Anaheim Healthcare Center, LLC

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services for three sampled residents (Residents 1, 2, and 3) reviewed for ADL care. * The facility failed to ensure a care plan were develop when Residents 1, 2, and 3 refused showers on their scheduled shower days. In addition, the facility failed to document interventions and notify the responsible party of Resident 1, 2, and 3's refusals. * The facility failed to complete Resident 3's shower skin inspection sheets. These failures had the potential for the residents' need not to be met and for the residents to experience physical discomfort.

Inspectors wroteBased on interview, document review, and medical record review, the facility failed to ensure the residents or their representatives were informed in advance of the proposed treatment regarding the use of psychotropic for two of five residents (Residents 6 and 13) reviewed for unnecessary medications and three of 35 final sampled residents (Residents 10, 214, and 238). * The facility failed to ensure Resident 6's informed consents for the trazodone (antidepressant) medication included the indication for use and duration of use, and for the Buspar (antianxiety) medication included the duration of use. In addition, the facility failed to obtain informed consent for the use of the PRN lorazepam (antianxiety) medication for Resident 6. [...]

Inspectors wroteBased on observation, interview, medical record review, and P&P review, the facility failed to maintain a safe, clean, and homelike environment for three of 35 final sampled residents (Residents 5, 6, and 14) and two nonsampled residents (Resident 26 and 171). * The facility failed to ensure a homelike environment was provided for Residents 5 and 26 who were residing in Room A. Resident 5's closet door was observed in disrepair with peeled paint and the bottom left corner of the closet door was observed chipped and missing. Additionally, the wall behind Resident 26's bed was observed with chipped paint. * The facility failed to ensure a homelike environment was provided for Residents 6 and 171 who were residing in Room B. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the residents were free from unnecessary psychotropic drugs for two of five residents (Residents 3 and 152) reviewed for unnecessary medication and three of 35 final sampled residents (Residents 15, 212, and 214). * The facility failed to ensure the behaviors related to the use of quetiapine fumarate (antipsychotic), fluphenazine (antipsychotic), and sertraline (antidepressant) medications were monitored for Resident 3. In addition, the facility failed to ensure nonpharmacological interventions were provided prior to the use of sertraline medication for the resident. * The facility failed to ensure non-pharmacological interventions were provided prior to the use of olanzapine (antipsychotic) medication for Resident 15. [...]

Inspectors wroteBased on interview, medical record review, and P&P review, the facility failed to revise the comprehensive care plan for four of 35 final sampled residents (Residents 10, 80, 174, and 238). * The facility failed to ensure Resident 10's care plan for pain and use of pain medication was revised to address the use of nonpharmacological interventions prior to the administration of the pain medications. * The facility failed to ensure Resident 80's care plan was revised to reflect the resident's use of oxygen. * The facility failed to ensure Resident 174's comprehensive care plan was revised to reflect Resident 174's current fluid restriction of 1200 ml per day. * The facility failed to ensure Resident 238's care plan intervention for the mirtazapine (antidepressant) medication was revised to show the correct behavior manifestation. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary quality of care and services were provided for three of 35 final sampled residents (Residents 6, 11, and 15). * The facility failed to ensure the injection sites for the insulin (medication to control blood glucose levels) administration were rotated for Residents 6 and 11. These failures had the risk for lipodystrophy (buildup of fatty lumps) and decreased insulin absorption. * The facility failed to ensure Resident 15 was continuously monitored when the resident had a change in condition related to weight loss. These failures had the potential for the residents to not receive the necessary care and services and negatively affect the residents' well-being.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and P&P review, the facility failed to ensure three of four final sampled residents (Residents 1, 4, and 15) received the appropriate services needed to maintain acceptable parameters of nutritional status. * The facility failed to implement a systematic approach to ensure effective monitoring of acceptable parameters of nutritional status when Resident 1 experienced severe weight loss. The severe weight loss of -24 lbs. was not assessed and monitored by the IDT. In addition, the facility failed to ensure the physician was notified and the resident's centered plan of care was revised related to Resident 1's severe weight loss. Resident 1 who had severe weight loss and poor PO intake ultimately received a GT placement. [...]

Inspectors wroteBased on observation, interview, medical record review, and P&P review, the facility failed to provide the necessary care and services related to GT feeding for four of four final sampled residents (Residents 6, 11, 130, and 238) reviewed for tube feedings. * The facility failed to ensure Residents 6, 11, and 238 were administered the complete dose of the GT enteral feeding and water flushes as per the physician's order. * The facility failed to ensure Resident 130 was administered the complete dose of GT enteral feeding and water flushes as per the physician's order. In addition, the facility failed to follow the RD recommendations to increase the GT enteral feeding. These failures had the potential to not meeting the residents' nutritional needs and put the residents at risk for weight loss and/or dehydration.

Inspectors wroteBased on observation, interview, medical record review and facility P&P review, the facility failed to provide the necessary pain management care and services for four of 35 final sampled residents (Residents 3, 22, 152, and 214) reviewed for pain management. * The facility failed to ensure the nonpharmacological interventions were provided and documented to Residents 3 and 214 prior to administering the pain medications. * The facility failed to accurately document the pain level as ordered by the physician when pain medication was administered to Resident 22. * The facility failed to ensure pain medication was administered as per physician's order for Resident 152's complaint of 9/10 pain. In addition, the facility failed to ensure the non-pharmacological pain interventions were implemented and documented before the resident was administered pain medication. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services for three of three final sampled residents reviewed for hemodialysis (Residents 8, 158, and 174). * The facility failed to ensure Resident 8 and 158's fluid intake were monitored accurately. In addition, the facility failed to ensure Resident 8 and 158's hemodialysis access were monitored accurately * The facility failed to ensure Resident 174 was monitored for any extra fluids at bedside, and the appropriate emergency kit was provided for the resident who has a Permacath. These failures had the potential to result in accurate assessment of fluid status, complications associated with fluid overload, and delayed intervention in the event of a dialysis access emergency.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the kitchen employees had the appropriate competencies and skill sets to carry out the functions of the food and nutrition services department. 1. Two of 32 kitchen employees (DAs 1 and 2) failed to follow proper manual ware washing procedures. 2. One of 32 kitchen employees (Cook 2) failed to show competency in checking the sanitizing solution concentration. 3. Two of 32 kitchen employees (DA 1 and [NAME] 1) failed to perform proper hand hygiene. These failures had the potential for cross contamination and food preparation equipment, dishware, and utensils not to be cleaned and sanitized correctly.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure food safety and sanitation guidelines were followed when: 1. The cool down process for time, temperature control for safety (TCS) food, food that needs to be kept at specific temperatures to prevent bacteria growth and foodborne illnesses, was not monitored.2. Two of 32 kitchen employees failed to perform proper hand hygiene.3. The thawing process for fish and meat was not followed.4. The manual ware washing process was not followed.5. The kitchen utensils and equipment were not clean and were not stored in a sanitary manner.6. One of 32 kitchen employees failed to don an appropriate hair restraint.7. Food service equipment was not air-dried.8. Five cutting boards were heavily marred, and one was not clean.9. Two can opener blades were heavily worn and were not clean. [...]

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure safe food handling of the food brought for the residents from outside sources. * The facility failed to ensure the visitors and family members were educated on safe food handling practices when bringing food from outside sources. This failure had the potential to cause foodborne illness to the medically vulnerable resident population who consumed food [NAME] from outside resources.

Inspectors wroteBased on interview and facility document review, the facility failed to ensure the Facility Assessment addressed or included the following:1. Active involvement of required individuals in developing the Facility Assessment;2. A plan to maximize recruitment and retention of direct care staff; and3. A contingency plan for staffing needs. These failures had the potential not to meet the residents' care needs if the assessed population's needs and resources were not comprehensively identified and addressed.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to implement the facility's infection prevention and control program in accordance with the facility's P&P. * The facility failed to maintain an accurate infection control surveillance program for January 2026 through May 2026. * The facility conducted surveillance based solely on whether the residents' were prescribed antimicrobial medications. * The facility failed to include the residents who exhibited signs and/or symptoms of infection but were not prescribed antimicrobials on the surveillance report. [...]

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to accurately monitor and address the use of the antibiotics for one final sampled resident (Resident 1) and nine nonsampled residents (Residents 21, 37, 55, 104, 243, 244, 245, 246 and 247) reviewed for antibiotic stewardship. * The facility failed to ensure the Infection Screening Evaluation and Antibiotic Time Out were conducted when Resident 1 was prescribed an antibiotic therapy. * Residents 21, 37, 55, 104, 243, 244, 245, 246, and 247 who did not meet the McGeer's criteria (a set of specific definitions to identify true infections in long term nursing facilities) were prescribed antimicrobial therapy. [...]

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to offer and provide education for the pneumococcal immunizations for three of five final sampled residents (Residents 5, 11, and 69) reviewed for immunizations. * The facility failed to ensure Residents 11 and 69's consent for the pneumococcal vaccination specified the type of pneumococcal vaccine to be administered. * Resident 5's consented for the pneumococcal 21 (type of pneumococcal vaccine) vaccine; however Resident 5 was administered the Prevnar 20 (type of pneumococcal vaccine) vaccination. These failures had the potential for the residents and/or their representatives not being fully informed of the pneumococcal vaccines and to not be aware of the exact type of pneumococcal vaccine being offered by the facility.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to maintain the essential equipment in safe operating condition when the ice machine manufacturer guidelines for sanitizing the ice machine and ice storage bin were not followed. This failure created the potential for the residents to receive ice from the kitchen that was not adequately clean for safe consumption.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to determine if the residents were safe to self-administer the medications left at the bedside for two of 35 final sampled residents (Residents 49 and 113). * The facility failed to ensure it was safe for Resident 49 to self administer the vitamin C (supplement) medication observed at bedside. Additionally, there was no physician's order or care plan problem developed to address the resident's self administration of this medication. * The facility failed to ensure it was safe for Resident 113 to self-administer refresh eye drop (used to lubricate and instantly soothe dry, burning and irritated eyes) medication observed at the bedside. In addition, there was no physician's order, assessment or care plan for the self-administration of the medications. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the physician was informed of a change of condition for one or three final sampled residents (Resident 1) reviewed for nutrition. * The facility failed to notify Resident 1's physician and the resident's responsible party of the 24 lbs. (16.56%) weight loss from 12/2/25 to 4/1/26. This failure had the potential for Resident 1 to not received the necessary care and treatment to manage the resident's weight loss.

Inspectors wroteBased on interview, medical record review, and P&P review, the facility failed to ensure the MDS assessment was accurate for three of 35 final sampled residents (Residents 1, 11, and 183) reviewed for MDS. * The facility failed to ensure the MDS assessment was accurately coded related to Resident 1's weight loss of 5% in one month or 10% in six months. * The facility failed to ensure the MDS assessment was accurately coded related to Resident 11's use of the hypoglycemic (including insulin) medication. Additionally, the facility coded Resident 11's MDS for the use of the anticonvulsant medication; however, Resident 11 was not prescribed any anticonvulsant medication. * The facility failed to ensure the MDS assessment was accurately coded related to Resident 183's use of enoxaparin (blood thinner medication) subcutaneously. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to develop a comprehensive person-centered care plan for one of 35 final sampled residents (Resident 4). * The facility failed to ensure a care plan was developed to address Resident 4's impaired communication related to bilateral hard of hearing and use of the bilateral hearing aids. This failure had the potential for the resident to receive inconsistent, inappropriate, and inadequate care.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure one of four final sampled residents (Resident 10) reviewed for pressure injury were provided with the necessary care and services. * The facility failed to ensure Resident 10's LAL mattress setting was accurate to the resident's weight and was not in static mode while the resident was in bed. These failures had the potential for the resident not to receive the appropriate care and services to promote the skin healing.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the respiratory services in a safe and sanitary manner in accordance with the facility's P&P for one of three final sampled residents (Resident 80) reviewed for the respiratory care.* The facility failed to ensure Resident 80 had a physician's order for the use of oxygen. In addition, the facility failed to ensure the oxygen tubing was labeled and the signage Oxygen In Use was posted on Resident 80's door. These failures had the potential to result in negative health outcomes for a highly vulnerable resident population due to poor infection control practices and the administration of oxygen therapy without a physician's order.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure safe and effective pharmaceutical services for one of 35 final sampled residents (Resident 152) and one nonsampled resident (Resident 110). * A delayed-release medication was crushed and administered to Resident 152. This failure had the potential to release all the medication into the body at once, causing toxicity and preventable resident harm. * A nebulizer treatment was not administered at the right time to Resident 110 in accordance with the manufacturer's specifications (requirements). This failure had the potential for the ineffective use of the drug which could result in fluctuations (uneven) drug levels in the body leading to increased risk of side effects or subtherapeutic treatment with the resident experiencing breathing problems.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the Pharmacist Consultant identified and reported all irregularities during the monthly medication regimen for one of 35 final sampled residents (Resident 8) and one nonsampled resident (Resident 110). * The facility failed to ensure the consultant pharmacist identified and reported a medication irregularity for Resident 110's roflumilast medication (used in adults to decrease the number of flare-ups (exacerbations) in severe (COPD) chronic obstructive pulmonary disease) dose. * The facility failed to ensure the Pharmacy Consultant's recommendation to inform physician about Resident 8's elevated systolic blood pressure readings was acted upon. These failures had the potential for the residents to experience adverse outcomes.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of 35 final sampled residents (Resident 113) and one nonsampled resident (Resident 110) were free from the unnecessary medications. * The facility failed to follow the physician's order to hold the atenolol (antihypertensive) and benazepril (antihypertensive) medications when Residents 113's pulse rate was below 70 beats per minute. * The facility failed to ensure the potassium levels were closely monitored for Resident 110 who was receiving at the same time the medications potassium chloride oral solution and an ACE inhibitor (antihypertensive). These failures had the potential for the residents to receive unnecessary medications and develop significant side effects.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure safe medication labeling practices in accordance with accepted professional standards. * Three opened eye drop bottles and an opened nasal spray bottle were not properly labeled with sufficient information to clearly identify the specific resident for Residents 108, 109, 195, and 212 in Medication Carts A and B. This failure had to potential to cause medication errors and preventable infections from cross-contamination from other residents if accidently mixed up with other residents similar or same drugs.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure:* Federal regulations related to the education qualification requirements of the dietary manager were followed as outlined in the California Code, Health and Safety Code (HSC 1265.4), * The Dietary Manager was competent in managing the day-to-day functions of the food and nutrition department and,* The Registered Dietitian provided an adequate oversight of the day-to-day functions of the food and nutrition department. [...]

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to offer and provide education for the COVID-19 vaccine for one of five final sampled residents (Resident 11) reviewed for immunizations. * The facility failed to ensure Residents 11's informed consent for the COVID-19 vaccination specified the type of COVID-19 vaccine to be administered. This failure had the potential for the resident and/or the resident's representatives not being fully informed of the COVID-19 vaccines and to not be aware of the exact type of COVID-19 vaccine being offered by the facility.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of four sampled residents (Resident 4) received the appropriate care and services related to the use of an indwelling urinary catheter (a thin, flexible tube inserted into the bladder to collect and drain urine). *The facility failed to ensure Resident 4's urinary drainage bag and tubing were not touching the floor. This failure posed the risk for the growth of bacteria causing urinary tract infections (an illness in any part of the urinary tract, the system of organs that makes urine).

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of four sampled residents (Resident 4) was treated with dignity and respect related to the use of an indwelling urinary catheter (a thin, flexible tube inserted into the bladder to collect and drain urine). * The facility failed to ensure the urinary drainage bag (a medical device connected to the indwelling urinary catheter which collects and stores urine from the body) for Resident 4 was placed inside the privacy bag (a bag used to cover and hold the catheter drainage/collection bag) to provide privacy. This resulted in Resident 4's urine contents inside the urinary drainage bag visible to everyone going inside the resident's room. This failure had the potential to affect the privacy and dignity of the resident.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to maintain the infection control practices to help prevent the transmission of diseases and infections for one of five sampled residents (Resident 3) . * The facility failed to ensure the staff wore a PPE when entering the room of Resident 3 who was on contact precautions for C. diff infection. Additionally, the facility failed to ensure the correct signage was posted at Resident 3's door. This failure placed the resident and staff at risk for infection and the transmission of disease-causing microorganisms.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the food was served palatable and at an appetizing temperature for four of four sampled residents (Residents 1, 2, 3, and 4). This failure resulted in the residents not enjoying their food which potentially will impact the residents' nutritional status.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the menus were followed for one of four sampled residents (Resident 4) who received food prepared in the kitchen. * Resident 4 was not served the choice of breakfast meat or seasonal fruit cup as per the menu. This failure had the potential for the resident to not receive adequate nutrition and appropriate servings to meet the resident's individual needs.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the medical record was accurate and complete for one of five sampled residents (Resident 1). * Resident 1's informed consent for a bolster pillow was not signed by the provider who had obtained the informed consent. In additon, there was no physician's order for the use of the bolster pillow. This failure had the potential for the resident's care needs not being met as their medical information was inaccurate and incomplete.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to ensure one of three sampled residents (Resident 1) attained and maintained the highest practicable physical well-being. * The facility failed to ensure Resident 1's colostomy bag was emptied according to the standards of practice when CNA 1 poured hot water in the colostomy bag. While the hot water was being poured, the colostomy bag touched the resident's skin, resulting in Resident 1 sustaining a burn on the left thigh and requiring pain medication administration and wound treatment. This failure had caused the burn to the resident's skin and the resident to experience pain and need wound treatment.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the nurse aide was able to demonstrate competency in skills and techniques necessary to care for the residents' needs as identified through resident assessments and described in the plan of care. * The facility failed to ensure the nursing staff' competency on how to empty Resident 1's colostomy bag. This failure caused Resident 1 to sustain a burn on the left thigh and had the potential for adverse outcomes to the resident. [...]

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the lunch meals were provided to the residents at the scheduled mealtime for 196 of 216 residents residing in the facility, who received food prepared in the kitchen. This failure led to the residents experiencing hunger, frustration, and aggravation; and had the potential to affect the medications scheduled to be administered in accordance with food consumption, which posed the risk for negative health outcomes.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the food safety requirements were met in the kitchen as evidenced by: * Defrosted meat stored in the walk-in refrigerator was not labeled with a pull date or use by date. * Several veggie sausage patties were stored in the walk-in refrigerator past the use by date. * The walk-in refrigerator wall and floor were observed with dirt. * Food debris was observed on the bottom of the facility's dairy refrigerator. * Unlabeled food items were observed in the facility's snack refrigerator. * The facility failed to store a plastic rice scoop in a sanitary manner. These failures had the potential to cause food borne illnesses in a medically vulnerable population of residents who consumed food from the kitchen.

Inspectors wroteBased on interview, record review, and facility P&P review, the facility failed to ensure the accurate and complete consents were obtained for three of 35 final sampled residents (Residents 11, 76, and 117) and two nonsampled residents (Residents 75 and 193). * Residents 75, 117, and 193's consents were not signed appropriately as per the facility's P&P. * Residents 11 and 76's informed consents were not completed to include the date and signature of the person who placed the call; date when the eligible provider or clinician signature signed; date and name/signature of witness; and date and signature of the resident/POA, the name of the two licensed nurses who signed on the consents and the resident/resident's representative name and signature and date. This failure had the potential for violating the residents' rights of not being fully informed of the medications and treatments.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the comprehensive care plan was revised for one of 35 final sampled residents (Resident 80). * The facility failed to ensure Resident 80's comprehensive care plan was revised to reflect a physician's order for one-to-one feeding assistance for aspiration precautions. This failure placed the resident at risk for not being provided appropriate, consistent, and individualized care.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure necessary care and services were provided to five of 35 final sampled residents (Residents 44, 59, 79, 117, and 197). * Resident 117's monitoring for orthostatic hypotension (a sudden drop in blood pressure when a person stands up from a seated or lying position. This drop in blood pressure can cause symptoms like dizziness, lightheadedness, blurred vision, or even fainting.) was not being conducted correctly, and the physician's order did not have parameters for when to notify the physician. * Resident 44's physician's order for monitoring the orthostatic hypotension did not have parameters for when to notify the physician. * The facility failed to follow Resident 197 physician's order to provide one-to-one feeding assistance during meals. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 35 final sampled residents (Resident 80) remained free from accident hazards. * The facility failed to provide one-to-one feeding assistance for aspiration precautions during lunch for Resident 80 as per the physician's order. Resident 80 was observed consuming lunch independently, without the facility staff present and outside of the facility staff view. This failure had the potential to place the resident at risk for serious injury and negative health outcomes.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the respiratory care and services were provided for three of three final sampled residents (Residents 74, 81, and 83) and one nonsampled resident (Resident 70) reviewed for respiratory care. * The facility failed to ensure Resident 74's nebulization mask, tubing, and canister were labeled. * The facility failed to ensure the suction canister with tubing and Yankauer suction tip (an oral suctioning tool) at Resident 81's bedside were labeled and stored in a set-up bag. The facility failed to ensure the physician's order for the oxygen therapy was followed for Resident 81. In addition, there was no documentation of the oxygen administration. * Resident 83 received oxygen therapy without a physician's order. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure pharmaceutical services were provided to meet the needs for one final sampled resident (Resident 59) and two nonsampled residents (Residents 118 and 574) reviewed. * The facility failed to ensure the narcotic medication for Resident 118 was accurately signed out, documented and disposed of per the facility's P&P. * The facility failed to ensure Resident 574's order for docusate sodium (bowel movement medication) was followed as ordered by the physician. * The facility failed to ensure Resident 59's hypertension medication was held when the SBP below 130 mmHg. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure four of 35 final sampled residents (Resident 65, 76, 81, and 197) reviewed were free from unnecessary medications. * The facility failed to ensure the non-pharmacological interventions were implemented for Resident 197 use of aripiprazole medication. * The facility failed to ensure the non-pharmacological interventions were implemented for the depression and anxiety behaviors exhibited by Resident 81. * The facility failed to ensure the non-pharmacological interventions, AIMS assessment, and specific side effects monitoring for Abilify were assessed for Resident 65. * The facility failed to ensure Resident 76 was properly assessed and monitored related to the use of antipsychotic medication. [...]

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure the proper storage and disposal of the medications as evidence by the following: * The facility failed to ensure the arformoterol (medication used to treat chronic obstructive pulmonary disease) medication found in Medication Cart E and Medication Cart F were stored as per the manufacture's storage instructions. * The facility failed to ensure the medical supplies/items that were expired in Medication Carts G and H, and Medication Storage Room B were discarded and/or properly disposed. * The facility failed to ensure Medication Carts B and C was maintained in clean sanitary condition. [...]

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the facility's posted meal Week at A Glance menus met Resident 17's needs. * The facility failed to follow Resident 17's item request of tuna melt during lunch meal was served. This failure placed Resident 17 at risk of not receiving the meal as planned.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the food preference was honored for one nonsampled resident (Resident 173). This failure had the potential for poor meal intake and negatively impact Resident 173's psychosocial well being

Inspectors wroteBased on interview, medical record review and facility P&P review, the facility failed to ensure the complete and accurate medical records for five of 35 final sampled residents (Residents 50, 106, 117, 574, and 674) and two nonsampled residents (Residents 75 and 193). * Residents 75, 117, and 193's H&P examinations showed the residents had no capacity to make medical decisions; however, their face sheets showed they were self-responsible. * Resident 117's Physician Progress Note showed the resident's cognitive level was reevaluated and showed they had capacity, and to update the H&P examination. However, the H&P examination was not updated. * The facility failed to ensure the hold parameters of Resident 574's metoprolol tartrate (blood pressure medication) were accurate. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the arbitration agreement was explained and agreed with the appropriate IDT members for three of three residents reviewed for arbitration agreements (nonsampled residents, Residents 75 and 193; and final sampled resident, Resident 117). This failure posed the risk for the resident to not have the right to file an appeal if there was any issue of medical malpractice.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to implement their infection control program in accordance with the facility's P&P and accepted standards of care. * LVN 11 and CNA 1 failed to follow proper infection control when entering and leaving resident rooms under contact/droplet precautions. * There was a piece of paper trash and staff personal item observed in the clean linen area. * The facility's infection control surveillance did not include residents with signs/symptoms of infection. * The facility failed to ensure the staff wore proper PPE for a COVID-19 isolation room. * The facility failed to ensure the staff wore proper PPE when administering medications via GT. * The facility failed to ensure the staff sanitized the stethoscope after use. * The facility failed to ensure Resident 676's urinal was properly stored. [...]

Inspectors wroteBased on interview, facility document review, and facility P&P review, the facility failed to maintain the accurate and complete antibiotic stewardship program designed to reduce the use of unnecessary antibiotics. * The facility failed to properly assess and document signs and symptoms of infection in their infection screening evaluation component of their antibiotic stewardship review. The infection screening evaluation component of antibiotic stewardship also lacked clear guidelines as to how many criteria must be met to be considered true infection and escalate those instances where true infection may be undiagnosed or showing no clinical improvement. This failure has the potential to impair the physiological well being of the residents in the facility. [...]

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure two of five final sampled residents (Residents 127 and 160) reviewed for Influenza and pneumococcal immunizations were administered with the vaccine. * The facility facility did not administered the pneumococcal vaccine (a vaccine to protect against infection by pneumococcal bacteria) to Resident 127) * The facility facility did not administered the influenza vaccine to Resident 160. These failures posed the risk for the residents of contracting pneumococcal disease and influenza.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the COVID vaccine was administered to one of five final sampled residents (Resident 160) reviewed for immunization. * The facility failed to ensure COVID -19 vaccine was administered to Resident 160. This failure had the potential to put the resident and staff at risk for increased infection and transmission of COVID-19 infection.

Inspectors wroteBased on observation and interview, the facility failed to ensure the accuracy of documentation on the Blood Glucose Monitoring System Quality Control Record for Medication Cart C. This failure had the potential risk of inaccuracy for the glucose test results.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one nonsampled resident (Resident 173) was provided with the necessary care in the manner that promoted dignity and respect. * The facility failed to provide the meal tray to Resident 173 at the same time with other residents during lunch in the dining room. This failure had the potential to not treat the resident with respect.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the privacy was provided for one of two nonsampled residents (Resident 179) with GT during the medication administration observation. * The privacy curtain was not pulled completely in Resident 179's room when the licensed nurse administered the medications via GT. This failure had the potential to negatively affect the dignity of the resident and violate the resident's rights to privacy.

Inspectors wroteBased on observation and interview, the facility failed to maintain a homelike environment for one nonsampled resident (Resident 72). * Resident 72 resided in Room A. Room A closet drawer was observed in disrepair as evidenced by chipped paint and unpainted areas. This failure had the potential to negatively impact the resident's quality of life.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the MDS was coded accurately for one of one nonsampled resident (Resident 70) reviewed for respiratory care. * Resident 70's MDS was inaccurately coded to reflect the resident's oxygen use. This failure had the potential for the resident to not receive individualized plans of care to address their individual care needs and inaccurate data for quality measures.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to develop and implement the comprehensive care plans for one of 35 final sampled residents (Resident 120). * The facility failed to develop a care plan problem to address Resident 120's indwelling urinary catheter use. This failure had the potential for the resident to not be provided with the appropriate, consistent, and individualized care.

Inspectors wroteBased on observation and interview, the facility failed to ensure the garbage was properly stored in the facility's six garbage dumpsters. This failure had the potential to attract pests/rodents that carried a disease.

Inspectors wroteBased on observation, interview, medical record review, and facility document review, the facility failed to implement the infection control program and practices designed to help prevent the development and transmission of diseases and infections in the facility. * The facility failed to ensure the licensed staff practiced the EBP during high contact care for one of four sampled residents (Resident 3). This failure posed the risk for the transmission of diseases and infections in the facility.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to ensure one of four sampled residents (Resident 4) attained and maintained their highest practicable well-being. * The facility failed to monitor Resident 4 after the resident had an unwitnessed fall. This failure had the potential for delay and not providing the necessary care and services if the resident had a change in condition.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to develop the comprehensive plan of care to address the IV hydration and clogged nephrostomy tube for one of two sampled residents (Resident 1). This failure posed the risk of not providing appropriate individualized care to Resident 1.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to maintain the comfortable temperatures for seven of 83 resident rooms (Rooms A, B, C, D, E, F, and G) housing 19 residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, A, B, C, D, E, F, G, H, I, J, and K). This failure had the potential to negatively affect the residents' health and well-being.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the personal property for one of two sampled residents (Resident 1) was protected from theft or loss. This failure had the potential for the resident's property to get lost or stolen.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to one of two sampled residents (Resident 2) as ordered by the physician. * The facility failed to notify the physician regarding Resident 2's continuous refusal of medications. This failure had the potential to negatively affect the residents' health condition and well-being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the resident was free from the medication errors for one of five sampled residents (Residents 5). * The facility failed to provide the correct insulin medication to Resident 5 as ordered. This failure had the potential to negatively affect the resident's health.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the physician's visits were conducted for three of four sampled residents (Residents 1, 3, and 4) and six nonsampled residents (Residents 5, 6, 8, 9, 10, and 11). This failure had the potential for not addressing the residents' health conditions and care needs.

Inspectors wroteBased on interview, medical record review and facility P&P review, the facility failed to evaluate the resident to determine if the resident was safe to self-administer the medications for one of four sampled residents (Resident 2). This failure had the potential for unsafe self-administer medication.

Inspectors wroteBased on interview, observation, and facility P&P review, the facility failed to ensure Shower Room A was maintained in a sanitary condition. This failure had the potential for not providing clean home like environment for the residents in the facility.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility to provide the appropriate supervision for one of four sampled residents (Resident 3). This failure resulted in Resident 3 leaving the facility unsupervised, which could put the resident at risk of injury while out on pass.

Inspectors wroteBased on interview, medical record review and facility P&P review, the facility failed to ensure the residents were free from the medication errors for two of four sampled resident (Residents 2 and 4). * Resident 2 was administered glucose gel outside of the physician's ordered parameters. * Resident 4's nurse failed to ensure the correct dose of medication was prepared before going to administer the medication to the resident. These failures had the potential for undesirable outcomes.

Inspectors wroteBased on interview, record review, and facility P&P review, the facility failed to ensure the resident was free from the significant medication error when one of four sampled residents (Resident 2) received the incorrect insulin prepared by the licensed nurse. This failure had the potential for poor health outcomes due to adverse effects of the medication.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the resident to have access to a refrigerator for storing the resident food brought from outside for one of four sampled residents (Resident 2). This had the potential for the resident not able to obtain or store perishable food of their liking.

Inspectors wroteBased on interview, medical record review, and the facility's P&P review, the facility failed to ensure the accurate and complete medical records for one of four sampled residents (Resident 2) and eight nonsampled residents (Residents 5, 6, 7, 8, 9, 10, 11, and 12). * Insulin administration for Residents 2, 5, 6, 7, 8, 9, 10, 11, 12 were documented past the administration time. * Medication administration documented in the MARs were incomplete for Residents 2 and 6. These failures had the potential for not having an accurate information in the residents' medical record.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to follow-up on a request to change the physician for one on four sampled residents (Resident 3). This failure had the potential for not promoting the resident's right to choose own physician.

Inspectors wroteBased on interview, closed medical record review, and facility P&P review, the facility failed to notify the responsible party of the resident's changes in conditions for one of four sampled residents (Resident 1). This failure had the potential for delay of notification of the resident's changes of condition to the resident's responsible party.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure Resident 1 was free from physical abuse when Resident 2 yelled at and pushed Resident 1 to the floor, resulting in Resident 1 sustaining a cut to his left thumb. This failure had the potential for not protecting the resident and negatively impact the resident's well-being.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure one of five sampled residents (Resident 1) received the appropriate care and services related to the use of an indwelling urinary catheter. * Resident 1 had a physician's order to discontinue the use of the indwelling urinary catheter; however, the physician's order was not carried out for a period of greater than three weeks. This failure put Resident 1 at risk of complications such as infection.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the appropriate infection control practices were implemented for one of five sampled residents (Resident 2). * Resident 2 had a history of organ transplants and had a central line (CVC) in place but was not placed on the enhanced standard precautions as per the facility's P&P. This failure put Resident 2 at increased risk for infection transmission.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the proper storage and label of the medications as evidenced by: * The oral medication was stored together with the suppository medication and nail polish remover and expired supplies were found in Medication Storage 1. * The oral medications were stored with wound supplies in Medication Carts 4 and 8. * The medication bottles with stick residues were found in Medication Carts 1, 5, 6, and 7. * The quality control for a glucometer in Medication Cart 5 was not performed daily and the log was not maintained with the test strip lot number, expiration dates, and normal high lot number. * An expired medication was found in Medication Storage room [ROOM NUMBER]. * Insulin vials in the plastic bags stored in Medication Storage rooms [ROOM NUMBERS] had two different expiration dates on the vials and bags. [...]

Inspectors wrote9.a. Review of the facility's P&P titled Nourishment Refrigerator/ Freezer Storage Guide revised 5/2023 showed the food from outside sources for residents must be labeled with the resident's name, date item placed, and a use-by date. Monitor for freshness. Review of the facility's P&P titled Use and Storage of Food Brought in by Family or Visitors revised 6/2023 showed it is the right of the residents of the facility to have brought in by family or other visitors. However, the food must be handled in a way to ensure the safety of the resident. All food items that are already prepared by the family or visitor brought in must be labeled with content and dated. The facility may refrigerate labeled and dated prepared items in the nourishment refrigerator. The prepared food must be consumed by the resident within two hours. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of 35 final sampled residents (Resident 78) was informed of the changes in the psychotropic medication (medication affecting brain activities associated with mental processes and behavior) dosage. * The facility failed to ensure the informed consent was obtained prior to administering the increased dosage of buspirone hcl (antianxiety medication) for Resident 78. This failure had the potential for Resident 78 not being informed of his medication and potential effects of increased dosage of buspirone hcl.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure two of 35 final sampled residents (Residents 135 and 171) and two nonsampled residents (Residents 194 and 810) were assessed to safely self-administer the medications prior to performing the self administration of medications. This failure had the potential to negatively impact the residents' physiological well-being and could administer the medications inaccurately.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the reasonable accommodations to meet the needs of four of 35 final sampled residents (Residents 62, 82, 136, and 195) and four nonsampled residents (Residents 3, 8, 36, and 127). * The facility failed to ensure Resident 3's bed light cord was within the resident's reach. * The facility failed to ensure Residents 8 and 136's call light and bed remote control were within the residents' reach. * The facility failed to ensure Residents 36, 82, 127, and 195's call light was within the resident's reach. * The facility failed to ensure the staff emptied Resident 62's urinal as per the resident's request. These failures had potential to negatively impact the residents' psychosocial well-being or result in a delay to provide care to these residents.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed obtain and maintain the copy of the advance directives (legal document that states a person's wishes about receiving medical care if that person is no longer able to make medical decisions) for one of 35 final sampled residents (Resident 9). This failure had the potential for the resident's decisions regarding their healthcare and treatment options not being honored.

Inspectors wroteBased on observation and interview, the facility failed to provide the clean, sanitary, homelike environment for five of five shower rooms. This failure had the potential to negatively impact the residents' well-being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of three closed record sampled residents (Resident 199) was discharged safely. * The facility failed to ensure the Notice of Non-Coverage and Termination of Services forms were given and explained to the resident while in the facility, and the Notice of Proposed Transfer/Discharge contained the reason for the resident's discharge. his posed the risk for Resident 199 to be deprived of her rights regarding the transfer and discharge, which included their right to file an appeal to the correct and appropriate agency within 10 days of being notified.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to send a copy of the notice of transfer/discharge to the representative of the Office of the State Long-Term Care (LTC) Ombudsman for one of 35 final sampled resident (Resident 104) and one closed record sampled resident (Resident 49). These failures posed the risk of the LTC Ombudsman not being aware of the circumstances of the resident's transfer/discharge should an appeal be filed or requested by the resident or their representatives regarding the transfer.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to develop the comprehensive plans of care to reflect the individual care needs for three of 35 final sampled residents (Residents 75, 115, and 134). * The facility failed to develop a comprehensive person-centered care plan to address Resident 75's use of antibiotic for treatment of infection and isolation precaution. * The facility failed to develop a comprehensive person-centered care plan to address Resident 115's weight loss. * The facility failed to develop a comprehensive person-centered care plan to address Resident 134's use of antibiotic medication for the treatment of infection. These failures had the potential risk of not providing appropriate, consistent, and individualized care to these residents.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the comprehensive plan of care for one of 35 final sampled residents (Resident 191) was revised to reflect the residents' current care needs and interventions. * Resident 191's care plan for tube feeding was not revised to address current continuous tube feeding order. This posed the risk of not providing the resident with individualized and person-centered care.

Inspectors wroteBased on interview, medical record review, facility P&P review, and facility document review, the facility failed to provide the necessary care and services for two of 35 final sampled residents (Residents 23 and 151) and one of three closed record sampled residents (Resident 199). * Resident 199 was provided with only one shower on 9/14/23, while she was on isolation from 9/4 to 9/14/23. * Resident 151 was provided with only one bed bath on 9/18/23, while the resident was on isolation from 9/14 to 9/24/23. * Resident 23's long fingernails were not trimmed for a month. These failures posed the risk of the residents not being provided with the appropriate care which could negatively impact their psychosocial well-being.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to provide an individualized and ongoing activity program to meet the needs and interests of one of 35 final sampled residents (Resident 120). * The facility failed to provide activities and initiated a care plan for Resident 120 to meet the resident's identified interests. This failure had the potential for the resident to experience feelings of social isolation and frustration.

Inspectors wroteBased on interview, medical record review, facility record review, and facility P&P review, the facility failed to provide the necessary services to attain or maintain the highest practicable well-being for four of 35 final sampled residents (Residents 78, 86, 171, and 195) and one close record sampled resident (Resident 199). * The facility failed to ensure the necessary care and services were provided timely for Resident 195 who had a fall, including the assessment of the resident's condition and neurological assessments after a fall, developing a care plan to address the actual fall, and notifying the physician and resident's representative of the incident. The resident sustained an acute left hip fracture and was transferred to the acute care hospital where the resident had a left hip hemiarthroplasty (surgical procedure where half of a joint is replaced). [...]

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the elbow splints were applied as per the physician's orders for one of 35 final sampled residents (Resident 191). * The facility failed to ensure the elbow splints for Resident 191 was applied for three to six hours daily per the physician's order. This failure had the potential for the resident's contractures (abnormal shortening of muscle tissue, rendering the muscle highly resistant to stretching; this can lead to permanent disability) and range of motion to worsen.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure two of 35 final sampled residents (Residents 195 and 710) remained free from accident hazards. * The facility failed to implement safety interventions for Resident 710 who smoked. * The facility failed to complete the assessment, notify the primary care physician, obtain the informed consent from the resident's representative, and develop a plan of care prior to the use of bolster pillows in bed for Resident 195. These failures had the potential for the residents to sustaint accidents and/or injuries.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the nursing staff provided care for three of 35 final sampled residents (Residents 9, 75, and 113) with the indwelling urinary catheters (a flexible tube that drains urine from the bladder) as evidence by: * The facility failed to ensure Resident 113's indwelling urinary catheter, physician's order for the indwelling urinary catheter, and the care plan for the indwelling urinary catheter were accurate. In addition, the facility failed to obtain a physician's order for clarification when RN 2 was observed changing the indwelling urinary catheter order without first calling the physician or nurse practitioner for clarification. [...]

Inspectors wroteBased on observation, interview and medical record review, the facility failed to provide hydration for one of 35 final sampled residents (Resident 120). * The facility failed to provide a water pitcher and monitor the hydration status of Resident 120 when her fluid restriction order was discontinued on 3/14/23. This failure had the potential for Resident 120 to be at risk for dehydration.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to provide the necessary GT care and services for one of 35 final sampled residents (Resident 191). * The facility failed to ensure Resident 191 was administered the total amount of enteral feeding as ordered by the physician. In addition, the facility failed to ensure the GT bag was not empty and there was no air in the feeding tube while connected to Resident 191's GT feeding. These failures posed the risk for developing complications related to GT.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the respiratory services were provided as ordered for five of 35 final sampled residents (Residents 82, 135, 118, 171, and 191) and four nonsampled residents (Residents 6, 112, 146, and 203). * The facility failed to ensure Resident 6 received 4 liters per minute oxygen via nasal cannula as per the physician's order. In addition, the facility failed to ensure the bag containing the nebulizer mask and tubing was not on the floor. Furthermore, the facility failed to ensure the oxygen tubing was changed weekly. * The facility failed to ensure the nebulizer medication cup (the container which holds liquid medication to be converted into mist for inhalation) and tubing for Resident 146 were not on the floor. [...]

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary care and services to attain the highest physical wellbeing for one of 35 final sampled residents (Resident 809). * The facility failed to ensure Resident 809 was accurately monitored for the intake and output. This failure had the potential for Resident 809 not being provided the appropriate care and treatment, which could lead to medical complications.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the assessment for the risk for entrapment and informed consent were obtained prior to the use of side rails for one of 35 final sampled resident (Resident 129). This failure had the potential to put Resident 129 at risk for serious injury.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the staff properly communicated with the pharmacy to refill the narcotic pain medication for one nonsampled resident (Resident 125). This failure created the risk for not having the pain medication available to meet the resident's needs.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure one of 35 final sampled residents (Resident 163) was free from the unnecessary drugs. * Resident 163 was administered metoprolol (used to treat high blood pressure), furosemide (used to treat fluid retention) and hydralazine (used to treat high blood pressure) medications without checking the heart rate and blood pressure parameters as per the physician's orders. This failure had the potential for Resident 163 to develop significant side effects such as bradycardia (slower than normal heart rate) and hypotension (low blood pressure).

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure seven of 35 final sampled residents (Residents 9, 26, 75, 78, 87, 151, and 206) were free from unnecessary psychotropic medications (medication affecting brain activities associated with mental processes and behavior). * The facility failed to ensure Resident 78's use of psychotropic medications were accurately monitored to identify a specific behavior manifestation associated with the use of trazadone hcl for in order to determine the effectiveness of the medication. Additionally, the monitoring of adverse reactions of the psychotropic medications were not specific to the drug classifications for antidepressant and antianxiety. In addition, the facility also failed to follow up with the psychiatrist's recommendation to discontinue Resident 78's antidepressants. [...]

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 12.5%. * LVN 2 failed to accurately follow a physician's order and administered an expired medication to Resident 859. * The staff failed to notify the physician of Resident 78's refusal of paroxetine HCl. These failures had the potential to compromise the health and safety of the residents.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure the recipes were followed. This failure had the potential for the residents to not receive adequate nutrition to meet their individual needs.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure the food served was palatable. * The cooked vegetables were mushy and watery in texture. This failure had the potential for the residents to not eat the food served and could affect their nutritional status.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the dietary texture guidelines were followed for the residents on pureed diet. * The pureed rice was observed with grains of rice in the serving container. This failure had the potential to lead to choking or aspiration (a condition in which food, liquids, saliva, or vomit is breathed into the airway) and posed the risk for residents to receive inadequate nutrition.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the medical records for one of 35 final sampled residents (Resident 189), one closed record sampled resident (Resident 207), and one nonsampled residents (Resident 709) were complete and accurate as evidenced by: * The facility failed to ensure Residents 709 and 189's medical records had the complete POLST Forms. * The facility failed to ensure Resident 207's Record of Death was complete and accurate. These failures had the potential for not having the information to provide necessary care and services.

Inspectors wroteBased on interview, facility document review, and facility P&P review, the facility failed to implement their infection control surveillance program in accordance with the facility's P&P and failed to maintain the infection practices to help prevent the development and transmission of diseases and infection. * The facility failed to maintain the accurate infection surveillance program for August, September, and October 2023. * The facility failed to ensure the clean personal clothing rack was covered during transportation. * The facility failed to ensure the infection control practices were implemented in the facility's laundry room. * The facility failed to ensure Resident 189's urinal was properly labeled and stored to maintain infection control. [...]

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the COVID-19 vaccination information was documented for one of 35 final sampled residents (Resident 195). This failure posed the risk of not tracking the resident's COVID-19 vaccination status accurately.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the residents' entrapment assessments were accurate, complete; and the measurements were recorded during the bed inspection when identifying areas of possible entrapment with the use of bed side rails for four of 35 final sampled residents (Residents 9, 86, 129, and 134) and four nonsampled residents (Residents 172, 711, 712, and 713). These failures had the potential to negatively impact the residents resulting in possible entrapment, serious injury, and death.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to promote the dignity and respect for one nonsampled resident (Resident 67). CNA 8 was observed standing over Resident 67 while assisting the resident to eat her meal. This posed the risk of not treating the resident with respect.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the annual assessment for one nonsampled resident (Resident 111) was completed within 14 calendar days after the ARD (assessment reference date) of the annual assessment. This failure had the potential for the staff not identifying the residents' preferences and goals of care, functional and health status, strengths, and needs.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the medications were secured and attended to. * A medication cart (Medication Cart A) was observed unlocked and unattended. This failure had the potential for unauthorized access and drug diversion in the facility.