Alamitos West Health & Rehabilitation

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of five sampled residents (Resident 1) was informed of the risks and benefits of proposed care, treatment, and treatment alternatives or options, and the choice to choose an alternative option in advance. * The facility failed to ensure Resident 1 and Family Member 1 were informed of the physician's order for psychiatry consult, as well as providing alternative options for treatment. These failures had the potential for Resident 1 and Family Member 1 to not to be informed of the psychiatry consultation and prevent the resident and resident's representative from participating in choosing the resident's treatment decisions.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to ensure one of five sampled residents (Resident 1) attained and maintained their highest practicable physical well-being. * The facility failed to ensure the sleep study results were obtained and followed up for Resident 1. This failure had the potential to cause a delay in providing care to Resident 1, which would cause negative impact to the resident's well-being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the resident's responsible party or Power of Attorney (POA) was informed of a change on the resident's condition for one of six sampled residents (Resident 1). * The facility failed to notify Resident 1's POA of the change in condition on 6/4/26. This failure had the potential for Resident 1's responsible party uninformed of the resident's status.

Inspectors wroteBased on interview, facility document review, and facility P&P review, the facility failed to implement their P&P for pre-employment investigations for one of three sampled employees (CNA 1) prior to working with the elderly or vulnerable individuals. * The facility failed to conduct a background check for CNA 1 prior to the date of hire. This failure had the potential to put the residents at risk for elder abuse.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the necessary physician services was provided for one of six sampled residents (Resident 1). * The facility failed to ensure the cardiologist recommendations for Resident 1's diagnostic tests were signed by the physician for the staff to ensure the appointments were scheduled in a timely manner. This failure had the potential for the resident to not receive the necessary services in a timely manner.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure necessary dental services was coordinated for one of six sampled residents (Resident 2). * The facility failed to ensure a follow up dental appointment was scheduled for Resident 2 as per resident's request and per the facility's dental progress notes. This failure had the potential for the resident to not receive the necessary dental care.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to report an abuse allegation to CDPH, L&C Program for one of four residents (Resident 1) reviewed for abuse. * The facility failed to ensure SOC 341 was submitted and the alleged abuse was reported to CDPH, L&C Program, Ombudsman, and law enforcement on the day the alleged abuse was reported to the facility staff. This failure had the potential for the abuse allegation going unreported and uninvestigated.

Inspectors wroteBased on observation, interview, medical record 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 for two of four sampled residents (Residents 2 and 3). * The facility failed to ensure LVN 1 wore a gown when providing catheter care to Resident 2. In addition, the facility failed to ensure Resident 2 was placed on EBP related to the use of the indwelling urinary catheter. Furthermore, the facility failed to ensure an EBP signage was posted on the resident's door, and an orange dot was placed by the resident's name by the door. * The facility failed to ensure Resident 3's indwelling urinary catheter drainage tubing was not touching the floor. [...]

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the discharge planning process was thoroughly completed for one of three sampled residents (Resident 1). * The facility failed to notify the Ombudsman 30 days prior to the facility-initiated discharge date for Resident 1. * The facility failed to develop a care plan for Resident 1's discharge. These failures had the potential for the residents to have an inappropriate discharge.

Inspectors wroteBased on interview and medical record review, the facility failed to provide the necessary care and services to ensure adequate supervision was provided for one of four sampled residents (Resident 1). * Resident 1 was left unattended outside the facility while waiting for the transportation to take the resident to the doctor's appointment. This failure had the potential to place Resident 1 at risk for accidents and serious injuries.

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 two sampled residents (Resident 1). * The facility failed to ensure Resident 1's physician's orders for carbidopa-levodopa (medication to treat Parkinson's disease) was clarified with the physician, when there were two duplicate orders with different dates. This failure had the potential for the resident's care needs not being met as the medical information was inaccurate.

Inspectors wroteBased on observation, interviews, medical record review, and facility P&P review, the facility failed to ensure the residents' needs were accommodated in a timely manner for four of 27 final sampled residents (Residents 8, 14, 141, and 146) and one nonsampled resident (Resident 37). * The facility failed to ensure the call lights were promptly answered for Residents 8, 14, 37, 141, and 146 when the residents called for assistance from the staff. This failure placed the residents at risk for not receiving the assistance from staff to meet their needs and potentially compromise their safety and dignity.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure two of five sampled residents (Residents 13 and 41) reviewed for unnecessary medications were free from unnecessary psychotropic medications. * The facility failed to ensure Resident 13's orthostatic (a sudden drop in blood pressure when standing up, causing symptoms like dizziness, lightheadedness, and fainting) blood pressure was accurately monitored as ordered by the physician for the use of the risperidone (antipsychotic) medication. * The facility failed to ensure Resident 41's orthostatic blood pressure was accurately monitored as ordered by the physician for the use of the Seroquel (antipsychotic) medication; in addition, the facility failed to ensure the accurate monitoring of Resident 41's behavior was done for the use of the Seroquel medication. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide services to attain or maintain the highest practicable well-being for two of 27 final sampled residents (Residents 29 and 141). * The facility failed to ensure the right arm sling was applied as ordered by the physician for Resident 29. * The facility failed to ensure Resident 141's physician was notified timely of the UA (urine analysis) results and the resident's signs and symptoms of UTI (urinary tract infection). These failures had the potential for not providing the necessary care and services to the residents to meet their needs and delay in treatment.

Inspectors wroteBased on observation, interview, medical record 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 three of six final sampled residents (Residents 8, 9, and 29) reviewed for pressure ulcers. * The facility failed to ensure the wound treatment was administered as per the physician's order for Resident 8. * The facility failed to conduct the Weekly Skin Evaluations and IDT Skin Review for Resident 9's coccyx to right buttock wound, as per the facility's P&P and care plan. * The facility failed to ensure the LAL mattress setting was appropriate for Resident 29's weight. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of two final sampled residents (Resident 3) reviewed for falls were provided the necessary services after a fall. * The facility failed to ensure Resident 3's fall risk evaluation was completed after Resident 3 had a fall on 8/9/25, and failed to ensure Resident 3's Fall Risk Evaluations were completed accurately. These failures had the potential risk of inaccurate fall risk score and the failure to implement the appropriate fall risk interventions for Resident 3.

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 one of one final sampled resident (Resident 4) reviewed for dialysis. * The facility failed to ensure Resident 4's dialysis communication forms were accurately completed. * The facility failed to ensure Resident 4 had a clamp scissors (a device for dialysis residents that control bleeding or secure tubing) available in the emergency kit at bedside. * The facility failed to ensure Resident 4's 1000 ml fluid restriction in a 24-hour period was maintained. These failures had the potential of not identifying possible negative outcomes related to the dialysis treatment for the resident.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the pharmaceutical services for two of 27 final sampled residents (Residents 29 and 85) and one nonsampled resident (Resident 18) to meet the needs of each resident. * The facility failed to verify with the physician the medication route for Resident 18's medication ordered. * The facility failed to ensure the metoprolol (medication to treat high blood pressure) was administered as ordered by the physician for Resident 29. * The facility failed to ensure the amlodipine (medication to treat high blood pressure) was administered as ordered by the physician for Resident 85. These failures posed the risk for negative health outcomes to the residents.

Inspectors wroteBased on interview, medical record review, facility document review, and P&P review, the facility failed to ensure the pharmacy recommendations for one of five final sampled residents (Resident 11) reviewed for unnecessary medications were followed through. * The facility failed to ensure Resident 11's physician was notified of the pharmacy recommendations to notify the physician of the resident's risk for bleeding on allopurinol (medication to lower excess uric acid levels in the blood) and aspirin (medication to treat pain, fever, and inflammation). This failure had the potential to cause negative outcomes for Resident 11.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 6.67%. * LVN 5 failed to apply pressure to the right tear duct or wipe the tear from the eye area right away after the administration of eye drop to Resident 107. * LVN 4 failed to administer metformin (medication to treat high blood sugar) to Resident 117 with food as ordered by the physician. These failures posed the risk for adverse health outcomes.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure proper medication storage, timely disposal of expired medications, and accurate reconciliation of controlled substances were followed. * The facility failed to reconcile controlled substances for Resident 152. * The facility failed to ensure proper storage of the medications in one of two medication rooms (Station A) inspected. * The facility failed to discard the expired medications from two of five medication carts (Medication Carts C and D) inspected. These failures had the potential to negatively impact the residents' well-being.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure 17 of 17 residents who received pureed food from the kitchen received the proper diets when the facility's puree recipes and menu were not followed. * The facility failed to ensure the puree recipe for herb mash potatoes was followed. This failure had the potential for the residents on special diets to not receive the adequate nutritional and caloric intake as recommended on the recipes.

Inspectors wroteBased on observation, interview, facility P&P review, and facility document review, the facility failed to ensure the food safety and sanitary requirements were met in the kitchen. * The facility failed to ensure the two-compartment preparation sink had an air gap. * The facility failed to ensure food preparation utensils and equipment were in good, sanitary, and cleanable working conditions. * The facility failed to ensure that food items were dated and labeled. * The facility failed to ensure food items were discarded by the best by date. * The facility failed to ensure the kitchen staff wore hair restraint. * The facility failed to ensure fruits with tough rinds or peels like cantaloupes were washed with a brush. These failures had the potential to cause foodborne illnesses to the medically vulnerable resident population who consumed food prepared in the kitchen.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the facility's P&P about the Food Brought by Family or Visitor was implemented. * The facility failed to ensure the visitors and staff were educated on safe food handling practices of food brought from outside of the facility. This failure had the potential to cause foodborne illnesses to the 131 medically vulnerable resident population who received food prepared by the facility and may potentially receive foods prepared from the outside sources.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the appropriate infection control practices designed to provide a safe and sanitary environment and help prevent the development and transmission of infections were implemented. * The facility failed to ensure the staff performed proper doffing in a COVID-19 positive isolation room as per the facility's COVID-19 Mitigation Plan. * The facility failed to ensure the ice scooper attached to the ice bucket in Hallway A was not exposed. * The facility failed to ensure the staff wore the proper PPE while emptying Resident 77's indwelling urinary catheter bag. * The facility failed to ensure CNA 2 donned the gown when repositioning Resident 29. Resident 29 was on EBP due to her wound. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of three final sampled residents (Resident 85) reviewed for urinary catheter care received the necessary care and services. The facility failed to provide a dignity bag to cover Resident 85's urinary catheter drainage bag. This failure had the potential to compromise Resident 85's rights to be treated with respect and dignity.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the P&P were followed for one of eight final sampled residents (Resident 41) reviewed for advance directives. * The facility failed to obtain and maintain copies of the advance directive in the medical records for Resident 41. This failure had the potential to not provide the care and life sustaining measures in accordance with the resident's treatment wishes.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the MDS assessment was completed accurately for one of 27 final sampled residents (Resident 3). * The facility failed to accurately code Resident 3's history of fall in the MDS assessment dated [DATE], when Resident 3 had a fall on 7/21/25. This failure posed the risk of Resident 3 not receiving the individualized plan of care based on the resident's specific needs.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the PASRR (Preadmission Screening and Resident Review) screening was accurately completed and updated for one of two final sampled residents (Resident 4) reviewed for PASRR. * Resident 4's PASRR Level 1 screening completed by the acute care hospital prior to the admission to the facility showing inaccurate information was not updated to include serious mental illness diagnosis and the use of psychotropic (drugs that affect the mind, emotions, and behavior, used to treat various mental health conditions). This failure had the potential of not providing the resident to be screened for mental illness or intellectual disabilities with additional resources if needed.

Inspectors wroteBased on observation, interview, medical record review, and P&P review, the facility failed to provide the necessary care and services for one of one final sampled resident (Resident 148) reviewed for oxygen and nebulizer (a machine which turns liquid medication into a fine, inhalable mist that is delivered directly to the lungs, which provides fast relief for respiratory symptoms like wheezing, shortness of breath, and coughing) use. * The facility failed to ensure the the oxygen tubing and nebulizer equipment were dated for Resident 148. This failure placed the resident at risk for the untimely replacement of the respiratory equipment which may lead to increased risk for infection or compromised respiratory care.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the medical record for one of 27 final sampled residents (Resident 60) was accurate. * CNA 4 failed to ensure Resident 60's turning/repositioning record was documented accurately. This failure had the potential for the resident's care needs not being met as their medical information was inaccurate.

Inspectors wroteBased on interview, medical record review, and facility document review, the facility failed to ensure the Arbitration Agreement was explained in a form, manner, and language the residents or their representative understood for two of three residents (one final sampled resident (Resident 11) and one nonsampled resident (Resident 122) reviewed for the Arbitration Agreements. * The facility allowed Residents 11 and 122 who had no capacity to understand and make medical decisions, to enter and sign the Arbitration Agreement. This failure posed the risk for the residents to not have a clear understanding of the arbitration process they signed.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to ensure one of three sampled residents (Resident 1) attained or maintained their highest practical physical well-being. * The facility failed to ensure Resident 1 was turned and repositioned every two hours as ordered by the physician. This failure 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 the medical record was complete and accurately maintained for one of three sampled residents (Resident 1). * The facility failed to ensure Resident 1's TAR (Treatment Administration Record) was complete for August 2025. * The facility failed to accurately document the oral hygiene provided to Resident 1. These failures had the potential for Resident 1's care needs not being met as their medical information was incomplete.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the appropriate infection control practices designed to provide a safe and sanitary environment and help prevent the development and transmission of infections were implemented. * The facility failed to dispose the used gloves inside Shower room [ROOM NUMBER]. * The facility failed to place the soiled towel inside the dirty linen barrel. These failures posed the risk for the transmission of disease-causing microorganisms.

Inspectors wroteBased on observation and interview, the facility failed to ensure to clean and disinfect three of three shower rooms. * The facility failed to clean the shower heads for Shower rooms [ROOM NUMBER]. This failure had the potential risk of affecting the residents' health condition.

Inspectors wroteBased on observation, interview, medical record review, facility P&P review, and facility document review, the facility failed to ensure two sampled residents (Residents 3 and 4) was provided the necessary care and services as evidenced by: * The facility failed to continuously monitor Resident 3 after the resident had developed a right buttock pressure injury. * The facility failed to have the specific direction for the settings of the LAL mattress for Resident 4. These failures had the potential for the residents not to receive the appropriate care and services to promote skin healing.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to implement the infection control practices designed to provide a safe and sanitary environment for one of one sampled resident (Resident 2) observed for wound care treatment. * LVN 1 and CNA 3 failed to don the gowns before starting the wound care treatment for Resident 2 who was on the EBP. This failure posed the risk of not preventing the transmission of infection to the other residents throughout the facility.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to maintain the safe environment for three nonsampled residents (Residents A, B, and C). * The facility failed to ensure Residents A, B, and C's bed wheels werelocked while the residents were in bed. This failure had the potential to result to injury while care was being provided.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of four sampled residents (Resident 1) was treated with dignity and respect. This failure had the potential to negatively affect Resident 1's well-being.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the food preferences were followed for one of four sampled residents (Resident 1). This failure had the potential to negatively impact the resident's well-being.

Inspectors wroteBased on interview, medical record review, and the facility P&P review, the facility failed to notify the physician of thechanges in the resident's status for one of four sampled residents (Resident 1). * The facility failed to notify the physician that Resident 1 had been refusing the bowel management medications from 1/1-1/3/25. This failure had the potential for the resident not to receive the necessary care and services which would negatively affect the resident's well-being.

Inspectors wroteBased on interview, medical record review, and the facility P&P review, the facility failed to ensure the necessary care and services for two of two sampled residents (Resident 2 and 4) to prevent the elopement. * The facility failed to update the elopement assessment when Resident 2 had an increased on wandering behavior resulting in the use of Wander Guard. * The facility failed to ensure Resident 4's elopement risk assessments were completed quarterly as per the facility's P&P. These failures posed a risk for Residents 2 and 4 not to receive the necessary care and services to prevent elopement.

Inspectors wroteBased on interview, medical record review, and the facility P&P review, the facility failed to ensure the resident's rights were respected for one of four sampled residents (Resident 1). * The facility failed to ensure Resident 1's medications were administered as per Resident 1 and family member's request. This failure had the potential to negatively affect the residents' well-beinig.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of three sampled residents (Resident 1) received the appropriate treatment and services to prevent the urinary tract infections to the extent possible. * The facility failed to provide the daily indwelling urinary care to Resident 1 after his indwelling urinary catheter was inserted on 11/21/24. This failure posed the risk for Residents 1 to develop catheter-associated urinary tract infections.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of three sampled residents (Resident 1) was free from the unnecessary drugs. * Resident 1 was administered the docusate sodium (stool softener) medication when Resident 1 had loose bowel movement or diarrhea. This failure had the potential for Resident 1 to receive unnecessary medication and experience adverse effects from the medication.

Inspectors wroteBased on interview and medical record review, the facility failed to meet the needs and preferences for one of three sampled residents (Resident 1). * The facility failed to provide Resident 1 a bath when he requested a bath on 11/24/24. This failure led to the resident feeling frustrated, which posed the risk to negatively impact the resident's physical and emotional well-being.

Inspectors wroteBased on interview, medical record, and facility P&P review, the facility failed to develop the comprehensive plan of care to reflect the individual care needs for one of three sampled residents (Resident 1). * The facility failed to develop a care plan problem to address Resident 1's change in condition on 11/11/24, when Resident 1 had mild weakness and flushed face. This failure posed the risk of Resident 1 not to receive the appropriate, consistent, and individualized care.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the accurate administration of the medications was provided to one of three sampledresidents (Resident 1). * The facility failed to ensure Resident 1's psyllium (a soluble fiber used primarily as a gentle bulk-forming laxative) wasadministered as ordered by the physician. This failure had the potential to negatively affect Resident 1's well-being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the medical records for three of three sampled residents (Residents 1, 2, and 3) were accurate. * The facility failed to ensure the CNAs' documentation in the Task-Bladder elimination when residents had an indwelling urinary catheter were accurate. This failure had the potential for the residents' care needs not being met as their medical information were inaccurate.

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 for two of four sampled residents (Residents 1 and 2). * The facility failed to notify the physician when Resident 1 had no bowel movements for more than three days. * The facility failed to apply the splints three times a day on Resident 2's feet as ordered by the physician. These failures had the potential to negatively impact these residents' well-being.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to provide reasonable accommodations to meet the care needs for one of four sampled residents (Resident 2). * The facility failed to ensure Resident 2 had the correct dental toothbrush for oral hygiene. This failure had the potential to negatively impact Resident 2's well-being.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements in the kitchen were followed. * The facility failed to ensure the dietary staff and non-dietary staff inside the kitchen wore hair restraints. * The facility failed to ensure proper labeling and dating of food items in the kitchen. * The facility failed to ensure kitchen equipment and plates were clean. The facility failed to ensure the microwave utilized to warm up the residents' food was in sanitary condition and the plates used in trayline were free of food residue. * The facility failed to ensure pan and cutting boards were in sanitary condition. * The facility failed to air dry plates and insulated domes for plates. * The facility failed to ensure the scoop was stored properly. [...]

Inspectors wroteBased on observation, interview, medical record review, facility P&P review, and facility document review, the facility failed to maintain the infection control practices to help prevent the development and transmission of diseases and infections. * The facility failed to show documentation of the Legionella (a bacteria that can cause a serious type of lung infection) facility risk assessment, control measures, and Legionella testing protocols. * CNAs 11 and 12 failed to wear proper PPE before providing care to Resident 34 in his room who was in EBP. In addition, CNAs 11 and 12 failed to perform hand hygiene before providing care to Resident 34. * The facility failed to ensure employee personal items were not stored in the clean laundry area. * The facility failed to ensure the visitors observed contact isolation precaution practices while inside Resident 109's room. [...]

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 for one of 24 final sampled residents (Resident 414) and seven nonsampled residents (Residents 1, 24, 31, 36, 60, 78, and 104). * Resident 24 had waited for 30 minutes for a staff to assist her to use the toilet which resulted the resident to wet her diaper. * The facility failed to ensure the call light was within reach and accessible for Residents 1, 60, and 78. * The facility failed to ensure Resident 104's call light was within the resident's reach. * The facility failed to ensure Resident 36's bed control was within the resident's reach. * The facility failed to ensure Resident 414's head light cord was within reach. * The facility failed to ensure Resident 31's TV remote control was within reach. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the copy of advance directive was obtained or information on how to formulate an advance directive was provided for eight of 24 final sampled residents (Residents 34, 59, 75, 81, 89, 109, 414, and 566). * The facility failed to offer Resident 34 with written information regarding advance directives. * The facility failed to review the copy of the advance directives provided by Resident 59 and resident's representative, and ensure it was complete to show the resident's wishes and instructions for healthcare. * The facility failed to provide Resident 75 with written information regarding advance directives and ensure Resident 75's right to formulate an advance directive. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the comprehensive care plans were developed to reflect the individual care needs for three of 24 final sampled residents (Residents 20, 42, and 81). * The facility failed to develop a care plan to address Resident 20's fall on 9/15/24. * The facility failed to develop a care plan to address Resident 42's use of antidepressant medication. * The facility failed to develop a care plan to address Resident 81's Keflex medication. These failures had the potential for the residents to not be provided with appropriate, consistent, and individualized care.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure eight of 24 final sampled residents (Residents 10, 42, 75, 76, 89, 414, 564, and 814) and three nonsampled residents (Residents 87, 417, and 418) reviewed for respiratory care were provided the appropriate respiratory care when: * The facility failed to ensure Resident 814's oxygen nasal cannula tubing, humidifier, and Yankauer were dated, labeled, and the nasal cannula and Yankauer were stored in a set-up bag when not in use. The facility failed to develop a care plan to address Resident 814's oxygen use and monitoring of oxygen saturation level when the Resident 814 was using the oxygen. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to attain or maintain the highest physical well-being for one of five final sampled residents (Resident 108)reviewed for hemodialysis care. * The facility failed to ensure the medications scheduled to be administered to Resident 108 on the days the resident had dialysis treatments had a physician's order to be held or were rescheduled. This failure had the potential for the resident's poor health outcomes.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the pharmaceutical services to meet the resident's needs. * The facility failed to ensure the medications were available for one of six final sampled residents (Resident 564)observed and reviewed for medication administration. This failure had the potential to result in medication administration errors and poor health outcomes to the residents.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the necessary pharmacy services for one of five final sampled residents (Resident 81) reviewed for unnecessary medications. * The facility failed to ensure the pharmacy consultant's recommendation to reduce venlafaxine (antidepressant)dosage was acted upon by Resident 81's physician. * The facility failed to ensure the Consultant Pharmacist identified the duplicate therapy for the use of acetaminophen (analgesic). These failures 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 one of five final sampled residents (Resident 81) reviewed for unnecessary medications was properly monitored for the medications. * The facility failed to ensure Resident 81 had no duplicate therapy for the acetaminophen medication. * The facility failed to ensure Resident 81 was monitored for side effects of Keflex (medication used to treat bacterial infections) medication. * The facility failed to ensure Resident 81 was monitored for the side effects of hydrocodone-acetaminophen (a controlled pain medication) medication. These failures 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 two of five final sampled residents (Residents 75 and 566) reviewed for unnecessary medication were free from unnecessary psychotropic (medications which affect the brain and the nervous system to treat mental illness and conditions which impact behavior and emotions) drugs. * The facility failed to ensure the side effects and behaviors were monitored for Resident 566 related to the resident's use of sertraline (antidepressant medication) and quetiapine (antipsychotic medication). * The facility failed to ensure the physician's documentation of the rationale for extending the physician's order for doxepin (antidepressant medication) beyond the 14-day duration for Resident 75. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medication error rate during the medication pass observation was less than five percent (5%). The facility had a cumulative medication error rate of 18.52% when five of 27 opportunities for errors were observed between three licensed nurses (LVNs 3, 8, and 9) who administered medications to three nonsampled residents (Residents 33, 51, and 65). The observed medication administration errors were: * LVN 8 added 90 ml of water to Resident 51's ClearLax (a laxative to treat occasional constipation) polyethylene glycol 3350 powder instead of four or eight ounces of beverage as per the direction on the ClearLax container. [...]

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure proper storage, labeling, and disposal of the medications. * The facility failed to ensure Resident 51's Artificial Tears (lubricate dry eyes and help keep moisture on the outer surface of your eyes) ophthalmic solution was not left unattended on the resident's bedside table. * Medication Room A room temperature log had multiple documentation of out-of-range room temperatures above 77 degrees Fahrenheit. * Medication Room B had no room temperature log. * Medication Cart F had two topical prescription medications that were not labeled with a specific resident name. * Medication Cart C had oral medications stored with externally used medications. [...]

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the pureed recipes were followed for 12 of 12 residents who received pureed food from the kitchen. * The facility failed to ensure the puree recipes for chicken ala king, steamed broccoli, and brown rice were followed. This failure had the potential for not providing nutritional meals to meet the needs of residents on pureed diet.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to follow the facility's P&P regarding the use and storage of food brought to the residents by the family or visitors. In addition, the facility failed to ensure the staff were aware of the facility's P&P on safe food handling of outside food. These failures had the potential to cause foodborne illnesses to the medically vulnerable resident population who consume food brought from outside sources.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to provide the necessary care and services to ensure one of three final sampled residents (Resident 59) reviewed for hospice services attained and maintained their highest practicable well-being. * The facility failed to communicate with the hospice agency regarding missing hospice aide visitations for Resident 59. This had the potential of a delay in hospice care for Resident 59.

Inspectors wroteBased on interview, medical record review, facility P&P review, and facility document review, the facility failed to monitor and address the use of antibiotics 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 two of five nonsampled residents reviewed for infection prevention (Residents 40 and 64). 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 five residents reviewed for immunization (Resident 50) received the influenza vaccine and failed to ensure the risks and benefits of the influenza vaccination were reviewed with the resident and/or resident representative when influenza vaccine was refused. These failures had the potential for the resident and/or their representative not being informed of influenza vaccine, the benefits and risks of influenza vaccination to make an informed decision.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to maintain essential kitchen equipment in safe operating condition. * The facility failed to ensure the dish machine in kitchen was working. * The facility failed to ensure the digital thermometers used in the kitchen were calibrated. These failures had the potential for the equipment to not function in the way it was intended, which could cause food borne illnesses for the residents.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure the resident food preference was followed for one nonsampled residents (Resident 418). * Resident 418 disliked cooked carrots but was served with carrots for lunch. This failure had the potential to negatively impact the residents' well-being.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure trash was disposed in a sanitary manner. * The facility failed to ensure three of four dumpsters were properly covered. This failure had the potential to harbor pests.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the medical record was accurate for one of 24 final sampled residents (Resident 564). This failure had the potential for not able to properly obtaining consent or providing information related to care needs for this resident.

Inspectors wroteBased on interview, facility document review, and facility P&P review, the facility failed to implement their infection control program to include identifying, monitoring, tracking and reporting of facility infections. These failures had the potential to delay identifying trends in the facility infections.

Inspectors wroteBased on interview, facility document review, and facility P&P review, the facility failed to implement the antibiotic stewardship program. * The facility failed to ensure the residents placed on antibiotics were accurately and timely reviewed for the appropriate use of antibiotics. This failure had the potential for inappropriate antibiotic use and increased risk of drug resistant organisms.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide information regarding the rights to formulate the advance directives (legal document that states a person's wishes about receiving medical care if that person is no longer able to make medical decisions) to one of 24 sampled residents (Resident 6). This failure had the potential to result in Resident 6's wishes related to the provision of medical treatment and services to not be followed if Resident 6 was unable to make decisions for herself.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure foot care was provided for one of 24 final sampled residents (Residents 13) and one nonsampled (Resident 39). * Residents 13 and 39's podiatric services were not provided in a timely manner. These failures had the potential to result in foot problems which could affect the resident's mobility and foot health.

Inspectors wroteBased on interview and medical record review, the facility failed to provide the necessary care and services to prevent resident injuries and accidents for one of 24 final sampled residents (Resident 42). * The facility failed to ensure the floor mats were provided on both sides of Resident 42's bed when Resident 42 was assessed to be at risk for falls and had a history of falls with the intervention to use bilateral floor mats. This failure had the potential to increase the risk for injury to Resident 42.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to provide the necessary care and services for the use of an indwelling urinary catheter for one of 24 final sampled residents (Resident 50). * Resident 50's urinary drainage bag and tubing were observed touching the floor. This deficient practice had the potential to increase the risk for the resident to develop urinary tract infection ( an infection involving any part of the urinary system, including urethra, bladder, ureters, and kidney).

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the medications were stored in accordance with currently accepted professional practices when: * Medication Cart 1 was left unlocked and unattended while parked in the hallway. * Resident 475's Tum (antacid) tablets were left at the bedside table. * Resident 471's albuterol inhaler (a medication used for wheezing and/or shortness of breath) was observed on top of the bedside table. * Resident 31's Sytane lubricant eye drops (medication for dry eyes) was observed left at the bedside. These failures had the potential to allow unauthorized access to medications.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure the sanitary and proper storage of fruit. This failure had the potential to cause foodborne illnesses in a medically vulnerable resident population who consumed affected food items in the kitchen.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary hospice services to one of 24 final sampled residents (Resident 68). * The facility failed to ensure the hospice plan of care was integrated in Resident 68's care. In addition, documentation such as physician certification, resident assessments, hospice services to be provided including the discipline and frequency of care, progress notes from hospice visits were in Resident 68's medical record. These failures had the potential to put the resident on at risk for uncoordinated medical care between the facility and hospice agency.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the clinical record for one final sampled resident (Resident 117) was accurate when the Inventory of Personal Effects form was not completed. This failure increased the potential for a residents' personal effects to be unaccounted for and/or misappropriated when the documentation was incomplete.