Alvarado Care Center

Inspectors wroteBased on interview and record review, the facility failed to ensure a significant change in condition was appropriately assessed, reported, documented, and incorporated into the comprehensive care plan for one of three sampled residents (Resident 1). This failure resulted in lack of direction for staff to address Resident 1's left knee pain and swelling, and had the potential to result in delayed or inadequate care. During a review of Resident 1's admission Record, indicated Resident 1 was admitted to the facility on [DATE] with diagnosis of hepatic encephalopathy (a reversible decline in brain function occurring in people with severe liver disease, such as cirrhosis or liver failure), cirrhosis of liver (a type of liver damage where healthy cells are replaced by scar tissue), reduced mobility, cellulitis of left leg (an infection of the deeper layers of skin and underlying tissue. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement an updated, person-centered care plan following a significant change in condition for one of three sampled residents (Resident 1). This failure resulted in lack of clear interventions and monitoring to address Resident 1's left knee pain and swelling, impaired mobility, or risk for further injury, and had the potential to result in delayed or inadequate care. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure that call light systems were functioning properly and that staff consistently verified functionality to promote timely response to resident needs for one of three sampled residents (Resident 2). This failure resulted in inconsistent implementation of monitoring practices, resulting in a non-functioning call light for Resident 2, and had the potential to result in delayed care and unmet resident needs. During a review of Resident 2's admission Record, indicated Resident 2 was admitted to the facility on [DATE] with diagnosis of type 2 diabetes (DM2- A condition that happens because of a problem in the way the body regulates and uses sugar as fuel), hypoglycemia (a condition characterized by blood sugar levels falling below normal. [...]

Inspectors wroteBased on interview and record review, the facility failed to:-Ensure Risperdal (a medication used to treat mental illness) was used to treat a medical diagnosis clearly documented in the medical record for one of five residents (Resident 1) sampled for unnecessary medications-Define specific problematic behaviors related to the use of Risperdal and Depakote (a medication used to treat mental illness) for one of five sampled residents (Resident 69) for unnecessary medications (Resident 69).-Monitor for adverse effects (unwanted or dangerous medication-related side effects) related to the use of Cymbalta (a medication used to treat mental illness) in one of five residents sampled for unnecessary medications (Resident 69.)The deficient practices of failing to define specific problematic behaviors, ensure medication was used to treat a resident's specific, diagnosed condition, and monitor [...]

Inspectors wroteBased on interview and record review, the facility failed to accurately complete the Minimum Data Set (MDS - a comprehensive resident assessment tool) assessment Section I (active diagnoses) by failing to include diagnoses of bipolar disorder (a mental illness characterized by having rapid changes in mood from depression to mania) and depression (a mental illness characterized by depressed mood, insomnia, and lack of energy or interest in usually enjoyable activities) per information in the medical record for two of five residents sampled for unnecessary medications (Resident 1 and Resident 69). The deficient practice of failing to accurately assess active diagnoses and complete MDS Section I increased the risk that Resident 1 and Resident 69 may not have received care planning and treatment according to their needs possibly leading to a decline in their overall health and well-being.

Inspectors wroteBased on interview, and record review, the facility failed to develop an individualized person-centered care plan (a plan of care that summarizes a resident's health conditions, specific care and services facility staff need to provide a resident to promote healing and prevent a worsening of a condition, and current treatments) to meet the resident's needs for two of sixteen sampled residents (Resident 54, and Resident 69), by failing to: 1. Create and implement an at risk for falls care plan for Resident 54 on 11/11/25 after the resident suffered a fall.2. Create and implement a care plan for Resident 69 requiring supervision or touch assistance with meals.3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to revise the care plans for three of 10 sampled residents (Resident 2, Resident 5, Resident 8) by failing to: -Ensure to revise(update) Resident 2's care plan for impaired cognition (having difficulties with thinking, learning, remembering, concentrating, solving problems, or making decisions) related to dementia (a progressive state of decline in mental abilities). -Ensure to revise Resident 5's care plan for falls. -Ensure to revise Resident 8's care plan for smoking. These failures had the potential to impact Resident 2's provision of care and services and placed Resident 5 and Resident 8 at risk for injuries related to falls and smoking.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident safety for two five sampled residents (Resident 8 and Resident 56) by failing to:-Ensure to implement safety smoking precautions for Resident 8. -Ensure to complete a post fall neurological assessment for the fall on 9/2025 and 12/2025 and Interdisciplinary Team (IDT- group of healthcare staff from different disciplines involved in the care of the resident), met, reviewed, and/or revised Resident 56's care plans after the fall on 09/10/2025 and 12/24/2025 to implement fall precautions for Resident 56. These failures had the potential for Resident 8 to have injuries related to unsafe smoking practices and for Resident 56 to sustain an injury from preventable fall.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer five doses of Adderall (a medication used to treat mental illness) per the physician's order between 1/19/2026 and 1/21/2026 in one resident randomly sampled for medication errors (Resident 34). The deficient practice of failing to administer five doses of Resident 34's Adderall increased the risk that Resident 34 could have experienced medical complications from missing scheduled doses of her medication and caused Resident 34 to feel overwhelmed and anxious about the potential impact to her physical and mental health as a result or missing her medication.

Inspectors wroteBased on observation, interview, and record review the facility failed to:1. Remove one expired insulin aspart pen (a medication used to control high blood sugar) affecting Resident 67 from the medication cart in one of two inspected medication carts (Station 1 Medication Cart). 2. Remove two vials of expired injectable lidocaine (a medication used to treat pain) and one vial of expired haloperidol (a medication used to treat mental illness) from the emergency kit (E-kit - a kit containing a limited supply of medication to be used on an emergency basis) in one of one inspected medication rooms (Medication Room). 3. Label one opened Arnuity Ellipta inhaler (a medication used to treat breathing problems) with an open date per the manufacturer's requirements affecting Resident 83 in one of two inspected medication carts (Station 2 Medication Cart). [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the lunch menu was followed on 1/20/2026, when:1. One Dietary aide (DA2) did not communicate the allergies listed on two of three (the gluten free meal ticket [lists resident's food preferences, allergies, and the food items on the menu to be served and portions] and the lactose intolerant meal ticket) meal tickets.2. [NAME] 2 did not prepare the non-breaded plain hamburger patty replacement for the gluten free diets. As a result, the cooks served pureed country fried steak (breaded beef patty) containing gluten on a tray for a resident who was allergic to gluten, and potato gratin (sliced potatoes in creamy sauce) prepared with milk served on a tray for a resident who was lactose intolerant (milk intolerant). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure: The minced and moist diet (diet for residents who experience biting, chewing or swallowing limitations. Food is soft and moist; the size of the lumps should be approximately 4 mm in size fits through gaps of fork prongs.) Au gratin potatoes (sliced potatoes in creamy sauce) were served in a form that was in accordance with the international Dysphagia Diet initiative (IDDSI - a framework made up of levels and describes food textures and drink thickness) Level Five (Minced and Moist foods) when breaded beef patties were chopped and not minced and the texture of the minced and moist was not small (minced) did not fit through the gaps of fork prongs and breaded beef patty was dry. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe and sanitary food storage and preparation practices in the kitchen when: 1. Clean and sanitized resident trays and cups were stored on the counter next to the handwashing sink and in the splash zone (the area within roughly 3 feet of a handwashing sink or drain, where water spray and particles from handwashing can contaminate surrounding surfaces). 2. The floor in the dry storage area located in the kitchen was not kept clean, food debris, a hair net, a lighter, condiments packages and plastic wrappers were on the floor. 3. Expired food was stored in the dry storage area. [...]

Inspectors wroteBased on interview and record review, the facility failed to obtain an informed consent (a process during which residents or caregivers are educated regarding the potential risks and benefits of medication therapy) from the resident or their responsible party (a person delegated to make medical decisions for the resident in the event they are unable to do so) prior to the treatment with Cymbalta (a medication used to treat mental illness) in one of five sampled residents (Resident 69) for unnecessary medications. The deficient practice of failing to obtain an informed consent prior to initiating treatment with a psychotropic (medications that affect brain activities associated with mental processed and behavior) medications could have prevented Resident 69 from exercising her right to decline treatment with Cymbalta. [...]

Inspectors wroteBased on interview and record review the facility failed to provide feeding assistance during meals for one of three sampled residents (Resident 69). This deficient practice had the potential not to meet Resident 69's specific needs and had the potential for Resident 69's activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) to decline.

Inspectors wroteBased on interview and record review, the facility failed to ensure that a Pre-admission Screening and Resident Review (PASRR - a federal requirement ensuring people with mental illness, intellectual disabilities, or related conditions are not inappropriately placed in nursing homes) was done for one of five sampled residents (Resident 42) diagnosed with a mental illness prior to admission in the facility. This failure had the potential for Resident 42 not to receive the necessary and appropriate psychiatric evaluation (is a comprehensive mental health assessment by a professional to diagnose emotional, behavioral, or cognitive conditions, guide treatment, and understand a person's overall mental state) and level of treatment at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 79) reviewed for skin care received the care required to prevent pressure ulcer/injury (localized damage to the skin and/or underlying tissue usually over a bony prominence) by failing to: -Ensure to set Resident 79's low air loss mattress (LALM - a medical bed surface designed for immobile patients to prevent or treat bedsores) according to Resident 79's weight. This failure had the potential for Resident 79 to develop pressure injuries and/or worsen skin wounds (injury that break the skin or other body tissues).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident received appropriate treatment and services to prevent urinary tract infections (UTI-an infection in any part of your urinary system, your kidneys, ureters, bladder and urethra) for one of two sampled resident (Resident 9) by failing to:1. Provide an on-going assessment of the use and removal of Resident 9's indwelling foley catheter (foley catheter - a hollow tube left implanted in a body canal or organ, especially the bladder, to promote drainage).2. Review and revise the individualized care plan when Resident 9 had UTI on 3/24/2025 and 09/15/2025.3. Initiate an interdisciplinary team (IDT) review when Resident 9 had UTI on 3/24/2025 and 09/15/2025 and a change of condition on 11/30/2025. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the necessary medication (Biktarvy) used to treat Human Immunodeficiency Virus (HIV- is a virus that attacks the body's immune system. HIV damages the immune system so that the body is less able to fight infection and disease. Without treatment, it can lead to acquired immunodeficiency syndrome- a chronic condition of the disease) was available and administered as ordered by the physician on six consecutive days for one of three sampled residents (Resident 2). This failure resulted in an interruption and delay of treatment for Resident 2, causing emotional and psychological distress for Resident 2, and placed Resident 2 at risk of avoidable decline in health status. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the necessary medication (Biktarvy) to treat Human Immunodeficiency Virus (HIV- a virus that attacks the body's immune system. HIV damages the immune system so that the body is less able to fight infection and disease. Without treatment, it can lead to acquired immunodeficiency syndrome- a chronic condition of the disease) was available and administered as ordered by physician for six consecutive days for one of three sampled residents (Resident 2). This failure resulted in an interruption and delay of treatment for Resident 2, causing emotional and psychological distress for Resident 2, and placed Resident 2 at risk of avoidable decline in health status. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive care plan for one of two sampled residents (Resident 1). For Resident 1 who was assessed on 5/29/25 as at risk for fall, the facility failed to develop a plan of care to address the risk of fall for Resident 1. This deficient practice had the potential to cause a delay or lack of necessary care for Resident 1. During a review of the admission Record indicated the facility admitted Resident 1 on 5/29/25 with diagnoses including diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), dysphagia (difficulty swallowing), lack of coordination and absence of right leg above knee. During a review of the Minimum Data Set (MDS, a resident assessment tool) dated 6/5/25 indicated Resident 1 had moderately impaired cognition. [...]

Inspectors wroteBased on interview and record review the facility failed to update and revise the care plan for one of two sampled residents (Resident 1). For Resident 1, the facility failed to update and revise the care plan when Resident 1 had a fall on 8/18/25 and 8/30/25. This deficient practice resulted in the facility failing to develop and implement new interventions for Resident 1 to prevent future falls.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents received adequate nutrition for one of two sampled residents (Resident 1). For Resident 1, the facility failed to provide interventions when Resident 1 refused to eat on 8/18/25 at 5:30 p.m. and refused to eat all meals on 8/19/25 and 8/23/25. This deficient practice resulted in Resident 1 not meeting his adequate nutritional status. During a review of the admission Record indicated the facility admitted Resident 1 on 5/29/25 with diagnoses including diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), dysphagia (difficulty swallowing), lack of coordination and absence of right leg above knee. During a review of the Minimum Data Set (MDS, a resident assessment tool) dated 6/5/25 indicated Resident 1 had moderately impaired cognition. [...]

Inspectors wroteBased on interview and record review the facility failed to maintain accurate and complete record for one of two sampled residents (Resident 1). For Resident 1 the facility failed to ensure:1. The Fall Risk Assessments dated 8/18/25 and 8/30/25 reflected Resident 1's risk of fall, whether Resident 1 was low risk or high risk for fall. 2. The Fall Risk assessment dated [DATE] accurately reflected that Resident 1 had a history of falls. These deficient practices resulted in an inaccurate and incomplete record for Resident 1. During a review of the admission Record indicated the facility admitted Resident 1 on 5/29/25 with diagnoses including diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), dysphagia (difficulty swallowing), lack of coordination and absence of right leg above knee. [...]

Inspectors wroteBased on interview and record review, the facility failed to prevent the development of pressure injuries and provided care and services consistent with professional standards of practice for one out of three sampled residents (Resident 1) by failing to: 1. Implement interventions to prevent PI (Pressure Injury - localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) development for Resident 1 who was admitted without PI, by not repositioning according to the Care Plan (CP- a document that details an individual's health conditions, treatments, needs, and goals, serving as a blueprint for their healthcare and support services) for quadriplegia dated 6/27/25. No documentation repositioning was done. Resident bedbound.2. Provide pressure-relieving mattresses as indicated in the CP for quadriplegia dated 6/27/25.3. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure their policy for Unusual Occurrence Reporting included major accidents and follow it to report a major accidental fall with injury according to the State and Federal regulations for one of three sampled residents (Resident 1). This deficient practice resulted an outdated policy and procedures being implemented when the facility made the decision not to report a major accidental fall with injury to the State Agency (SA). [...]

Inspectors wroteBased on interview and record review the facility failed to notify the resident's Power of Attorney (POA, allows someone else to manage the personal and financial matters of another person) for one of two sampled residents (Resident 1). For Resident 1, the facility failed to notify Resident 1's POA when Resident 1 had an appointment for Magnetic Resonance Imaging (MRI, medical imaging procedure for making images of the internal structures of the body) on 6/25/25. This deficient practice resulted in Resident 1 and Resident 1's POA not given their right to participate in decision making before services were provided. Findings. During a review of the admission Record indicated the facility admitted Resident 1 on 11/21/24 with diagnoses including dementia (a progressive state of decline in mental abilities), hypertension (high blood pressure) and depression. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to properly use the low air loss mattress (LAL, specialized mattress that prevents pressure ulcers [damage to an area of the skin caused by constant pressure on the area for a long time], according to the professional standard of practice for one of the two sampled residents (Resident 1). During observation on 6/27/25 at 9:20 a.m., Resident 1 had a blue reusable pad ( chux) while lying on the LAL mattress. This deficient practice had the potential to affect Resident 1's comfort level and delay healing of Resident 1's pressure ulcer.

Inspectors wroteBased on interview and record review the facility failed to ensure medications were administered as ordered by the physician for one of two sampled residents (Resident 1). For Resident 1, the facility failed to document medications were administered as soon as given and failed to document the reasons why the medications were not administered. These deficient practices resulted in the facility failing to determine if the medications were administered to Resident 1, prevent the potential for medication errors, medication duplication and delay in care and treatment to meet the needs of Resident 1.

Inspectors wroteBased on interview, and record review, the facility failed to develop individualized person-centered care plan (a plan of care that summarizes a resident's health conditions, specific care and services facility staff need to provide a resident to promote healing and prevent a worsening of a condition, and current treatments) to meet the residents needs for three of six sampled residents (Resident 25, Resident 28 and Resident 45) as evidenced by: 1. Failing to create a care plan with goals and interventions for Resident 25's pressure ulcers (also known as a pressure injury, a localized area of damaged skin or tissue caused by prolonged pressure on the skin). 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to monitor for behaviors and side effects (an effect of a drug or other type of treatment that is in addition to or beyond its desired effect) of antipsychotic medication (medication used to treat certain mental/mood disorders) for two of five sampled residents (Resident 8 and Resident 23) by failing to: 1. Monitor Resident 8 for behaviors and side effects of risperidone (Risperdal, an antipsychotic medication used to treat mental illness). 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe and sanitary environment and safe food storage practices were followed in the kitchen by failing to: 1. Ensure a bag of carrots and a bag of frozen corn was labeled and dated in the freezer. 2. Ensure a plastic bag full of personal clothing and shoes belonging to staff was not stored in the dry food storage area during the initial kitchen visit. 3. Ensure a staff member`s jacket and hat were not hanging on the shelf in the dry food storage area during a follow up visit of the kitchen. These deficient practices had the potential to place the facility residents at risk for foodborne illness (illness caused by food contaminated with bacteria, viruses, and other toxins) and the growth of harmful bacteria and cross contamination (transfer of harmful bacteria from one place to another).

Inspectors wroteBased on observation and interview, the facility failed to store the following food brought in by visitors in accordance with the facility's policy by not labeling items with the resident's name and the date it was brought to the facility: a. Three cartons of Almond Breeze. b. One plastic container of string cheese. c. One plastic bottle of Gatorade. d. One carton of Ensure original. e. One plastic container of clover honey. This deficient practice had the potential to result in the risk of food borne illness (illness caused by food contamination with bacteria, viruses, parasites, or toxins).

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident's oral status was assessed comprehensively for one of one sampled resident (Resident 40). This deficient practice may result in a failure to meet Resident 40's oral health needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 25), who had pressure ulcers (also known as a pressure injury, a localized area of damaged skin or tissue caused by prolonged pressure on the skin), was assessed quarterly using the Braden scale assessment (a tool used to assess a patient's risk of developing pressure ulcers). This deficient practice caused an increased risk in assessing a significant change to Resident 25's skin integrity.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the Minimum Data Set (MDS - a resident assessment tool) was transmitted timely to the Centers for Medicare and Medicaid Services (CMS) system for one of one sampled resident (Resident 3). This deficient practice had the potential to result in delayed services for the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to set the resident's Low Air Loss Mattress (LALM - a pressure-relieving mattress used to prevent and treat pressure injuries) to the correct setting for one of one sampled residents (Resident 23) investigated under the pressure ulcer/injury (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) care area. This deficient practice had the potential to place the resident at risk for discomfort and the development of pressure ulcers/injuries.

Inspectors wroteBased on interview and record review, the facility failed to ensure that one of three sampled residents (Resident 35) received the necessary care and services to prevent accidents and falls by failing to: 1. Revise Resident 35`s fall care plan (a plan of care that summarizes a resident's health conditions, specific care needs, and current treatments) after Resident 35 fell on 7/31/2024 and 10/16/2024. 2. Assess Resident 35 accurately when developing fall risk assessments. These deficient practices placed Resident 35 at an increased risk for recurrent falls.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure latanoprost eye drops (a medication that required refrigeration and used to treat glaucoma) were stored in the refrigerator per the manufacturer's requirements for one resident (Resident 10) in one of one inspected medication carts (Medication Cart 1). The deficient practice had the potential to result in an increased risk that Resident 10 could have received medication that had become ineffective or toxic due to improper storage possibly leading to health complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its policy and procedure titled, Installation of Eye Drops (putting eye drops into residents' eyes) by failing to ensure Licensed Vocational Nurse 1 (LVN 1) washed and dried her hands thoroughly before treating each eye while administering eye drops to one (Resident 24) out of five residents investigated during a review of the infection control task. This deficient practice had the potential to cause cross contamination (unintentional transfer of bacteria/germs or other contaminants from one surface to another) infection (occurs when harmful microorganisms, such as bacteria or viruses enter the body and multiply) between Resident 24's eyes.

Inspectors wroteBased on interview and record review the facility failed to provide range of motion (ROM, activity aimed at improving movement of a specific joint) exercises as ordered by the physician for two of three sampled residents (Resident 2 and Resident 3). For Resident 2 and Resident 3, the facility failed to: 1. Ensure the restorative nursing assistants (RNA, assist recovering residents to regain physical and cognitive capabilities through mobility and exercises) provided ROM exercises to Resident 2 and Resident 3 daily five times a week as ordered by the physician. Resident 2 and Resident 3 did not receive ROM exercises on 11/5/24, 11/7/24 and 11/12/24. 2. Create care plan that would address the restorative needs of Resident 2 and Resident 3. [...]

Inspectors wroteBased on interview and record review the facility failed to develop a person-centered care plan after a change in condition (CIC - clinically important deviation from a patient ' s baseline in physical, cognitive, behavioral, or functional domains that, without intervention, may result in complications or death) for one of four sampled residents (Resident 1). On 8/20/24, Resident 1 alleged that a person came into Resident 1 ' s room and placed a hand over Resident 1 ' s mouth. The facility failed to create a care plan that will address Resident 1 ' s allegations and the interventions and services that would be provided to Resident 1. This deficient practice had the potential for the facility not to meet the needs of Resident 1.

Inspectors wroteBased on interview and record review the facility failed to provide the necessary social services for one of four sampled residents (Resident 1). For Resident 1, the facility failed to provide social services to Resident 1 who made allegation on 8/20/24 that a person went into her room and placed a hand to cover Resident 1 ' s mouth. This deficient practice had the potential to affect Resident 1 ' s psychosocial well-being and ensure that Resident 1 felt safe.

Inspectors wroteBased on interview and record review the facility failed to maintain medical records that were accurate and concise for one of four sampled residents (Resident 1). On 8/21/24 at 7 a.m., the Nurses Progress Notes indicated Resident 1 alleged that a staff member physically assaulted Resident 1. The registered nurse supervisor (RNS 1) stated Resident 1 ' s allegation that a staff member physically assaulted Resident 1 was wrong. This deficient practice resulted in the inaccurate medical record for Resident 1.

Inspectors wroteAmended on 4/22/2025 Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse (deliberate, aggressive, or violent behavior with the intention to cause harm) for one of two sampled residents (Resident 1), when on 6/26/2024 Resident 2 hit Resident 1 on the nose causing pain and redness to the nose. Resident 1 was subjected to abuse and psychosocial (mental health) harm by Resident 2, while under the care of the facility.

Inspectors wroteBased on interview and record review, the facility failed to developo a care plan (a document outlining a detailed approach to care customized to an individual resident's need) for psychotropic (a medication that affects behavior, mood, thoughts, or perception) medication for one of four sampled residents (Resident 2). This deficient practice had the potential to result in Resident 2 not receiving the appropriate care and to experience adverse (harmful) side effects which could result in injury.

Inspectors wroteBased on interview and record review, the facility failed to obtain informed consent (a communication between a patient and physician that results in the patient's authorization or agreement to undergo a specific medical intervention or treatment) for an increase in the dosage of Fluvoxamine Maleate [a medication used to treat depression (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily activities of living), with side effects that include nausea, diarrhea, tremors, seizures, fast heartbeat, insomnia (trouble sleeping), and restlessness] for one of four sampled residents (Resident 1). This deficient practice had the potential to result in Resident 1 not being informed about the medications Resident 1 was receiving and had the potential to cause the resident to experience adverse (harmful) side effects of the medication.

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of five sampled residents (Resident 1) diagnosed with unspecified dementia (loss of cognitive functioning-thinking, remembering, and reasoning) and major depressive disorder (a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once brought joy) severe with psychotic symptoms (a collection of symptoms, including delusions [false beliefs, for example, that people on television are sending them special messages or that others are trying to hurt them] and hallucinations [seeing or hearing things that others do not, such as hearing voices telling them to do something or criticizing them] which happen when a person experiences a disconnection from reality) with a court delegated durable power of attorney (POA - authorizes someone else to handle certain [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a safe, comfortable, and homelike environment by failing to ensure residents ' rooms were kept with comfortable sound levels maintained for two of six sampled residents (Resident 5 and Resident 6). This deficient practice placed Resident 5 and 6 an increased level of discomfort and inability to sleep during the night that had the potential to negatively impact the resident ' s quality of life. Cross Reference F656.

Inspectors wroteBased on interview and record review, the facility failed to implement a comprehensive care plan (CP) that met the care/services based on the resident's individual assessed needs for three of seven sampled residents (Resident 1, Resident 5, and Resident 6) regarding Resident 5 and 6 ' s inability to sleep and complained due to Resident 1 ' s noise at nighttime. This deficient practice had the potential to result negative impact on residents ' health and safety, as well as the quality of care and services received. Cross Reference F584.

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) who was a smoker was assessed for their ability to smoke safely prior to being allowed to smoke independently while in the facility. This deficient practice had the potential for fire related accidents in the facility among residents, staff and visitors.

Inspectors wroteBased on observation, interview and record review the facility failed to have the call light (a mechanism used by residents to promptly communicate with staff) within reach for two of five sampled residents (Resident 2 and 3). This deficient practice had the potential to result in an accident and/or injury.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents had specific choices and treatments communicated through an Advance Directives and copies of the Advance Directives (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) were maintained in the Resident's clinical record for four of forty-three Residents (Resident 2 , 28, 38 and 56). This deficient practice had the potential to cause conflict with a resident's wishes regarding health care for Residents (2, 28, 38 and 56).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure therapeutic diets were served as prescribed by the physician for three of ten sampled residents (Residents 23, 25, and 41). These deficient practices had the potential to result in the risk for decreased nutritional intake and weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe and sanitary environment, including food storage practices in the kitchen, as evidenced by: -Observation of visible dirt and stains on the dish washing machine. -Failing to label and date an open bag of grapes and cilantro in the refrigerator and a bag of shredded cheese inside the freezer. These deficient practices had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness or infection.

Inspectors wroteBased on interview, and record review, the facility failed to follow its Informed Consent, policy and procedure (a process by which residents or their responsible parties have the choice to accept or decline certain medication therapy or treatments once they are educated about the risks and benefits) for two of five sampled residents (Resident 22 and 25) by failing to: -Ensure the facility obtained Resident 22's signature for declination of the COVID-19 (Coronavirus disease 2019 is an infectious disease caused by virus that can result in different symptoms from mild to severe respiratory illnesses and is spread during close contact and through the air from person to person) vaccination. [...]

Inspectors wroteBased on interview, and record review, the facility failed to inform a Medicare and/or Medicaid eligible resident of changes made to services covered by Medicare and/or Medicaid prior to the last covered day for one of three sampled residents (Residents 50). This deficient practice had the potential to result in Resident 50 not being provided the information needed to decide to continue or refuse receiving the specific skilled services and have those options honored.

Inspectors wroteBased on interview, and record review, the facility failed to develop an individualized person-centered care plan to meet the residents' need for two of five sampled residents (Resident 30 and 38). For Resident 30 the facility failed to develop a care plan with goals and interventions for Urinary Tract Infection (UTI- an infection in any part of the urinary system). -For Resident 38, the facility failed to develop a care plan with goals and interventions when the resident refused to receive the influenza (a high contagious viral infection of the respiratory passages), and COVID-19 (Coronavirus disease 2019 is an infectious disease caused by virus that can result in different symptoms from mild to severe respiratory illnesses and is spread during close contact and through the air from person to person) vaccinations. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received proper assistive devices to maintain hearing abilities by not providing both hearing aids for one of one sampled resident (Resident 18). This deficient practice had the potential to result in resident's needs not being provided and not being able to hear adequately during a conversation.

Inspectors wroteBased on observation, interview and record review, the facility failed to change the oxygen tubing for one of 21 sampled residents (Resident 38). This failure had the potential to result in a respiratory tract infection (an infection that affects the part of your body responsible for breathing) for Resident 38.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 55) who was receiving hemodialysis (HD-a medical procedure to remove fluid and waste products from the body) had an emergency kit (supplies can be used to stop bleeding during emergency) at his bedside. This deficient practice had the potential to result in the resident to receive delayed interventions during accidental bleeding.

Inspectors wroteBased on observation, interview and record review, the facility failed to post daily the Direct Care Service Hours Per Patient Day (DHPPD - refers to the actual hours of work performed per patient day by a direct caregiver) actual hours worked by licensed staff providing direct care to the residents per shift. As a result, residents and visitors did not know the accurate number of hours of staff working.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of 21 sampled residents (Resident 45) was free of an unnecessary psychotropic (acting on the mind) medication. This deficient practice resulted in Resident 45 receiving Quetiapine (generic name Seroquel, a medication to treat mental and mood disorders) without a clinical indication or reason for use.