All Saints Healthcare Subacute

Inspectors wroteBased on observation, interview, and record review, the facility failed to:A. Ensure one of five sampled residents (Resident 18), who was investigated for pressure ulcers/injuries (also known as pressure sores and decubitus ulcers, localized damage to the skin and/or underlying tissue caused by prolonged pressure or friction, often over bony areas), received care consistent with professional standards of practice to prevent pressure ulcers and maintain skin integrity (the condition of the skin being intact, healthy and free from damage). [...]

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 restraints (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 two (2) of two (2) sampled residents (Resident 26 and 39) reviewed for physical restraints by failing to: 1. Complete a restraint assessment prior to application of the hand mitten (a large, soft glove that covers a patient's hands and prevent them from pulling out any lines or tubes) for Resident 26. 2. Ensure Resident 39's restraint bed placed against the wall had a/an: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were incontinent of bladder received services and assistance for three of three sampled residents (Residents 42, 43, and 3) reviewed for urinary tract infection (UTI, a common infection that occurs when bacteria enters and multiplies in the urinary system, which includes the kidneys, bladder, and urethra) by failing to ensure: 1. Resident 42 and 43's suprapubic catheter (a urinary catheter that is inserted into the bladder from a small cut in the tummy, just above the pubic bone) had a leg strap (a common and simple medical device used to securely hold the catheter tubing or a urine collection bag (leg bag) against the patient's leg) or a securement device in place. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the staff providing care and services to residents who had feeding tubes (are soft plastic tubes through which liquid nutrition travels through the gastrointestinal tract [the series of organs that food and liquids pass through as they are digested, absorbed, and leave the body as feces]) were aware of, competent in, and utilized facility protocols regarding feeding tube nutrition and care for four of five sampled residents (Residents 42, 3,105 and 41) reviewed for tube feeding by failing to ensure: 1. Resident 42's tube feeding bag was labeled with the complete name of the resident, the rate of infusion, and the initials of the licensed nurse who hung the tube feeding bag. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow professional standards of practice for respiratory care by failing to: 1. Ensure Respiratory Therapist (RT) 4 provided tracheostomy (trach - opening surgically created through the front of the neck and into the trachea [windpipe] that is held open by a specialized tube [cannula]) care per the physician's orders by cleaning the resident's stoma (actual physical opening in the skin at the front of the neck) with hydrogen peroxide (H2O2 -a liquid chemical used to clean wounds and reduce risk of infection from a wide variety of microorganisms) for one of five sampled residents (Resident 93) reviewed for respiratory care. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to assure that all nursing staff possess the competencies, and skill sets to safely provide nursing and related services to meet the resident's needs for two of five sampled staff, reviewed for sufficient and competent nurse staffing by failing to ensure: 1. Registered Nurse (RN) 1 was competent in documenting and monitoring for adverse effects (an unwanted, harmful, or unpleasant result of a medical treatment, drug, or other intervention) on the use of antibiotics (a medicine used to treat infections caused by bacteria) as prophylaxis (any action taken to prevent a disease or stop it from spreading). 2. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Reconcile (the process of comparing transactions and activity to supporting documentation) one (1) medication emergency kit ([eKIT] - kit containing medications needed to be used during emergencies) containing narcotics (medications which have a potential for abuse and may also lead to physical or psychological dependence, also known as Controlled Medication [CM] or Controlled Drug [CD]) for January 2026, in one (1) of two (2) inspected medication storage areas (Medication storage Nursing Station 1.) 2. Include the verifying signatures of either the Director of Nursing (DON) or a Registered Nurse (RN) along with Licensed Vocational Nurse (LVN) on the Controlled Drug Record accountability logs for two (2) of two (2) narcotics awaiting disposal (removal, destroying) in the CD locked cabinet. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that resident's drug regimen was free from unnecessary drugs (medication that is not needed for the current medical condition) for one (1) of two (2) sampled residents (Resident 97) reviewed for anticoagulant use by failing to monitor the resident for signs and symptoms of bleeding for the use of Eliquis (also known as apixaban, an AC used to treat and prevent blood clots). This deficient practice had the potential for Resident 97 to receive suboptimal (less than the highest standard or quality) care leading to the use of unnecessary medications causing potential side effects and negatively impacting their physical, mental, and psychosocial well-being. Cross-reference F656.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five (5) percent (%.) Three (3) medication errors out of 30 total opportunities contributed to an overall medication error rate of 10% affecting one (1) of two (2) residents observed for medication administration (Resident 61.) The medication errors were as follows: 1. Licensed Vocational Nurse (LVN) 5 failed to wait at least five (5) minutes in between administration of brimonidine tartrate (a medication used for glaucoma [a condition of increased pressure in the eyeball,]) dorzolamide hydrochloride (a medication used for glaucoma,) and refresh tears (a medication used to moisturize dry eyes) ophthalmic (eye) drops to Resident 61. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free of any significant medication errors (meaning 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) for one (1) of one (1) sampled resident (Resident 6) reviewed for anticoagulant (a substance that is used to prevent and treat blood clots in blood vessels and the heart) use by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) heparin (an anticoagulant) administration sites. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to store medications in accordance with manufacturer specifications, professional principles and facility policy and procedures by failing to: 1. Monitor and record medication storage area room temperature on a temperature monitoring log for January 2026, for one (1) of two (2) inspected medication storage areas (Medication storage Nursing Station 1.) 2. Label and store one (1) levalbuterol (a generic name for medication used to treat and prevent shortness of breath) inhalation solution foil pouch (a package made of foil protecting the inhalation solution from light and degradation) for Resident 79 at room temperature in accordance with the manufacturer's requirements in one (1) of ten (10) inspected Medication Carts (Medication Cart room [ROOM NUMBER].) 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure to store, prepare, and serve food in accordance with professional standards for food service safety for 19 out of 109 residents by failing to ensure: 1. The facility discarded the bag of deli bread and an unopened bag of deli hot dog buns with the best by date of 1/20/2026. 2. The facility did not hang a spoodle (is a hybrid kitchen utensil that combines the features of a spoon and a ladle) with butter residues on the clean rack near the steam table. These deficient practices had the potential to cause food-borne illnesses.

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

Inspectors wroteBased on interview and record review, the facility failed to implement its antibiotic stewardship program (a coherent set of actions which promote using antimicrobials responsibly) that includes antibiotic (ATB, a medicine that fights bacterial infections by killing bacteria or stopping them from multiplying) use protocols and a system to monitor antibiotic use for two of three sampled residents (Residents 39 and 71) reviewed for antibiotic use by failing to ensure: 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care in a manner that promoted dignity and respect for one of one sampled resident (Resident 23) reviewed under dignity care area by failing to ensure that Housekeeping (HSK) 1 moved Resident 23's wheelchair to create adequate space when bringing the large gray bin (storage bin container used to store used reusable gowns [a personal protective equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses]) into the room, which resulted in the bin colliding with the foot of Resident 23's bed and bedside table, as observed on 1/28/2026. This deficient practice had the potential to affect Resident 23's self-esteem and self-worth.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide reasonable accommodation of resident needs and preferences by failing to ensure the pad call light (a specialty alerting device that have ultra-sensitive touch surface for patients with limited mobility for nurses or other nursing personnel to assist a patient when in need) was within reach for one (1) of one (1) sampled resident (Resident 6) reviewed under the environment task. This deficient practice had the potential to result in a delay of care and services and possible injury to Resident 6 when the resident was unable to call for assistance.

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 (1) of one (1) sampled resident (Resident 13) reviewed for change of condition by failing to notify the responsible party when the resident was transferred to the hospital. This deficient practice had violated the resident's responsible party's right to be informed of the care services provided.

Inspectors wroteBased on interview, and record review, the facility failed to develop and implement a baseline care plan (an initial, temporary care document that is developed within 48 hours of a resident's admission, providing essential, person-centered care instructions to staff to ensure safety and continuity of care while a more comprehensive plan is developed) for one (1) of five (5) sampled resident (Resident 6) reviewed for unnecessary medications review when Resident 6 was readmitted to the facility on [DATE]. This deficient practice placed Resident 6 at risk of not receiving the appropriate care and treatment specific to the residents' needs.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive care plan (CP, a plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and function needs) by failing to: 1. Develop and implement a CP for the resident's use of Eliquis (also known as apixaban - an anticoagulant [AC] medication used to treat and prevent blood clots) included measurable goals and outcomes for monitoring signs and symptoms of bleeding for one of two sampled residents (Resident 97) reviewed for AC medications. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to revise one of four sampled residents (Resident 18) care plan when Resident 18's care plan was not updated to reflect current left buttock stage 2 pressure ulcer interventions addressing Resident 18's risk for worsening PU. This deficient practice had the potential to result in inconsistent implementation of the care plan that may lead to a delay in or lack of delivery of care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide needed care and services that are resident centered in accordance with the resident's goals for care and professional standards of practice for two of two sampled residents (Residents 65 and 81), reviewed under quality of care, by failing to ensure: 1. Resident 65's bilateral sequential compression devices (SCD's, are medical devices used to prevent blood clots in patients who are immobile) were applied to the lower extremities at all times. 2. Resident 81's water flush was administered via gastrostomy tube (g-tube) gavage (a medical term for giving liquid food, fluids, or medicines directly into the stomach through a special, surgically placed tube) per physician`s order. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents received adequate supervision to prevent accidents by failing to: 1. Ensure mupirocin calcium external cream (a topical medication used to treat bacterial skin infections) was not left unattended and readily available in the residents shared room for one of one sampled resident (Resident 114) reviewed during the Accidents care area. 2. Ensure a resident`s medications were not left unattended on the bedside table without a physician's order for one randomly sampled resident (Resident 61). This deficient practice had the potential to result in residents obtaining medication without staff knowledge resulting in unsupervised self-administration and accidental ingestion causing harm to residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Respiratory Therapists (a specialized healthcare professional who treats, manages, and cares for residents of all ages who have trouble breathing) demonstrated training and competency to perform tracheostomy (trach - opening surgically created through the front of the neck and into the trachea [windpipe] that is held open by a specialized tube [cannula]) care treatments for one of three sampled residents (Resident 93) reviewed under the Respiratory care area by failing to: 1. Ensure Respiratory Therapist (RT) 4 provided tracheostomy care per the physician's orders by cleaning the resident's stoma (actual physical opening in the skin at the front of the neck) with hydrogen peroxide (H2O2 - a liquid chemical used to clean wounds and reduce risk of infection from a wide variety of microorganisms). 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases (infectious diseases that can be transmitted from one individual, or species, to another) and infections by failing to: 1. Ensure suction canisters (a disposable container connected by tubing to a device used to suction respiratory secretions) were changed and labeled per facility Policy and Procedure (P&P) for one of three sampled residents (Resident 93) reviewed during the Respiratory care area. 2. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure two of four sampled residents (Resident 85 and Resident 41) reviewed under the infection control facility task were screened for, administered, or obtained and documented refusal or medical contraindication for the pneumonia (a lung infection that causes inflammation in one or both lungs, specifically filling the tiny air sacs with fluid or pus) vaccine (medication that teaches the immune system to recognize and fight off dangerous viruses or bacteria) for Resident 85 and Resident 41. This deficient practice placed residents at risk for acquiring pneumococcal disease and related complications.

Inspectors wroteBased on interview and record review the facility failed to ensure one of four sampled residents (Resident 85) reviewed under the infection control facility task was screened for the Covid-19 (a highly contagious respiratory illness caused by the virus SARS-CoV-2) vaccine (medication that teaches the immune system to recognize and fight off dangerous viruses or bacteria) upon admission. This deficient practice placed residents at risk for acquiring Covid-19 and other related complications.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) received care in accordance with professional standards of practice to attain or maintain the highest practicable physical well-being by failing to: 1. Ensure Registered Nurse (RN 2) documented a Change of Condition (COC - when a significant change in a resident's physical, mental, and/or psychosocial well-being occurs that requires licensed nurses to take action per professional standards of practice), according to the facility's policy, that detailed what happened to Resident 1 on 12/30/2025, which led Nurse Practitioner (NP 1) to order a STAT (immediate) chest x-ray (a test that uses radiation - a form of energy - to take pictures of the inside of a person's body). 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the medical record of one of three sampled residents (Resident 1) was complete and accurately documented, by failing to:1. Ensure Registered Nurse (RN 2) documented a Change of Condition (COC-when a significant change in a resident's physical, mental, and/or psychosocial well-being occurs that requires licensed nurses to take action per professional standards of practice)according to the facility's policy, that detailed what happened to Resident 1 on 12/30/2025 which led Nurse Practitioner (NP 1) to order a STAT (immediate) chest x-ray (a test that uses radiation - a form of energy - to take pictures of the inside of a person's body). 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1), a two-year old, with severely impaired cognition (mental action or process of acquiring knowledge and understanding) and dependent on staff for activities of daily living (ADL-activities such as bathing, dressing and toileting a person performs daily), remained free from accident. The facility failed to: 1. Ensure Certified Nursing Assistant (CNA) 1 did not turn her back on Resident 1, leaving Resident 1 unattended on a shower bed which had two gaps (open space) on each side of the side rails measuring eight inches (unit of measurement) in height and 22.5 inches in width, after CNA 1 transferred Resident 1 from his crib (a small bed for a baby or young child, with high bars to prevent the child from falling) to the shower bed. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure Business Office Staff (BOS) was aware that residents and their Resident Representative (RR) can rescind (officially cancel or take back something like a contract, law, or offer) the facility's arbitration (a private process where disputing [disagreement] parties agree that one or several other individuals can make a decision about the dispute after receiving evidence and hearing arguments) agreement (a written contract in which two or more parties agree to settle a dispute out of court) within 30 days after obtaining the signature for three of three sampled residents (Residents 1, 2, and 3). These failures could potentially result in the residents and RR not knowing or understanding what an arbitration agreement is and violated residents and RRs rights to rescind from an arbitration agreement.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its infection control measures for three of five sampled staff (Licensed Vocational Nurse [LVN] 4, Registered Nurse [RN] 4 and RN 5), during a respiratory virus season (a specific period, typically during the fall and winter months, when common respiratory illnesses like influenza [flu - a contagious {spread from one person to another by direct or indirect contact} respiratory illness caused by influenza viruses], Coronavirus Disease 2019 [COVID-19 - a highly contagious respiratory disease thought to spread from person to person through droplets], and Respiratory Syncytial Virus [RSV - common respiratory virus that primarily affects infants and young children, but can also cause illness in older adults and people with underlying health conditions] become more prevalent [widespread] and circulate widely [...]

Inspectors wroteBased on interview and record review, the facility failed to accurately update Facility Assessment (an evaluation of the physical environment necessary to meet the needs of the residents) 2025 by:1. Failing to ensure Facility Assessment 2025 indicated the use of shower bed in pediatric (medical specialty dealing with the development and care of children and with the diagnosis and treatment of childhood disease) and adult subacute (a transitional care setting that provides more intensive skilled nursing care than a standard nursing home, but less than an acute hospital stay, for patients recovering from surgery, injury, or illness) residents.2. Failing to ensure Facility Assessment 2025 indicated the use of the updated health information technology. These deficient practices had the potential to delay necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to maintain an accurate and complete medical record for one of three sampled residents (Resident 1) by:1. Failing to ensure Registered Nurse (RN) 6 documented administration of Resident 1's tacrolimus (medication used to prevent organ rejection after a transplant [the surgical removal of a healthy organ or tissue from one person and its transfer into another person, or from one part of the body to another]) on 10/7/2025.2. Failing to ensure Resident 1's Baseline Care Plan, dated 9/12/2025, was accurately documented. These failures had the potential to cause confusion in care and the medical records containing inaccurate documentation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of three sampled residents (Resident 1 and Resident 2) received care consistent with professional standards of practice to prevent pressure ulcers (PU, a localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure, or pressure in combination with shear) by failing to: 1. Ensure Resident 1 and Resident 2's low air-loss mattress (LALM - a mattress composed of inflatable air cushions used to relieve pressure on body parts) was set to appropriate settings per Physician Orders. 2. Ensure staff used one sheet and one chux (an absorbent under pads or bed pads used to protect surfaces from incontinence or spills) on Resident 1's LALM as indicated in the facility's policy. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the State Survey Agency (SSA) with a written report of the findings of the investigation of an allegation of abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment that may result in physical harm, pain or mental anguish) within five working days of the incident for one of four sampled residents (Residents 1). This failure had the potential to place residents at risk of unidentified abuse.

Inspectors wroteBased on interview and record review, the facility failed to provide services to residents by qualified persons in accordance with each resident's written plan of care for one of four sampled residents (Resident 1), when Certified Nurse Assistant (CNA) 1 provided oral suctioning (a medical procedure where sections such as saliva or mucus are removed from the mouth using a suction device) to Resident 1. This failure had the potential to place Resident 1 at risk for aspiration (when secretions or other substances enter the lungs instead of the stomach) and injury.

Inspectors wroteBased on interview and record review, the facility failed to report immediately not later than two hours an allegation of abuse to the State Survey Agency (SSA) for one of three sampled residents (Resident 1) when on 4/30/2025 at 2 p.m. Resident 1 reported to the Social Worker (SW) an unnamed certified nursing assistant (CNA) touched him (Resident 1) inappropriately. This abuse allegation was reported to the SSA on 5/1/2025 at 4:02 p.m. This deficient practice placed Resident 1 at risk for further abuse.

Inspectors wroteBased on interview and record review, the facility failed to inform one of three sampled residents (Resident 1), attending physician (MD) when there was a significant change (a change in the resident's physical, mental, or psychosocial status that causes either life-threatening conditions or clinical complications) in the resident's condition. Resident 1 had a Change of Condition (COC- a major decline in a resident's status) on 4/19/2025 when Resident 1 became tachycardia (a medical condition characterized by a rapid heart rate, typically defined as a resting heart rate of over 100 beats per minute) and had a low-grade temperature. This deficient practice had the potential for a delay in the care of Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to implement its policy and procedure for ensuring the reporting of an allegation of abuse for one of three sampled residents (Resident 1). Resident 1 alleged being physically abused (intentional act of causing injury or trauma to a person through bodily contact) by an employee (name not indicated), but the facility did not respond in investigating or reporting such allegation to the California Department of Public Health (CDPH - licensing and certification division). This deficient practice delayed the investigative process and placed Resident 1 at an increased risk for further distress such as physical harm, emotional pain, and further trauma associated with the allegation of abuse. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident was free from any significant medication error for one of three sampled residents (Resident 2) by not following the physicians order, by: 1. Failing to hold the midodrine (medication used to treat low blood pressure) six times on 10/2024. 2. Failed to administer the midodrine on [DATE], at 9 a.m. These deficient practices had the potential to result in significant increase in Resident 2's blood pressure.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections by failing to: 1. [...]

Inspectors wroteBased on 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 biologicals) for one of three sampled residents (Resident 1) by not following the physician's orders. This deficient practice had the potential to result in Resident 1's increase in blood pressure (BP- pressure of circulating blood against the walls of blood vessels).

Inspectors wroteBased on interview and record review, the failed to maintain accurate and complete medical record for one of three sampled residents (Resident 1). This deficient practice had the potential to cause confusion in care and the medical records containing inaccurate documentation and can result in the delay of delivery of care.

Inspectors wroteBased on observation, interview, and record review the facility failed to keep the pad call light (an alerting device for nurses or other nursing personnel to assist a patient when in need) within reach for four of six sampled residents (Resident 463, 75, 18, and 4) reviewed during investigation of the environment facility task. This deficient practice had the potential to result in the residents 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. a. [...]

Inspectors wroteBased on interview and observations, the facility failed to maintain resident protected health information ([PHI] - any health information that can be used to identify a specific individual which must remain confidential to prevent harmful consequences) by not shredding or covering pharmacy medication labels (a label that includes the residents name, date of birth , name of pharmacy, name of medication, dose, its indication and instructions of use) containing resident medical information on medication bubble packs (medication packaging system that contains individual doses of medication per bubble) prior to disposing in the waste container, affecting two (2) residents (Resident 69 and 80) in one of one inspected biohazard (any biological or chemical substance that is dangerous to humans, animals, or the environment) room. [...]

Inspectors wrote3. During a review of Resident 45's admission Record indicated the facility admitted the resident on 5/17/2024 and was readmitted on [DATE] with diagnoses including chronic respiratory failure (a long term condition in which the lungs have a hard time loading the blood with oxygen and can leave a patient with low oxygen), tracheostomy (a surgical procedure to create an opening through the neck into windpipe to facilitate breathing), and gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). During a review of Resident 45's History and Physical (H&P) dated 9/27/2024, the H&P indicated the resident did not have the capacity to understand and make decisions. [...]

Inspectors wroteBased on interview and record review the facility failed to develop and implement a comprehensive care plan for three of five sampled residents (Residents 45, 37 and 463) investigated under physical restraints (device or manual holds that limit a person's movement or access to their body) by: 1. Failing to develop and implement a care plan for Resident 45's use of right-hand mitten (a type of glove that covers patient hand to prevent from pulling out any essential line or tubes). 2. Failing to develop and implement a care plan addressing placement of Resident 37's bed against the wall. 3. Failing to develop and implement a care plan addressing use of full side rails (horizontal bars attached to the side of a bed to help prevent falls and provide a sense of security) for Resident 463. These deficient practices had the potential for a delay in care and services of residents.

Inspectors wroteBased on interview and record review, the facility's licensed nursing staff failed to provide care in accordance with professional standards for one of five sampled residents (Resident 81) investigated under unnecessary medications by failing to rotate (a method to ensure repeated injections are not administered in the same area) the subcutaneous (SQ - beneath the skin) insulin (a hormone that lowers the level of sugar in the blood) administration sites. This deficient practice had the potential for adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin such as lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate services to prevent decline in joint range of motion (ROM, full movement potential of a joint) for three out of nine sampled residents (Residents 15, 93, and 94) who had limited ROM and were assessed at risk for decline in joint ROM, as indicated in the resident's care plans. The facility failed to: 1. Ensure Resident 15 did not wear both hand splints (rigid material or apparatus used to support and immobilize a broken bone or impaired joint) for more than one hour as ordered by the physician. 2. Ensure Resident 93 wore both hand rolls (device to keep fingers open) at all times. 3. Ensure Resident 94 wore both hand rolls at all times and right heel protector at all times. These deficient practices had the potential to cause further decline in Residents 15, 93, and 94's ROM and skin integrity.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the resident environment was free of accident hazards for four of four sampled residents (Residents 19, 35, 100, and 87) by failing to ensure: 1. Resident 19's albuterol (a medication to prevent and treat wheezing and shortness of breath caused by breathing problems) and Atrovent (a medication to make breathing easier) medications were not left at the bedside. 2. Resident 35's bottle of milk of magnesia (a medication to treat constipation, upset stomach and heart burn) was not left at the bedside. 3. Resident 100's fall mat (a floor mat designed to reduce the risk of injury from a fall by providing a soft-landing surface) did not have medical equipment or furniture on top of them for a longer period of time. 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were incontinent (having no or insufficient control) of bladder (an organ inside the body that stores urine until it can be excreted) received appropriate treatment and services to prevent urinary tract infection (UTI, an infection in the bladder/urinary tract) for three of four sampled residents (Residents 80, 7, and 94) being investigated under urinary catheters (a hollow tube inserted into the bladder to drain or collect urine) by failing to ensure: 1. Resident 80's suprapubic catheter (a medical device that helps drain urine from the bladder) had a securement device/anchor (a device that support the weight of the leg bag and keeps a urinary catheter in place). 2. Residents 7 and 94's urinary catheter tubing systems were not coiled while hanging off the sides the beds. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents receiving enteral feeding (EF - also known as tube feeding, a method of supplying nutrients directly into the gastrointestinal tract) received appropriate care and services to prevent complications of enteral feeding for six of six sampled residents (Residents 75, 38, 11, 104, and 65) investigated under the tube feeding care area by: 1. Failing to ensure Licensed Vocational Nurse 5 (LVN 5) discarded the EF formula that remained in Resident 75's irrigation bottle after medication administration with the medication syringe left inside. 2. Failing to ensure Resident 38's EF formula bottle indicated the start date. 3. Failing to ensure Resident 11's EF bag was labeled with the resident's name, date and time, and the licensed nurse's initials when it was changed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer parenteral (a route outside the digestive system, such as by injection) fluids or medications consistent with professional standards of practice by failing to: 1. Ensure the peripheral intravenous catheter (IV, a thin, flexible tube that is inserted into veins to give treatments including fluids, drugs, or blood transfusions) dressing (clear protective cover placed over the IV catheter insertion site) was labeled per the facility policy for five of eight sampled residents (Resident 97, 81, 45, 461 and 462). 2. Ensure residents with IV catheters had physician orders for IV catheters for three of three sampled residents (Resident 97, 81, and 45 3. Ensure the IV catheter was routinely removed and replaced every 72 hours per facility policy for three of three sampled resident (Resident 97, 81, and 45) 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate and sufficient nursing staff to provide care for adult residents requiring Restorative Nursing Aide (RNA, nursing aide program that helps residents to maintain their function and joint mobility) services. This deficient practice had the potential for 70 adult subacute residents with physician's orders for daily RNA to experience a decline in range of motion (ROM, full movement potential of a joint), mobility, and activities of daily living (ADL, basic activities such as eating, dressing, toileting) function.

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Have an available supply of simethicone (a medication used to treat symptoms of gas such as painful pressure, fullness, and bloating) and renal multivitamin (a multivitamin designed for dialysis [a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed] patients to replace the vitamins lost during dialysis) in the medication carts affecting 1 of 5 observed residents (Resident 106) during the medication administration task. As a result, Resident 106 did not receive simethicone and renal multivitamin on 10/22/24 at 10 a.m. 2. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure the entire medication regimen of the resident was managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being by failing to: 1. Monitor for adverse effects (a harmful or abnormal result) for the use of Remeron (a type of antidepressant, a medication used to treat depression [a mental condition that can affect how a person feels, thinks, and acts]) for one out of five sampled residents (Resident 50) 2. Monitor for adverse effects for the use of Buspar (a type of medication primarily used to treat generalized anxiety disorder (a mental health condition that involves excessive and persistent feelings of fear, dread, and uneasiness) for one of five sampled residents (Resident 50) 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a medication error rate below 5 percent (%) by having three (3) medication errors out of 33 opportunities contributing to an overall error rate of 9.09% for two (2) out of five (5) sampled residents (Resident 44 and 106) observed during the Medication Administration facility task. The medication errors were due to unavailability of two (2) medications resulting in not administering doses at the scheduled administration times and overlooking to administer one (1) medication at the scheduled time. The medication errors were as follows: 1. Resident 44 did not receive labetalol (a medication used to for hypertension [a condition in which the blood vessels have persistently raised pressure]) at the scheduled time as ordered by Resident 44's physician, and 2. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure residents were free of any significant medication errors for one (1) out of five (5) sampled residents (Resident 81) investigated under unnecessary medications by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (SQ - beneath the skin) insulin (a hormone that lowers the level of sugar in the blood) administration sites. This deficient practice had the potential for adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin such as lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin).

Inspectors wroteBased on observation, interview, and record review the facility failed to 1. Store one (1) lorazepam (a medication used to treat seizure [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness]) vial (form of medication that is used for injections) for Resident 7 in accordance with manufacturer's requirements and facility policy and procedures, in one (1) of three (3) inspected medication refrigerators (Refrigerator 2) located in Nursing Station Subacute. 2. Remove and discard from use one (1) open and expired lorazepam vial for Resident 11, in accordance with manufacturer's requirements and facility policy and procedures, in one (1) of three (3) inspected medication refrigerators (Refrigerator 2) located in Nursing Station Subacute. 3. [...]

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. One cell phone was placed in the dry storage area next to boxes of nutritional supplements. 2. One dented can was placed in the non-dented can area in the dry storage area. 3. Two cans of sodas were found on the floor beneath the shelves in the dry storage area. These deficient practices had the potential to result in harmful bacterial growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (transfer of bacteria from one object to another) in 20 of 111 residents who receive food from the kitchen.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure safe and sanitary storage, handling, and consumption of foods for one of one sampled residents (Resident 53) investigated during review of kitchen facility task by failing to ensure food brought from home were labeled with resident's name, and the date and time the food was brought into the facility for resident's consumption. This deficient practice had the potential to result in food-borne illnesses (food poisoning) for Resident 53, with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever that can lead to other serious medical complications and hospitalization.

Inspectors wrotef. During a concurrent observation and interview on [DATE], at 10:05 a.m., with Licensed Vocational Nurse 15 (LVN 15), in the facility hallway, Linen Cart A was covered with a permeable/loosely woven material to protect the clean linens for the residents to use. LVN 15 stated Linen Cart A cover does not protect the linen from splashes and minute viruses and bacteria due to the mesh/permeable material used. LVN 15 stated the permeable/loosely woven cover can let water splashes in, viruses and bacteria. During a concurrent observation and interview on [DATE], at 10:23 a.m., with Licensed Vocational Nurse 3 (LVN 3), in the facility hallway, Linen Cart B was covered with a permeable/loosely woven material to protect the clean linens for residents to use. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a homelike environment by failing to ensure resident privacy curtains are free of splash stain for one of eight sampled residents (Resident 97) reviewed under the environment task. This deficient practice had the potential to negatively affect Resident 97's psychosocial wellbeing by feeling uncomfortable in his living space and violated the resident's rights to a safe, clean, and homelike environment.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the comprehensive care plan was reviewed and revised by an interdisciplinary team to meet the individual needs for three of 13 sampled residents (Residents 93, 37, and 15) by failing to: 1. Ensure Resident 93's bedrails/side rails (a board or a rail that runs along the side of a bed, connecting the headboard and footboard) care plan (a written document that outlines the care and support needs of a person) followed Resident 93's physician's order. 2. Ensure Resident 37's bedrails/side rails care plan followed Resident 37's physician's order. 3. Ensure Resident 15's Restorative Nursing Restorative Nursing Assistant program [(RNA), nursing aide program that help residents to maintain their function and joint mobility] care plan reflected Resident 15's current RNA orders. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident was provided with showers for one of two sampled residents (Resident 104) investigated under activities of daily living. This deficient practice had the potential for Resident 104 to feel frustrated and embarrassed, due to lack of or delay in receiving sufficient services to maintain good grooming, personal and oral hygiene; and incontinence care and had the potential to lead to skin breakdown, and social isolation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident's low air loss mattress (LALM, a specialized mattress designed to distribute a resident's body weight over a broad surface area and help prevent skin breakdown) was set to the resident's weight for one of two sampled residents (Resident 261). This failure had the potential for Resident 261's skin to break down.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Respiratory Therapist 1 (RT 1) provided tracheostomy (opening surgically created through the front of the neck and into the windpipe) care per the physician's orders by cleaning the resident's stoma (a surgically created hole) with water and rinsing with normal saline (NS, a sterile solution) for one of four sampled residents (Resident 15). This deficient practice placed Resident 15 at risk for respiratory distress and infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure an allegation of abuse including injuries of unknown source were reported immediately, but not later than 24 hours to the State Survey Agency (SSA), the Ombudsman Program (advocates for residents in nursing home) and law enforcement (police) in accordance with the facility's policy and procedure for one of three sampled residents (Resident 1). On 5/31/2024, Certified Nursing Assistant 1 (CNA 1) observed a fading greenish yellowish bruise (occurs when blood vessels break and leaked blood into the skins top layer) to Resident 1 ' s left jaw. This deficient practice resulted in no investigations conducted to rule out abuse and placed the residents at risk for further abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control measures for one of three sampled residents (Resident 1) by failing to ensure Licensed Vocational Nurse 1 (LVN 1) was wearing a protective gown while giving medications via gastrostomy tube (GT- a surgically placed device used to give direct access to the stomach for feeding, hydration or medicine) to Resident 1, who was placed on enhanced standard precaution (expand the use of personal protective equipment and refers to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of multidrug resistant organisms [MDRO- are germs that are difficult to treat because they are resistant to many antibiotics]). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than 5 percent (%). Eleven (11) medication errors out of 26 total opportunities contributed to an overall medication error rate of 42.3% affecting 3 of 5 sample residents (Residents 22, 43, and 68) observed for medication administration performed by 3 of 5 Licensed Vocational Nurses (LVNs 1, 2, and 3). The facility failed to: 1. Ensure LVN 1 did not mix three of eight medications for administration through Resident 22's gastrostomy tube (GT, a soft tube inserted during surgery into the stomach through the belly to deliver food and medications on a person unable to swallow) and followed the facility's policy and procedure (P&P) on Medication Pass to give medications one at a time. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 3 of 5 sample residents (Residents 22, 43, and 68) observed for medication administration performed by 3 of 5 Licensed Vocational Nurses (LVNs 1, 2, and 3) on 10/18/2023, were free from significant medication errors (one or more observed or identified preparation or administration of medications ordered by a physician causing the resident discomfort or jeopardizes his or her health and safety). The facility failed to: 1. Ensure LVN 1 did not mix three medications for administration through Resident 22's gastrostomy tube (GT, a soft tube inserted during surgery into the stomach through the belly to deliver food and medications on a person unable to swallow) and followed the facility's policy and procedure (P&P) on Medication Pass to give medications one at a time. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents' call lights are within reach for three (Resident 16, 22, and 51) of 52 sampled residents (Resident 16, 22, and 51). This deficient practice had the potential to result in a delay in or lack of necessary care and services that can negatively affect the resident's comfort and well-being.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a safe, comfortable, and homelike environment to three out of 52 sampled residents (Residents 32, 16, and 81) by: 1. Failing to ensure Resident 32's bed remote control with exposed wires was replaced. 2. Failing to ensure Resident 16's call light button with loose electrical tape on the electrical cord was replaced. 3. Failing to ensure Resident 81's electric fan was dust-free. These deficient practices had the potential to result in accidental injury, residents not being to call for help, affect the comfort of residents and increase the risk of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for three of six sampled residents (Resident 1, 47, and 76), by failing to: 1. Develop an accurate care plan addressing placement of bed rails for Resident 1. 2. Develop a care plan addressing the use of a physician ordered low air loss mattress (LALM, is a medical device that helps prevent pressure ulcers [bed sores] by providing constant airflow to keep the skin cool and dry) for Residents 47 and 76. These deficient practices had the potential to result in the delay of necessary care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure professional standards were met by 3 of 5 Licensed Vocational Nurses (LVNs 1, 2, and 3) affecting three of five sampled residents (Resident 22, 43, and 68) investigated during Medication Administration task. The facility failed to: 1a. Ensure LVN 1 read the medicine label and compare with the Medication Administration Record (MAR) to ensure Resident 22 received the correct dose of Potassium chloride (KCl, medicine used to prevent or treat low potassium levels in the body; potassium is a mineral the body needs for proper functioning of several organs including the heart) through Resident 22's gastrostomy tube (GT, a soft tube inserted during surgery into the stomach through the belly to deliver food and medications on a person unable to swallow), as ordered by the physician. 1b. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice to three out of three sampled residents (Resident 54, Resident 5, and Resident 61) by: 1. Failing to ensure Resident 54 and Resident 5 sequential compression device (SCD, a method of deep vein thrombosis [DVT, occurs when a blood clot forms in one or more deep veins in the body, usually in the legs] prevention that improves blood flow in the legs) to bilateral lower extremities was on. The deficient practice had the potential for residents to develop deep vein thrombosis (DVT). 2. Failing to ensure Resident 61 had an identification band. This deficient practice created the potential for misidentification of the Resident 61, which could lead to medication error.

Inspectors wrote3. A review of Resident 18's Record of admission indicated the facility admitted the resident on 1/7/2022 with diagnoses including chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body), dependence on respirator (ventilator, a device for maintaining artificial respiration), and pressure ulcer of other site, unspecified stage. A review of Resident 18's H&P, dated 9/28/2023, indicated the resident does not have assay to understand and make a decision due to encephalopathy (damage or disease that affects the brain). A review of Resident 18's MDS, dated [DATE], indicated the resident had severely impaired cognitive skills for daily decision making. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident who has an indwelling catheter, receives the appropriate care and services to prevent urinary tract infections (UTI, common infections that happen when bacteria, often from the skin or rectum, enter the urethra [duct that transmits urine from the bladder to the exterior of the body during urination], and infect the urinary tract) to the extent possible for four of 52 sampled residents (Residents 16, 31, 94, and 20) by: 1. Failing to apply a leg strap (a device to secure the catheter to prevent tugging and pulling) to secure the urinary catheter (a procedure used to drain the bladder and collect urine, through a flexible tube called a catheter) of Resident 16. 2. Failing to ensure Resident 31 and Resident 94's drainage bags were attached to the side where the leg strap was placed. 3. [...]

Inspectors wroteb. A review of Resident 1's Record of admission indicated the facility readmitted the resident on 2/26/2018 with diagnoses including chronic respiratory failure, encounter for attention to gastrostomy, and GERD. A review of Resident 1's History and Physical, dated 2/11/2023, indicated the resident does not have the capacity to understand and make decisions. A review of Resident 1's Physician Orders, dated 6/2/2023, indicated GT feeding: Promote with fiber at 60 cc/hr x22 hrs via pump to provide 1320 cc/1320 kcals every 24 hrs. A review of Resident 1's MDS, dated [DATE], indicated the resident required total dependence with bed mobility, dressing, and eating with physical assist from staff. The MDS indicated the feeding tube was performed while a resident of the facility. [...]

Inspectors wrote2. A review of Resident 61's admission Record indicated the facility admitted the resident on [DATE] and readmitted the resident on [DATE] with diagnoses including spastic quadriplegic cerebral palsy (CP - a condition that is caused by abnormal brain development that affects a person's ability to control their muscles ), chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body), and convulsion (rapid, involutory muscle contractions that cause uncontrollable shaking and limb movement). A review of Resident 61's History and Physical, dated [DATE], indicated the resident was non-verbal. [...]

Inspectors wrote2. a. A review of Resident 1's Record of admission indicated the facility readmitted the resident on 2/26/2018 with diagnoses including chronic respiratory failure, encounter for attention to gastrostomy, and gastro-esophageal reflux disease (GERD, a condition in which the stomach contents leak backward from the stomach into the esophagus). A review of Resident 1's History and Physical, dated 2/11/2023, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 1's MDS, dated [DATE], indicated the resident requires total dependence with bed mobility, dressing, and eating with physical assist from staff. A review of Resident 1's Physician Orders, dated 2/26/2018, indicated an order for side rails up due to non-restraint due to ADLs and mobility. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that licensed nursing staff have the specific competency (measurable pattern of knowledge, abilities, behaviors in order to perform occupational functions successfully) and skills set necessary to care for residents' needs for five out of five licensed nursing staff (Registered Nurse 1 [RN 1], Licensed Vocational Nurse 1/[LVN 1], LVN 2, LVN 3, and LVN 5 investigated under the Sufficient and Competent Nurse Staffing task. This deficient practice placed all residents care for by RN 1 and LVNs 1, 2, 3, and 5) at risk of not receiving care to meet their needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pharmaceutical services to assure its medication administration was accurate, free from errors, followed physician's orders, and established policies and procedures (P&P) for three of five sample residents (Residents 22, 43, and 68) and three of five licensed Vocational Nurses (LVNs 1, 2, and 3) observed for medication pass. The facility failed to: 1a. Ensure LVN 1 read the medicine label and compare with the Medication Administration Record (MAR) to ensure Resident 22 received the correct dose of Potassium chloride (KCl, medicine used to prevent or treat low potassium levels in the body; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food service safety for the following: 1. An open bottle of Worcestershire sauce with received date of 9/10/2022 and best by date of 6/25/2024 was without an open date. 2. An open [NAME] Red cooking wine with received date of 5/28/2022 and best by date of 10/9/2022 was without an open date. 3. Flavor glow (Dark) with no received date, with open date of 9/8/2022, and no best by date. 4. Corn bread mix with no received date, with open date of 10/3/2023, and no best by date. 5. Cayenne Pepper Hot 40,00 [NAME] with no received date, no open date, and with best by date of 9/2/2022. 6. Ground ginger with no received date, no open date, and with best by date of 3/15/2023. 7. Ground mustard with no received date, no open date, and with best by date of 5/28/2023. 8. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain medical records that are complete and accurate documentation for five of seven sampled residents (Resident 22, 31, 94, 99, and 38), by failing to: 1. Ensure respiratory therapists signed the respiratory therapy Documentation - Charting Record after administering medications for Residents 22, 31, and 94. 2. Ensure the intravenous (IV) Medication Administration Record (MAR) was completed for one out of three residents investigated under resident records (Residents 94). 3. Ensure respiratory therapists signed the respiratory therapy Documentation - Charting Record after providing treatment as ordered by the physician for Resident 99 and 38. These deficient practices had the potential to result in inadequate management of the residents' health condition and the medical records containing inaccurate documentation.

Inspectors wrote4.a. A review of Resident 19's Record of admission indicated the facility admitted the resident on 7/17/2009 and readmitted on [DATE] with diagnoses including chronic respiratory failure (a long-term condition in which your lungs have a hard time loading your blood with oxygen and can leave you with low oxygen), dependence on respirator (a machine that helps a patient breath when having surgery or cannot breathe on their own due to a critical illness), tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea [windpipe] from outside the neck), and gastrostomy (a surgical procedure to insert a tube through the abdomen and into the stomach used for feeding, usually via a feeding tube). A review of Resident 19's History and Physical, dated 2/22/2023, indicated the resident did not have the capacity to understand and make decisions. [...]

Inspectors wroteb. A review of Resident 109's admission Record indicated the facility admitted the resident on 9/11/2023 with diagnoses including spastic diplegic cerebral palsy (CP - a condition that is caused by abnormal brain development that affects a person's ability to control their muscles, mainly in the legs), epilepsy (brain disorder that causes recurring seizures), and neuromuscular dysfunction of the bladder (person lacks bladder control due to brain or nerve problems). A review of Resident 109's History and Physical, dated 9/14/2023, indicated the resident was non-verbal and had severe neurological impairment. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly treat a resident's contractures (muscles or tendons that have remained too tight for too long, thus becoming shorter) by not applying bilateral hand splints and right knee splint as ordered by the physician for one of two sampled residents (Resident 22) investigated under the position, mobility care area. This deficient practice had the potential to result in the decline of the resident's mobility and range of motion (the extent or limit to which part of the body can be moved around a joint or a fixed point) and worsening of the resident's contractures.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that each resident receives care and services for the provision of parenteral fluids (formulated liquids that are injected into a vein to prevent or treat dehydration [a condition caused by the loss of too much fluid from the body]) consistent with professional standards of practice for two out of two sampled residents (Residents 27 and 91) by failing to label the saline lock (a thin, flexible tube placed in a vein in the hand or arm) with the date and initials of the staff who started the saline lock. The deficient practice had a potential to cause infection such as phlebitis (inflammation of a vein).

Inspectors wroteBased on interviews and record reviews, the facility failed to act upon on the Pharmacist Consultant's monthly medication regimen review recommendations in a timely manner for one out of five sampled residents (Resident 103) investigated under the Unnecessary Medications, Psychotropic Medications (used to stabilize or improve mood, mental status, or behavior), and Medication Regimen Review care area, by failing to address the recommendation to change the administration time for Resident 103's sucralfate (antacid, used to treat and prevent ulcers/sores in the intestines) medication. This deficient practice had the potential to result in reduced effectiveness of the medication designed to form a protective barrier over the ulcer or damaged area in the gastrointestinal tract.

Inspectors wroteBased on observation, interview, and record review, the facility: 1. Failed to ensure the potassium chloride (KCL - a medicine used to prevent or treat low potassium [a mineral the body needs for proper functioning of the heart, muscles, kidneys, nerves, and digestive system] levels in the body) oral solution label matched the dosage the physician's order and Medication Administration Record (MAR) for one of five residents (Resident 22) observed during the Medication Administration task. This deficient practice placed Resident 22 at risk for receiving the wrong dosage of the medication which may lead to muscle weakness, chest palpitation (a skipped, extra, or irregular heartbeat), and arrhythmia (irregular heartbeat). 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement its antibiotic stewardship program for one of 52 sampled residents (Resident 23) by: 1. Failing to monitor and document Resident 23's erythromycin (a medication used as an antibiotic [medication used to treat bacterial infections] and gut motility [the process of moving food, liquids, and waste through the gut] stimulator) use in the facility's Resident Antibiotic Log for August, September, and October 2023. 2. Failing to indicate a duration in the physician's order for the use of erythromycin. These deficient practices placed Resident 23 at risk for adverse events, including the development of anti-biotic resistant organisms, from unnecessary or inappropriate antibiotic use.