Acute Care Hospital (GACH) on 1/14/2026.3. Failing to obtain a physician order for the use of wedge pillow (a firm, triangle-shaped foam cushion used to prop up parts of the body at an angle while sleeping, resting, or sitting in bed). These failures had the potential for the development and worsening of Resident 1's pressure ulcers.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of employee to resident abuse within two hours to the State Survey Agency (SSA- the agency that inspects long-term care facilities for the purposes of survey and certification), the Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities), and to the law enforcement agency (LLE) as per its policy on abuse for one of three sampled residents (Resident 2). This failure had the potential to place Resident 2 at further risk of abuse.

Inspectors wroteBased on interview and record review, the facility failed to maintain accurate and complete medical record for one of three sampled residents (Resident 1), by:1. Failing to accurately document number of pressure ulcers (localized damage to the skin and/or underlying tissue usually over a bony prominence) in Resident 1's medical record.2. Failing to accurately document medication administration. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow professional standards of practice by failing to:1. Ensure two of four sampled residents (Resident 1 and Resident 2), who presented with skin rashes and itching, was tested to rule out scabies (a contagious skin infestation by a microscopic mite, sarcoptes scabiei).2. Ensure Resident 2 (Resident 1's roommate), was tested for scabies before the scabies treatment was administered.3. Ensure three of seven sampled facility staff (Treatment Nurse [TxN] 1, Licensed Vocational Nurse [LVN] 2, and Certified Nursing Assistant [CNA] 1), who provided care to Resident 1, were informed about Resident 1's positive scabies result. 4. Ensure one of three sampled residents (Resident 4), who was exposed to Resident 1 was assessed for scabies. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure three of three sampled facility staff (Treatment Nurse [TxN] 1, TxN 2, and Infection Preventionist Nurse [IPN]) were competent to provide nursing services to the residents by failing to ensure competency skill assessments that included skin scraping (a procedure done to collect skin cells to diagnose skin conditions) were completed upon hire and annually. This deficient practice had the potential to negatively impact the residents' safety and prevent the residents from attaining or maintaining their highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure the medical records of four of six sampled residents (Resident 1, Resident 2, Resident 5, and Resident 6) were maintained in accordance with accepted professional standards and practice, complete, and accurately documented by failing to:1. Ensure TxN 1 documented the level of care provided to Resident 1 while the resident was in the facility when TxN 1 documented the level of care she provided to Resident 1 on 1/17/2026 but Resident 1 was discharged to the General Acute care Hospital (GACH) 1 on 1/16/2026.2. Ensure licensed nurses documented Resident 2's skin condition accurately when the resident was readmitted in the facility on 12/25/2025.3. Ensure Treatment Nurse (TxN) 1 accurately and timely documented Resident 2, Resident 5, and Resident 6's skin scraping procedures. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure interventions to prevent falls were in place for one of four sampled residents (Resident 1) when Resident 1 had a fall on 11/6/2025, by failing to: 1. Ensure interventions were developed through a care plan after Resident 1's fall on 11/6/2025. 2. Update Resident 1's Fall Risk Evaluation (a process used by healthcare providers to determine a person's likelihood of falling).3. Ensure monitoring was provided after Resident 1's fall. These deficient practices had the potential to place Resident 1 at risk for more falls in the facility.

Inspectors wroteBased on interview and record review the facility failed to inform the Medical Doctor (MD) and the Resident Representative (RR) for one of four sampled resident (Resident 1) when on 11/6/2025 at 3 p.m. Resident 1 had a fall. This deficient practice had the potential to negatively affect the care and services provided to Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of an employee-to-resident physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) to the State Survey Agency (SSA), the ombudsman (advocates for residents of nursing homes), and local law enforcement for one of three sampled residents (Resident 1) in accordance with the facility's policy and procedure (P&P) titled, Abuse & Mistreatment of Residents, when on 11/6/2025 at 3 p.m. Activities Assistant (AA) 1 alleged Certified Nursing Assistant (CNA) 1 pushed Resident 1. This deficient practice increased Resident 1's risk for further abuse, which could have led to additional unreported incidents and failure to protect other residents from potential harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety by failing to ensure:1. A container of thickener on the coffee tray was dated.2. A creamer with use by date of 8/15/2025 and a can of open fruit cocktail covered with saran wrap was labeled with an open date.3. A water pitcher with water and thickener (a substance which can increase the viscosity of a liquid without substantially changing its other properties) was labeled with the date it was poured on the pitcher.4. A pitcher with punch dated 6/27/25 and a can of opened sliced jalapenos dated 6/25/25 were discarded.5. A block of ham, a pan of packaged chicken. and bologna in the kitchen refrigerator was dated with the received date.6. A box of popsicle and fruit bars were labeled with an open date.7. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose of garbage and refuse properly. This deficient practice had the potential to attract pests that can bring diseases to all the residents in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to:1. Develop and implement a comprehensive person-centered care plan (is a tool that ensures residents receive personalized, comprehensive, and goal-oriented care in a nursing home setting) for one (1) of two (2) sampled residents (Resident 22) reviewed for dignity care area by failing to develop and implement a care plan on the resident's disrobing behavior.2. [...]

Inspectors wroteBased on interview and record review, the facility's licensed nursing staff failed to provide care in accordance with professional standards:1. For one of one sampled resident (Resident 35) reviewed for insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) use by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (sq - beneath the skin) insulin administration sites.2. For one of five sampled residents (Resident 25) reviewed for unnecessary medications by failing to rotate sq insulin administration sites. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment was free of accident hazards for seven of seven sampled Residents (Residents 24, 12, 45, 10, 34, 57, and 59) reviewed for accidents by failing to ensure:1. Residents 24, 12, 45, 10, and 34's fall mattress/floor mat (a cushioned floor pad designed to help prevent injury should a person fall) did not have any furniture or medical equipment on top of them.2. Residents 57's and 59's bed controller (device used to change the height and angle of the bed) cord did not have visible wires. (Cross Reference F908)These deficient practices increased the risk of accidents such as falls with injuries and electric shock on residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biological) for two of eight sampled residents (Residents 60, and 32) and for one of one inspected medication room (Medication Room Station 1) by:1. Failing to ensure Medication Disposition Log (a record that documents the handling and disposal of medications, ensuring compliance with regulations and maintaining accountability. It details the type of medication, the quantity, the reason for disposal, and the individuals involved in the process) was completed. [...]

Inspectors wroteBased on interview and record review, the Pharmacy Consultant (PC) failed to identify and report any irregularities in the monthly drug/medication regimen review (MRR) to the attending physician and director of nursing (DON) for one (1) of five (5) sampled residents (Resident 25) reviewed for unnecessary medication (any medication in excessive dose, excessive duration, without adequate indication for its use and monitoring) use by failing to ensure:1. Resident 25 had monitoring for specific, measurable target behaviors related to the use of valproic acid (a psychotropic medication [any medication capable of affecting the mind, emotions, and behavior] used for bipolar disorder [mental health conditions characterized by periodic, intense emotional states affecting a person's mood, energy, and ability to function,]) starting 5/22/2025. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that resident's drug regimen was free from unnecessary drugs (any drug in excess) for one (1) of five (5) sampled residents (Resident 32) for unnecessary medication review by failing to:1. Monitor for adverse effects (also known as adverse consequences - unwanted, uncomfortable, or dangerous effects that a drug may have) with the use of carbidopa-levodopa (a medication used for Parkinson Disease [a condition that affects movement causing tremors, stiffness, and difficulty with balance and coordination]) for Resident 32, between 6/1/2025 and 6/30/2025. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five (5) percent (%). Four (4) medication errors out of 26 total opportunities contributed to an overall medication error rate of 15.38% affecting one (1) of 15 residents observed for medication administration (Resident 81.) The medication errors were as follows:1. Resident 81 received famotidine (a medication used for peptic ulcer disease [PUD - painful sores in the stomach] prophylaxis [prevention,]) hydrochlorothiazide (a medication used for high blood pressure,) losartan (a medication used for high blood pressure,) and buspirone (a medication used for anxiety) at a different time than ordered by Resident 81's physician. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free of any significant medication errors (the observed or identified preparation or administration of medications or biologicals which are not in accordance with the prescriber's order, manufacturer's specifications, and accepted professional standards):1. For one of one sampled resident (Resident 35) reviewed for insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) use by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) insulin administration sites.2. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to label:1. one (1) budesonide (a medication used to treat and prevent shortness of breath) inhalation solution foil pouch (package made of foil protecting the inhalation solution from light and degradation) for Resident 55 at room temperature in accordance with the manufacturer's requirements in one (1) of one (1) inspected medication carts (Medication Cart Station 1.)2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the facility's menu and nutritional adequacy by failing to ensure residents with No Added Salt (NAS, leaves out all salt in preparing and cooking foods) diet were not provided with an extra packet of salt on their meal tray. The deficient practice had the potential for residents to consume more than allowable sodium intake that can affect their medical condition.

Inspectors wroteBased on interview and record review, the facility failed to maintain a complete and accurate medical records in accordance with accepted professional standards for three of eight sampled residents (Residents 22, 32, and 60) reviewed for informed consents (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) and infection control by:1. Failing to document the method used for verification that the physician discussed the risk and benefits of the proposed treatment to Resident 22 and resident representative.2. Failing to ensure Resident 32's informed consent form was completed and accurate prior to signing and acknowledging the form.3. Failing to ensure Augmentin (medication used to treat infection) was documented as administered on 6/5/2025, at 4 p.m. in Resident 60's medical record. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement infection control practices for one of three sampled staff (Laundry Staff 1 [LS 1]) reviewed for Infection Control by failing to ensure laundry area was kept clean and sanitary. On 7/1/2025 personal belongings (two bags, one sweater, one cellphone and one pair of sunglasses) were noted inside the clean laundry room. This failure had the potential for cross contamination (unintentional transfer of bacteria or germs or other contaminant from one surface to another) and spread infections and illnesses to residents, and staff.

Inspectors wroteBased on interview, and record review, the facility failed to implement policy for antibiotic (medication used to treat infection) stewardship (efforts in doctors' offices, hospitals, long-term care facilities, and other health care settings to ensure that antibiotics are used only when necessary and appropriate, means prescribing the right drug at the right dose at the right time for the right duration) for two of three sampled residents (Residents 60 and 78) by:1. Failing to monitor Resident 60 for the adverse effect (undesired or harmful effects) of Augmentin (medication used to treat infection) on the following dates and times:a. 7 a.m. to 3 p.m. on 6/6/2025, 6/7/2025, 6/9/2025, and 6/12/2025.b. 3 p.m., to 11 p.m. on 6/11/2025, and 6/12/2025.c. 11 p.m. to 7 a.m. on 6/5/2025, 6/6/2025, 6/7/2025, 6/8/2025, 6/10/2025, 6/11/2025. and 6/12/2025.2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the electrical and patient care equipment in safe operating condition for five of five sampled residents (Residents 19, 64, 44, 57, and 34) reviewed under environmental task by failing to ensure:1. Resident 19's fall mat/floor mat (a cushioned floor pad designed to help prevent injury should a person fall) did not have peeling covers.2. Residents 64, 44, 57, and 34's bed remote control did not have frayed/exposed wires. The deficient practices had the potential for residents to sustain accidents such as electrical shock and falls.

Inspectors wroteBased on observation, interview, and record review, the facility failed to honor the resident's right to a dignified existence for one of two sampled residents (Resident 22), reviewed for dignity care area by failing to prevent a confused resident from undressing and removing her top clothing and was vulnerable for visitors and staff's view when passing by the resident's bed. This deficient practice had the potential to cause emotional distress and affect their self-esteem and cause a loss of dignity and decline in psychosocial wellbeing.

Inspectors wroteBased on interview and record review, the facility failed to honor the resident's right to be informed in advance by the physician or other practitioner or professional, of the risks and benefits of proposed care, treatment and treatment alternative or option for two of two sampled residents (Residents 25 and 1) reviewed for informed consents (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) by failing to ensure:1. Resident 25's Zyprexa (treatment for mental health conditions such as schizophrenia and bipolar I disorder) had the correct dosage on the consent form.2. Resident 1's Depakote (it helps manage manic or mixed episodes [periods of high energy, irritability, or both] in adults with bipolar disorder) indicated the dosage on the consent form. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure one (1) of five (5) sampled residents (Resident 25) was free from unnecessary use of psychotropic drug (any medication capable of affecting the mind, emotions, and behavior) in accordance with facility policy and procedures by failing to ensure:1. Resident 25 had specific, measurable target behaviors monitored related to the use of valproic acid (a psychotropic medication used for bipolar disorder [mental health conditions characterized by periodic, intense emotional states affecting a person's mood, energy, and ability to function]) to ensure resident's drug regimen was free from unnecessary medications (any medication in excessive dose, excessive duration, without adequate indication for its use and monitoring). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received care consistent with professional standards of practice to prevent pressure injury (also called pressure ulcer, localized damage to the skin and/or underlying tissue usually over a bony prominence) for two of two sampled residents (Resident 6 and 10) investigated under pressure injury by:1. Failing to ensure Resident 6's bilateral heel protectors (protective cushions or coverings for the heels) were applied on the resident as ordered by the physician.2. Failing to ensure Resident 10's low air loss mattress (LALM - a mattress that helps prevent and treat pressure injuries by circulating air and relieving pressure on the body) was set according to resident's weight or comfort. These deficient practices had the potential for the development and worsening of pressure injuries to residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure physician visited one of three sampled residents (Resident 29) by:1. Failing to ensure the Attending Physician (AP) made an initial face-to-face visit within 30 days for the first 90 days following Resident 29's admission.2. Failing to ensure Resident 29 was seen the Psychiatrist Doctor (Psych MD- a medical doctor specializing in mental health, who can diagnose and treat mental, emotional and behavioral disorders) as per physician order. These failures had the potential to result in an undetected decline in medical, health or psychosocial condition and could lead to a delay in necessary care, treatment and services.

Inspectors wroteBased an observation, interview, and record review, the facility failed to ensure that two of eight residents (Residents 21 and 79) who attended the Resident Council Meeting (gathering of residents, typically in a long-term care or public housing setting, where they discuss issues, concerns, and suggestions related to their living environment and quality of life) were aware of the availability and location of the facility's latest survey results. This failure had the potential for the residents and their legal representatives not to be fully informed of the facility's deficient practices and how they were corrected.

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet the required room size of 80 square feet (sq feet - a unit of measurement) per resident in multiple resident bedrooms for 19 of 34 rooms (Rooms 1, 2, 4, 5, 6, 8, 10, 12, 14, 16, 17, 18, 19, 20, 21, 22, 23, 25, and 34). This deficient practice had the potential to result in inadequate useable living space for all the residents, negatively impacting the residents' privacy, and inadequate working space for the caregivers.

Inspectors wroteBased on interview and record review, the facility failed to respect the rights and dignity for one of three sampled residents, Resident 1. During lunch, a facility staff was witnessed yelling at Resident 1. This deficient practice prevents the facility ' s residents who are dependent on staff from maintaining and/or enhancing their mental health and social interactions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a call light device (also known as a call bell or nurse call button, is a device typically found near a patient's bed or within reach. consists of a button that, when pressed, sends a signal to the nursing station or a centralized system, alerting healthcare providers that assistance is required in the room) was within reach for two of three sampled residents (Resident 2 and 3). This failure had the potential to result in a delay in care and not receiving assistance timely.

Inspectors wroteBased on observation, record review, and interview, the facility failed to notify Medical Doctor (MD) 1 when two of three sampled residents (Resident 1 and Resident 2) had a change of skin condition and itchiness. This deficient practice had the potential to result in delayed medical intervention to Residents 1 and 2.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary care and services for two of three sampled residents (Resident 1 and Resident 2) when: 1. Resident 1 had a skin rash and itchiness on bilateral (both) upper and lower extremities (refers to the hands and feet, or parts of the body farthest from the center, like the arms and legs). Medical Doctor (MD) 1 was not informed of the change of Resident 1's skin condition. This deficient practice placed Resident 1 at risk for more skin irritation and delay in provision of care. 2. The facility failed to effectively manage Resident 2's discomfort by not identifying the cause of Resident 2's skin itchiness. Resident 2 stated the itchiness keeps her awake at night because she cannot sleep at night. This deficient practice had the potential for Resident 2 to experience unnecessary discomfort.

Inspectors wroteBased on interview and record review, the facility failed to implement and maintain an infection control program by failing to ensure the Nursing Station 1 and Nursing Station 2 high touch areas (surfaces that are frequently touched by healthcare providers and clients such as computers, telephones, and work surfaces) were routinely disinfected during an invasive group A streptococcus (IGAS, a severe and sometimes life-threatening infection in which the bacteria have invaded parts of the body where bacteria are not usually found, such as the blood, deep muscle and fat tissue) outbreak (OB, the occurrence of cases of disease in excess of what would normally be expected in a defined community, geographical area or season). This deficient practice had the potential to spread microorganisms, including IGAS, to facility residents, visitors, and staff.

Inspectors wroteBased on interview and record review, the facility failed to ensure a STAT (immediate or urgent) X-ray (a medical procedure that creates pictures of the structures of the inside of the body) was implemented timely for one of three sampled residents (Resident 1). This deficient practice resulted to a delay in obtaining results and delay in the necessary medical care impacting Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: a. Walk-in refrigerator shelves were chipped and cracked. b. Freezer one (1) and two (2) bottom shelves had dried up pink liquid, and dust buildup. c. One (1) dented can was stored with non-dented cans. d. Knife container had dust and sticky residue. e. One scoop had sticky and dirt debris was stored with the clean scoops. f. Scoop handles storage was not in one direction. g. Clean storage area for pots and pans had dust, crumbs, food residues and dried up food. h. Mixer had dirt and food buildup. i. Food carts used for lunch service had dried up milk spill and tape residues. j. Resident's food from home in the resident's refrigerator had no label and no received date. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to have a policy regarding the use and storage of food brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption when the policy did not include the facility's responsibility for storing food brought in by family and other visitors beyond one (1) mealtime. This deficient practice had the potential to cause a decrease food intake resulting to unintentional (without trying) weight loss, frustrations, and psychosocial harm to 78 of 78 facility residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose garbage and refuse properly by not maintaining the trash area free from trash, plastic utensils, other dirt debris and liquid drippings from the garbage bin. This deficient practice had a potential to attract birds, flies, insects, pest and possibly spread infection to 78 of 78 facility residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain sanitary conditions in the food services department when one (1) fly (a type of insect) was observed flying in the kitchen and landing on surfaces and yellow cake. This deficient practice had a potential to result in 78 of 78 residents, who received food from the kitchen, to acquire food borne illnesses (illness caused by consuming contaminated foods or beverages) by consuming potentially contaminated food.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide reasonable accommodation of resident needs and preferences to five out of twelve residents (Resident 25, 52, 61, 7, and 135) investigated during review of environment facility task by failing to ensure: 1. The call light (an alerting device for nurses or other nursing personnel to assist a resident when in need) was available for Resident 25. 2. The call light was within reach for Resident 52, 31, 57, and 35. These deficient practices had the potential to result in the resident not being able to call for facility staff assistance and delay in the provision of necessary care and services that can negatively affect resident's comfort and well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents' medical records were updated to show documented evidence that advance directives (AD, written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) were discussed with the residents and that the facility maintained a current copy of the resident's AD in the clinical record for three of four sampled residents (Resident 21, 52, and 57) reviewed under the Advance Directives care area. These deficient practices violated the resident's rights and/or representative's right to be fully informed of the option to formulate an AD and had the potential to cause conflict with a resident's wishes regarding health care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to notify the primary physician and responsible party of a significant change in condition (major decline or improvement in a resident's status that will not resolve itself without intervention) for one of five residents with limited range of motion ([ROM] full movement potential of a joint [where two bones meet]) and mobility (ability to move) concerns (Resident 68) and one of six sampled residents reviewed under the Infection Control task (Resident 76) by failing to: 1. Report Resident 68's refusal to participate in ROM exercises, especially to the right arm. 2. Report Resident 68's new onset pain and increased swelling in the right arm on 6/20/2024 to the primary physician and responsible party in accordance with Resident 68's care plan and the facility's policy. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the residents were free from any physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the patient's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) for one out of one sampled resident (Resident 46) investigated during a random observation by: 1. Failing to obtain an appropriate physician order for the use of bed pad alarm (a pressure-sensitive pad placed under the mattress or seat cushion that trigger an alarm or warning light when they detect a change in pressure). 2. Failing to assess Resident 46 quarterly for continued use of the bed pad alarm per facility policy and procedure. [...]

Inspectors wroteBased on interview and record review the facility failed to develop and implement a person-centered care plan with measurable objectives and timeframes to one out of three sampled residents (Resident 70) investigated during review of behavioral/emotional care area by failing to develop a care plan that addressed the resident's behavior of disrobing (the act of removing clothing). The deficient practice had violated Resident 70's right to maintain their highest practicable psychosocial well-being. Cross reference to F550.

Inspectors wroteBased on interview and record review, the facility failed to provide care in accordance with professional standards of quality by: 1. Failing to ensure the nurses were rotating (a method to ensure repeated injections are not administered in the same area) the insulin (a medication that regulates sugar in the blood) injection sites for one of two sampled residents, (Resident 10) investigated during review of insulin care area. 2. Administering insulin when the blood sugar (BS - the amount of sugar measured in the blood stream) was below the physician ordered parameters (a set of limits determining if a medication can be given) for one of two sampled residents (Resident 38) investigated during review of insulin care area. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services to four of five sampled residents (Resident 52, 68, 21, and 69) with limited range of motion ([ROM] full movement potential of a joint where two bones meet]) and mobility (ability to move) concerns by failing to: 1. Ensure Resident 52's left (L) thumb spica wrist brace (a device to decrease movement and provide support and comfort through immobilization after an injury) was applied per physician orders. 2. Monitor the placement of Resident 52's left thumb spica wrist brace. 3. Notify Resident 52's physician regarding Resident 52's refusal to wear the left thumb spica wrist brace at all times. 4. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide an environment free from accidents and hazards, ensure residents received adequate supervision, and implement interventions to prevent accidents for five out of five sampled residents (Residents 2, 22, 46, 62, and 68) investigated under the Accidents care area by: 1. Failing to ensure two tubes of hydrocortisone (a type of medicine used for treating dermatitis [inflammation of the skin with dry skin, redness, and itchiness] and other skin conditions that cause itching) 1 percent (% - a unit of measurement) cream were not left unattended and easily accessible on top of Resident 2's overbed table. This deficient practice placed other residents at risk for obtaining topical medication without staff knowledge resulting in accidental ingestion causing harm to residents. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a performance evaluation (PE - a formal and productive procedure to measure an employee's work and results based on their job responsibilities) every twelve months for three Restorative Nursing Aides (RNA - Certified Nursing Assistants [CNA] with specialized training to help residents regain their physical function and quality of life after illness or injury) reviewed under the sufficient and competent nurse staffing task. This deficient practice prevented the identified RNA's from receiving individualized training and education based on the outcome of their PE that could impact resident safety and satisfaction.

Inspectors wroteBased on interview and record review, the facility failed to ensure control and accountability of Controlled Substance (CS- medications which have a potential for abuse and may also lead to physical or psychological dependence, also known an Controlled Medication [Drug]) awaiting final disposition (process of returning and/or destroying unused medications) when the facility's Antibiotic or Controlled Drug Record accountability logs did not include the verifying signatures of either the Director of Nursing (DON) or a Registered Nurse (RN) along with the Licensed Vocational Nurse (LVN) for seven of seven sampled logs. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free of any significant medication errors for three of ten sampled residents (Resident 10, 38, and 76) by: 1. Failing to ensure nurses were rotating (a method to ensure repeated injections are not administered in the same area) the insulin (a medication that regulates sugar in the blood) injection sites for Resident 10 during review of insulin care area. 2. Administering insulin to Resident 38 when the blood sugar (BS - the amount of sugar measured in the blood stream) was below the physician ordered parameters (a set of limits determining if a medication can be given) during review of insulin care area. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare food by methods that conserved flavor and appearance when the broccoli was mushy, overcooked and did not have a garlic flavor. This deficient practice placed 21 of 78 facility residents on regular consistency texture (texture with no restriction) at risk of unplanned weight loss, a consequence of poor food intake, getting food from the kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to prepare foods in a form designed to meet individual needs when: 1. Resident (Resident 33) on vegan (a diet containing plant and plant products only), lactose free diet (diet that consist of food with no lactose, a type of sugar in milk, found in milk, cheese and dairy products) received grilled cheese and bread stuffing containing eggs, poultry seasoning, low sodium chicken stock and lactose on her lunch tray. 2. Fifteen (15) of 78 residents on puree diet (food with smooth, pudding like consistency) had parsley flakes on top of puree foods as garnish. These deficient practices had the potential to cause weight loss and frustrations (Resident 33), coughing, choking (to keep from breathing the normal way) and death for residents on puree diets.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents were treated with respect and dignity in a manner that promotes maintenance or enhancement of his or her quality of life for two of two sampled residents (Residents 55 and 70) investigated under the dignity care area by: 1. Failing to ensure Certified Nursing Assistant 11 (CNA 11) was at eye level with Resident 55 while providing feeding assistance for Resident 55. 2. Failing to ensure Resident 70 did not disrobe (removing clothing) within public view. These deficient practices had the potential to result in a decrease in the residents' psychosocial well-being and loss of dignity.

Inspectors wroteBased on interview and record review the facility failed to implement policies and procedures (P&P) related to screening (sometimes called background check - a process a person or company uses to verify that an individual is who they claim to be and do not possess a criminal record) procedures by failing to conduct a background check screening prior to employment of one of seven staff members (Restorative Nursing Assistant 1, [RNA 1] ) investigated under the sufficient and competent nurse staffing facility task. This failure placed the residents at risk for abuse, neglect, and exploitation, and misappropriation of resident property for approximately nine months.

Inspectors wroteBased on interview and record review the facility failed to ensure residents received treatment and care in accordance with professional standards of practice to meet the resident's physical, mental, and psychosocial needs for one of one sampled resident (Resident 2) investigated during a random observation by: 1. Failing to ensure Certified Nursing Assistant 4 (CNA 4) did not apply the hydrocortisone (a type of medicine used for treating dermatitis [inflammation of the skin with dry skin, redness, and itchiness] and other skin conditions that cause itching) 1 percent (% - a unit of measurement) cream on the resident's abdomen, bilateral lower extremities (BLE), and bilateral breast folds. This deficient practice placed the resident at risk for adverse reactions due to CNA 4's application of the medication without physician's orders and not within the scope of CNA 4's practice. 2. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents received care consistent with professional standards of practice to prevent pressure injuries (PI/PU, injuries to the skin and underlying tissue resulting from prolonged pressure) by failing to set the Low Air Loss Mattress (LALM, a mattress designed to prevent and treat PIs) in accordance with manufacturer's instructions for one randomly sampled resident (Resident 68) observed during the screening process. This deficient practice had the potential for the worsening of or development of PIs.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide individualized care approaches to meet the emotional and psychosocial needs of residents with mental disorder diagnosis for one of three sampled residents (Resident 70) residents investigated during review of behavioral-emotional care area by failing to address Resident 70's behavior of disrobing. This deficient practice had the potential to prevent Resident 70 from receiving appropriate treatment, approaches, and the ability to attain the highest practicable mental and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure the consultant pharmacist's (CP) recommendation for June 2024 Medication Regimen Review (MRR) (a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) note was carried out as per facility policy and procedure for one of four sampled residents (Resident 70). The deficient practice increased the risk of receiving medication that was not optimal for Resident 70's medical condition, that would not maintain the resident's highest level of physical, mental, and psychosocial well-being and/or increase the risk of adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have) from the medication therapy. Cross reference to F758.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sampled residents (Resident 70) drug regimen was free from the use of unnecessary (any medication in excessive dose, excessive duration, without adequate monitoring) psychotropic (any medication capable of affecting the mind, emotions, and behavior) medications in accordance with the facility policy and procedure by failing to identify specific, measurable target behaviors related to the use of Ativan (a psychotropic medication used to treat anxiety) for Resident 70. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five percent (%). Two medication errors out of twenty-five (25) total opportunities contributed to an overall medication error rate of eight % affecting one of seven residents observed for medication administration (Resident 14.) The medication errors were as follows: 1. Resident 14 did not receive a dose of Tylenol (a medication used for pain) as ordered by Resident 14's physician, and 2. Resident 14 received Keflex (a medication used to treat an infection) in a form that was not ordered by Resident 14's physician. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide appropriate hospice services (specialized care designed to give supportive care to people in the final phase of a terminal illness with a focus on comfort, quality of life rather than cure, and free of pain to live each day as fully as possible) to one of three sampled residents (Resident 68) receiving hospice care by failing to officially designate the facility's staff member responsible for coordinating hospice services in the facility's policy and ensure the facility's licensed staff were aware of the facility's designated coordinator for hospice care. These failures that the potential to prevent Resident 68 from receiving well-coordinated and comprehensive hospice services. Cross reference to F580.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement and maintain an infection control program for two of six sampled residents (Resident 76 and Resident 2) reviewed under the Infection Control task by failing to: 1. Ensure Licensed Vocational Nurse 3 (LVN 3) monitored, identified, and reported Resident 76's open wounds (a break in the skin) with signs and symptoms (s/s) of invasive group A streptococcus (IGAS - a severe and sometimes life-threatening infection that is spread from person to person through respiratory droplets or touching other surfaces contaminated with bacteria that may invade parts of the body where bacteria are not usually found) on the left wrist. 2. Ensure Treatment Nurse 1 (TN 1) identified and reported Resident 76's open wounds with s/s of IGAS on the left wrist. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain mechanical, electrical, and patient care equipment in safe operating condition for one of one sampled resident (Resident 46) investigated during a random observation when Resident 46's bed controller (device used to change the height and angle of the bed) cable was observed with exposed wires. This deficient practice had the potential to place Resident 46 at risk for injury.

Inspectors wroteBased on observation, interview and record review, the facility failed to post daily staffing information that included the total number of Registered Nurses (RN), Licensed Vocational Nurses (LVNs), Certified Nursing Assistants (CNAs) and their actual hours worked for three of three sampled dates (7/21/2024, 7/22/2024, and 7/23/2024) during a review of sufficient and competent staff facility task. This deficient practice resulted in residents, visitors, and facility staff not knowing how many staff were available to provide care to the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed ensure resident rooms meet the requirement of 80 square feet (sq feet - a unit of measurement) per resident in multiple resident bedrooms (Rooms 1, 2, 3, 4, 5, 6, 8, 10, 12, 14, 16, 17, 18, 19, 20, 21, 22, 23, 25, and 34). This deficient practice had the potential to result in inadequate usable living space and privacy for the residents and working space for the health caregivers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program regarding Invasive Group A Streptococcal disease (iGAS - occurs when GAS bacteria get into parts of the body where these bacteria were not usually found and cause severe infection) for one of five sampled residents (Resident 5) by failing to: a. Ensure facility staff's personal protective equipment (PPE - equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) was worn inside the facility. Housekeeping 1's (HKP 1) face mask was not covering the nose while talking to Resident 5. Resident 5 was not wearing a face mask. Kitchen [NAME] (KC) was not wearing a face mask while inside the facility kitchen. b. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 2) was provided privacy while talking on the phone. On 3/12/2024, observed Resident 2 talking on the phone while standing outside of Station 2. This deficient practice violated Resident 2's right to have a private conversation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its abuse policy by failing to report an allegation of family to resident abuse no later than two hours after the allegation was made, to the State Survey Agency (responsible for surveying/licensing the facility) for one of four sampled residents (Resident 2). This deficient practice placed Resident 2 at risk for further abuse.

Inspectors wroteBased on observation, interview and record review, the facility failed to report allegation of family to resident abuse no later than two hours after the allegation was made, to the State Survey Agency (responsible for surveying/licensing the facility) for one of four sampled residents (Resident 2). This deficient practice placed Resident 2 at risk for further abuse.

Inspectors wroteBased on interview and record review, the facility failed to follow its facility ' s policy and procedure on fall and accidents and failed to provide necessary care and services to ensure the safety of one of four sampled resident (Resident 1) when Certified Nursing Assistant 1 (CNA 1) witnessed Resident 1 slide down to the floor unassisted on 3/6/2024 by: 1. Failing to update the fall care plan after the fall. 2. Failing to complete a Rehab Post Fall Assessment. 3. Failing to complete a Post Fall Risk Assessment. 3. Failing to conduct an interdisciplinary team (IDT- a coordinated group of experts from several different fields who work together) meeting. These deficient practices had the potential to place Resident 1 at risk for injury from falls.

Inspectors wroteBased on interview and record review, the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one of three sampled residents (Resident 1) by failing to document administration of enalapril maleate (medication used to treat high blood pressure) accurately and per physician order. This deficient practice had the potential to result in inadequate management of Resident 1 ' s high blood pressure and the medical records containing inaccurate documentation can result in the delay of delivery of care.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement infection control practices for one out of nine sampled residents (Resident 6) by failing to ensure: 1. The suction canister (a temporary storage container for secretions or fluids removed from the body) and Yankauer suction tip (an oral suctioning tool used in medical procedures)of Resident 6 was dated and labeled with the name of the resident. 2. The Yankauer suction tip (an oral suctioning tool used in medical procedures) of Resident 6 was not touching the floor. These deficient practices had to potential for pathogens (an organism causing disease to the host) to grow in the canisters and tubing that could cause residents to get sick.