Anaheim Point

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure three of five sampled residents for unnecessary medications (Residents 2, 6, and 13), and three of 29 final sampled residents (Residents 3, 11, and 61) reviewed for informed consents were provided the right to self-determination regarding the use of the psychotropic medications and treatments. * The facility failed to ensure Resident 2's informed consent for the quetiapine (antipsychotic medication) was signed by the resident or resident's representative. In addition, the facility failed to ensure Resident 2's informed consent for the trazadone medication was verified by two licensed nurses when the resident's representative gave consent via telephone. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of five sampled residents for unnecessary medications (Resident 6), and two of 29 final sampled residents (Residents 5 and 13) were free from the unnecessary psychotropic medications. * The facility failed to ensure the behavior manifestation related to the use of Risperdal (antipsychotic) medication was monitored for Resident 5. In addition, the resident's psychoactive summary sheet for May 2026 did not match the behavior monitored. * The facility failed to ensure Resident 6 was provided with nonpharmacological interventions when the resident exhibited the behavior manifestation related to the use of the quetiapine (antipsychotic) medication. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the appropriate GT care and services were provided for two nonsampled residents (Residents 88 and 149). * The facility failed to ensure RN 1 checked the GT residual prior to flushing the GT with water for Resident 88. In addition, RN 1 failed to administer the water flush and diluted medications via GT by gravity flow as per the facility's P&P. * The facility failed to ensure LVN 2 put the TF (tube feeding) on hold prior to checking the GT residual and flushing the GT with water; and prior to administering the medications for Resident 149. In addition, LVN 2 failed to administer the diluted medications via GT by gravity flow as per the facility's P&P. [...]

Inspectors wroteBased on observations, interview, medical record review, and facility P&P review, the facility failed to provide the necessary respiratory care and services for three of four sampled residents (Residents 8, 126, and 148) reviewed for respiratory care. * The facility failed to ensure Resident 8 and 148's oxygen were administered as per the physician's order. * The facility failed to ensure Resident 126's Yankauer suction tip was stored in a set-up bag when not in use. In addition, the facility failed to ensure Resident 126 was assessed and provided education on how to independently suction herself, and how to store the Yankauer suction when not in use. These failures posed the risk for the residents to develop complications related to oxygen and suction use.

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 in the kitchen. * Proper hand hygiene was not followed,* Food preparation equipment was not clean, and* The kitchen floor was not intact. These failures posed a risk for food borne illness for 127 residents who received food prepared in the kitchen. Review of the facility's matrix dated 6/16/26, showed 127 residents received food prepared in the kitchen. 1. Review of the facility's P&P titled Dietary Department Infection Control for Dietary Employees dated 2022 showed, II. Proper Hand Hygiene A. Upon entering the kitchen, F. After handling soiled equipment or utensils. III. Hand Washing Facilities A. Kitchen sinks shall not be used for hand washing. [...]

Inspectors wroteBased on observation and interview, the facility failed to implement the infection control practices designed to provide a safe and sanitary environment and help prevent the development and transmission of diseases and infections. * The facility failed to protect the residents' clean linen from dust and contamination when the employee personal belongings were stored in the clean linen folding area. * The facility failed to ensure LVN 1 performed hand hygiene and changed gloves before administering the eye drop medications to Resident 25 after contact with potentially contaminated surfaces. * The facility failed to ensure RN 1 performed hand hygiene and changed gloves before administering the insulin medication to Resident 88. These failures posed the risk of infection, cross-contamination and the transmission of disease-causing microorganisms to highly vulnerable residents.

Inspectors wroteBased on observation, interview, document review, and facility P&P review, the facility failed to ensure the kitchen and front dining room were free of pests. * The facility failed to ensure there was no cockroach the kitchen. * The facility failed to ensure there was no gnat flying in front dining room. These failures posed the risk of contamination of the food prepared in the kitchen and of the front dining room for 127 residents who received food prepared in the kitchen.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to promote dignity and respect for one of 29 sampled residents. * The facility failed to ensure Resident 15's indwelling urinary catheter drainage bag was placed inside the dignity bag. This failure had the potential to affect the privacy and dignity of the resident.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide reasonable accommodation to meet the needs for two of 29 final sampled residents (Residents 52 and 90). * The facility failed to ensure Resident 52 and 90's call lights were within the residents' reach. This failure posed a risk in a delay in providing care to the residents with the potential to negatively impact on the residents' well-being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide a copy of the notification of the transfer/discharge to the office of the State Long-Term Care Ombudsman for one of the two final residents (Resident 9) transfer to the acute care hospital and one of three sampled residents (Resident 145) for closed record reviewed. * The facility failed to ensure the transfer/discharge notification was completed and a copy was sent to the Ombudsman when Resident 9 was transferred to Acute Care Hospital 2 (ACH 2) on 4/2926. * The facility failed to send a copy of Resident 145's notice of transfer/discharge to the representative of the Office of the State LTC Ombudsman. [...]

Inspectors wroteBased on observation, interview, medical record review, and P&P review, the facility failed to develop the comprehensive plan of care to reflect the individual care needs for three of 29 final sampled residents (Residents 8, 79 and 126). * The facility failed to implement the care plan to address Resident 8's head of bed while the resident was on continuous oxygen. * The facility failed to develop a care plan problem to address Resident 79's use of bed bolster (a raised foam edges along the sides of bed mattress to support positioning and prevent patient from rolling out of bed) for safety. * The facility failed to develop a care plan problem to address Resident 126's self-use of suction equipment. These failures had the potential risk of not providing appropriate, consistent, and individualized care to these residents.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the comprehensive person-centered care plan was revised to reflect the residents' current care needs and interventions for one of 29 final sampled residents (Resident 11) and one nonsampled resident (Resident 133). * The facility failed to ensure Resident 11's care plan interventions for the alprazolam (antianxiety) and duloxetine (antidepressant) medications were revised to show the nonpharmacological interventions were included as per physician's order. * The facility failed to ensure the care plan for Resident 133 was updated to reflect Resident 133's dislike of the facility food, and the food brought daily from home. These failures increased the risk for the residents to not receive an individualized and person centered care in accordance with their assessed needs.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to provide the necessary care and services for one of 29 final sampled residents (Resident 51) and one nonsampled resident (Resident 149) reviewed for ADL care. * The facility failed to ensure Resident 51 was provided with showers on her scheduled shower days. * The facility failed to ensure Resident 149 was provided with oral care. Resident 149's tongue was observed covered with thick white residue. These failures had the potential for the residents' need not met and for the residents to experience physical discomfort.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to provide the necessary services to attain or maintain the highest practicable well-being for one of 29 final sampled residents (Resident 61). * The facility failed to ensure Resident 61 was administered midodrine (antihypotensive) medication when Resident 61's systolic blood pressure (SBP) was less than 110 mmHg as prescribed by the physician. This failure had the potential to negatively affect Resident 61's health condition and well-being.

Inspectors wroteBased on interview, medical record review, and the facility P&P review, the facility failed to monitor the fluid intake accurately for one of one final sampled resident (Resident 126) and one nonsample resident (Resident 25) reviewed for hydration and nutritional status. * The facility failed to provide Resident 25's Nephro (nutritional supplements) oral liquid 237 ml as ordered by the physician. * The facility failed to ensure Resident 126's fluid intake was monitored accurately by the charge nurses and CNAs. The CNAs fluid intake documentation did not match the charge nurses' documentation, and often exceeded the volume documented by the charge nurses. In addition, the daily fluid intake documentation was inconsistent and incomplete. These failures placed the residents at risk for undetected fluid imbalances or weight loss and negatively impact the resident's well-being.

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 two of 29 final sampled residents (Residents 13 and 90) reviewed for pain management. * The facility failed to ensure Resident 13's pain was assessed prior to the administration of hydrocodone (narcotic analgesic) medication. * The facility failed to accurately document the pain level for Resident 90 according to the physician's order when the resident was administered with hydrocodone (narcotic analgesic) medication. These failures posed the risk for the residents not to receive the appropriate and necessary interventions to manage the residents' pain.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services for one of three final sampled residents (Resident 62) reviewed for hemodialysis. * The facility failed to ensure Resident 62's fluid intake related to dialysis was monitored accurately. In addition, the facility failed to monitor Resident 62 and notify the physician when his access site was assessed with redness, pain, swelling, or tenderness. These failures had the potential to result in accurate assessment of fluid status, complications associated with fluid overload, and delayed intervention to the resident 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 two of two licensed nurses (RN 1 and LVN 2) reviewed for competency had specific competencies and standard of practice skill sets needed to provide safe and efficient nursing care. * The facility failed to ensure RN 1 and LVN 2 were able to competently administer the medications via GT. These failures had the potential to put the residents at risks to receive care not provided in a safe and competent manner.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure the nurse staffing information was posted in a prominent place and readily accessible to residents and visitors. * The facility failed to post the DHPPD, CDPH Form 612 in a prominent place and readily accessible to residents and visitors. This deficient practice had the potential for residents and visitors to not have facility staffing information available at any given time.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure proper storage of medication for one of 29 final sampled residents (Resident 13) reviewed for self-administration of medication. * The facility failed to ensure a box containing fluticasone propionate (corticosteroid) nasal spray was not left at Resident 13's bedside table. This failure had the potential to negatively impact on the resident's well-being, unsafe administration of the medications, and the potential for the other residents, staff, and visitors to have access to the medication.

Inspectors wroteBased on observation, interviews, facility P&P review, and facility document review, the facility failed to ensure one of 12 kitchen employees (Dietary Aide 1) had the appropriate competency and skill set to perform daily kitchen duties. These failures posed the risk of cross contamination in the kitchen which could lead to food-borne illness in the 127 residents who received food prepared in the kitchen.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure nutritional needs were met for one of 127 residents (Resident 133) who had an option to received a vegetarian meal. * The facility failed to ensure Resident 133 was provided the vegetarian meal with the same amount of protein as the regular diet. This failure posed the risk for the resident's nutritional needs not be met which could lead to medical complications.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure visitors who brought food from the outside to the facility residents, and the staff who handled the food brought from the outside were educated on safe food handling practices. These failures posed the risk for unsafe food handling for the 127 facility residents who received an oral diet.

Inspectors wroteBased on observation, interview, medical record review, and the facility P&P review, the facility failed to ensure four nonsampled residents (Residents 38, 103, 110, and 144) were safe to self-administer the medications. * The facility failed to ensure a bottle of Refresh eyedrops (used to relieve dry and irritated eyes) was not in Resident 110's nightstand. Resident 110 stated she administered the eyedrops by herself; however, Resident 110 was not assessed for the safe self-administration of the medication. * The facility failed to ensure a container of Biofreeze pain relief cream (a topical rubefacient used to ease muscle and joint aches and pain) was not in Resident 103's nightstand drawer. Resident 103 stated he administered the cream by himself; however, Resident 103 was not assessed for the safe self-administration of the medication. [...]

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure one of 29 final sampled residents (Resident 20) needs and preferences were accommodated. * The facility failed to provide the properly fitted diaper to Resident 20. This failure posed the risk to negatively affect the resident's physical and emotional well-being.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the personal property of one nonsampled residents (Resident 100) was protected from loss or theft. * The facility failed to ensure Residents 100's personal items were labeled with the resident's name and included in the resident's inventory list. These failures had the potential for the resident's property to get lost or stolen.

Inspectors wroteBased on interview, facility documents review, and facility P&P review, the facility failed to ensure the abuse P&P was implemented for one of five sampled residents (Resident 120) investigated for abuse. * The facility failed to ensure two alleged perpetrators (LVNs 2 and 7) were immediately suspended pending the outcome of the investigation for the abuse allegation for Resident 120. This failure had the potential for the resident to be vulnerable for further abuse, mistreatment, and injury.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the comprehensive care plan was implemented for one of 29 final sampled residents (Resident 82). * The facility failed to implement the bilateral floor mats in accordance with Resident 82's fall risk care plan. This failure placed the resident at risk of not receiving the appropriate, consistent, and individualized care.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services for one of two sampled residents (final sampled resident, Resident 66) reviewed for IV antibiotic use and one of eight sampled residents (final sampled resident, Resident 394) reviewed for advance directives to attain and maintain their highest practicable well-being. * The facility failed to continuously monitor Resident 66 for the adverse reactions related to the IV antibiotics use and ESBL in the urine. * The facility failed to clearly identify the current code status for Resident 394. These failures had the potential for residents to not receive the necessary care and services in accordance with the resident's needs and treatment wishes.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure one of 29 final sample residents (Resident 82) and one nonsampled resident (Resident 643) remained free from accident hazards. * The facility failed to update the plan of care and provide the adequate supervision and necessary services for Resident 643 to prevent elopement. This failure had the potential for Resident 643 leaving the facility premises undetected. * The facility failed to implement the bilateral floor mats per the physician's order for Resident 82 who was at risk for falls. These failures had the potential to place the residents at risk for serious injury.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the dialysis care was provided for one of three final sampled residents (Resident 4) reviewed for dialysis as evidenced by: * The facility failed to ensure Resident 4's dialysis access site was assessed and monitored appropriately and consistently. This failure had the potential for Resident 4 not being provided with the appropriate care and treatment and the possibility of medical complications related to the resident's dialysis access site.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of five sampled residents (final sampled resident, Resident 394) reviewed for side rail use remained free from accident hazards due to the use of side rails. * The facility failed to ensure Resident 394 who was assessed for no indication for the use of side rails was not provided with the side rails. Resident 394 was provided with bilateral upper ½ (half) side rails. In addition, Resident 394's plan of care showed a care plan problem to address grab bars, not ½ side rails. These failures had the potential to place Resident 394 at risk for entrapment and serious injury from side rail use.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the pharmacy services as per the facility's P&P for one nonsampled resident (Residents 34). * The facility failed to ensure the accurate and complete documentation of the controlled medication administered to Resident 34 was maintained. This failure had the potential to pose the risk for the diversion of the medications.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medications were not stored at the bedside for one of 29 final sampled residents (Resident 104). In addition, the facility failed to ensure the proper disposal of the expired treatment supplies for one of five medication/treatment carts inspected for the medication storage and labeling. * The facility failed to ensure the expired culture swabs and dressing were removed from Treatment Cart 1. * Resident 104 was observed with sealed, unopened Wallgreens Redness Relief eye drops (eye redness relief) at bedside. These failures had the potential to result in unsafe medication administration and posed the risk for inaccurate test results and treatments.

Inspectors wroteBased on observation, interview, medical record review, and facility document review, the facility failed to follow the menu when preparing food for one of 29 final residents (Resident 88). * The facility failed to ensure the recipe for chef salad was followed. Resident 88 requested a chef salad and received only lettuce with shredded carrots and purple cabbage. This failure had the potential for the resident to not receive adequate nutrition based on their diet orders.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary adaptive equipment was provided for one of 29 final sampled residents (Resident 8). * Resident 8 was not provided with built-up utensils per the physician's order. This failure had the potential for Resident 8 not having an appropriate assistive device to consume her food.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the hair restraints were worn by the staff while in the kitchen and failed to ensure kitchen dry storage guidelines were implemented. * The DSS failed to donn a hair restraint while in the kitchen, in accordance with the facility's P&P. * A canister containing brown rice was observed without a lid inside of the dry storage room. These failures had the potential for unsafe food storage and infection control practices in a medically vulnerable resident population.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the provision of hospice services for two of three residents (final sampled residents, Residents 79 and 394), reviewed for hospice services. * Resident 79 was scheduled to receive care from a certified hospice aide twice per week; however, the medical record failed to show documentation the certified hospice aide provided care to Resident 79 twice per week as scheduled. * The facility failed to clarify the frequency of the hospice agency staff visits and to ensure the hospice aide visited and provided care to Resident 394. The facility failed to ensure the flowsheet and clinical notes from the hospice nurses and hospice aides were completed. In addition, the facility failed to ensure Resident 394's POLST and hospice agency's consents were completed. [...]

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to maintain the infection control program and practices designed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases. * The facility failed to implement the testing, monitoring, and establishment of acceptable ranges of disinfectant chemicals levels throughout the facility's water supply in accordance with the facility's water management P&P for water management, and the facility's plan for Legionella control. * The laundry room and equipment were not maintained to ensure a clean area, and free from potential contamination. These failures had the potential for the spread of infection to the residents, staff and visitors in the facility.

Inspectors wroteBased on interview, facility document review, and facility P&P (Policy and Procedure) review, the facility failed to implement the antibiotic stewardship program. * The facility failed to ensure the infection control data gathered in the surveillance log was accurately documented in the Infection Control Report for January 2025. * The facility failed to provide documentation of the McGeer's criteria used to determine if the residents met the criteria for true infection. * The facility failed to ensure Resident 54 was accurately assessed for true infection when an Ampicillin (antibiotic medication to treat infection) was prescribed. These failures had the potential for inappropriate use of antibiotics and increased risk of drug-resistant organisms.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the bed inspection and entrapment assessment were conducted for one of five final sampled residents (Resident 394) reviewed for side rail use. These failures had the potential to negatively impact the resident's well-being resulting in possible entrapment, serious injury, and death.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the MDS was coded accurately for one of three closed record sampled residents (Resident 142) reviewed. This failure had the potential for the resident to not receive appropriate treatment and/or services.

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

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the medical record was accurately maintained for three of 29 final sampled residents (Residents 79, 84, and 86). * Residents 79 and 84's POLST failed to show documentation as to whether the residents had formulated and advance directive. * Resident 86's medical record was found to have two other residents' medical records. These failures had the potential for the residents' care needs not being met as the medical record was inaccurate and incomplete.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the comprehensive plan of care was revised to reflect the resident's current wound care treatment and interventions for each individual wound site as ordered for one of seven sampled residents (Resident 3). * Resident 3's care plan was not revised to address the wound site of left foot first metatarsal base and head arterial wounds. This failure posed the risk of not providing the resident with individualized and person-centered care.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to provide the necessary tube feeding care and services for one of seven sampled residents (Resident 3). * The facility failed to ensure Resident 3 was positioned safely at 30 to 45 degrees during the enteral feeding via PEG tube. This failure posed the risk for developing complications related to resident's tube feeding and health consequences.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to implement the infection control practices designed to provide the safe and sanitary environment to prevent the transmission of diseases and infections in the facility. * The facility failed to ensure the staff practiced the EBP during high contact-care for one of seven sampled residents (Resident 3). This failure posed the risk for the transmission of diseases and infections.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medications were stored properly for one nonsampled resident (Resident E) when a medication bubble pack was observed at the counter of the nursing station. This failure had the potential for the unauthorized staff and visitors to have access to the medications.

Inspectors wroteBased on interview, medial record review, and facility P&P review, the facility failed to conduct an inventory of a resident's personal property in accordance with the facility's P&P for one of five sampled residents (Resident 2). * The facility failed to conduct the inventory of Resident 2's personal property when he was admitted and discharged from the facility. 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 to implement their P&P related to abuse reporting for one of five sampled residents (Resident 1). * The Activities Assistant failed to report the abuse allegation to the Administrator when Resident 1 informed the Activities Assistant that a CNA was mad and threw towels on Resident 1's bed. This failure had the potential for the abuse allegation not investigated thoroughly and posed a risk of not providing appropriate actions to prevent further abuse.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the information obtained from the physical assessment was documented in the resident's medical record for one of five sampled residents (Resident 2). This failure had the potential for not knowing the resident's health condition due to incomplete medical record.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure the routine changes of indwelling urinary catheter order were clarified with the physician for one of two sampled residents (Resident 2). This failure had the potential to put Resident 2 at risk for UTI.

Inspectors wroteBased on interview, medical record review, and the facility P&P review, the facility failed to provide the written information regarding the rights to formulate the advance directives for one of ninesampled residents (Residents 1). In addition, facility failed to ensure the POLST was completed for Resident 1. These failures had the potential for the residents' decisions regarding their healthcare and treatment options not being honored.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of nine sampled residents (Resident 1) was provided the necessary treatment and services to maintain and improve his ROM functions. * The facility failed to ensure the physician was notified of Resident 1's refusal of the PT and OT services and failed to develop the care plan problem to address Resident 1's refusal of the PT and OT services. These failures posed the risk for Resident 1 to develop complications from immobility leading to muscle atrophy and contractures (shortening of the tendons and muscles causing the joints to become stiff and unable to fully function).

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to maintain the accurate medical record for one of four final sampled residents (Resident 1). * The facility failed to ensure the licensed nurse documented the initials in the MAR when the medications were administered to Resident 1. * The facility failed to document when Resident 1 went out on pass and returned to the facility. * The facility failed to ensure the weekly skin/wound assessments were completed weekly in December 2023 for Resident 1. These failures had the potential for the resident's care not being met as the clinical information were not complete.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the hand hygiene practices were performed as per the facility ' s P&P. This failure posed the risk of spreading infectious organism to residents in the facility.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of four sampled residents (Resident 1) received the pain medication as prescribed in accordance with physician ' s orders. * Resident 1 had a physician ' s order for oxycodone-acetaminophen (a narcotic medication used to treat pain) 5-325 mg two tablets by mouth every four hours as needed for moderate pain; however, Resident 1 received the medication on multiple occasions outside of the ordered parameters. This failure had the potential for Resident 1 to not have their pain adequately addressed and adverse effects.

Inspectors wroteBased on interview and medical record review, the facility failed to develop the comprehensive person-centered care plan for one of four sampled residents (Resident 1). * Resident 1 consistently refused showers and hygiene care. The facility did not develop a care plan problem to address the refusal of care. This failure put Resident 1 at risk of not having their care needs met.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medications were administered in accordance with the standards of practice for one of four sampled residents (Resident 4). * Resident 4's medications were not administered in a timely manner as prescribed by the physician. This failure had the potential for medication errors and to negatively affect Resident 4's health conditions.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medications were stored properly for one of four sampled residents (Resident 4) when a medication cup filled with multiple tablets were observed at the bedside table in Resident 4's room. This failure had the potential for the residents, staff, and visitors to have access to the medication and unsafe administration of medications.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide a safe environment free from potentially serious accident hazards for seven of seven smoking residents (Residents 40, 52, 55, 62, 73, 87, and 529) who smoked in the facility and one nonsampled resident (Resident 82) who was at risk for falls. 1. The facility failed to ensure the safe smoking practices were followed for seven residents (Residents 40, 52, 55, 62, 73, 87, and 529) who smoked in the facility as evidenced by: - The residents were not accurately and thoroughly assessed and reassessed to determine if they required supervision or any adaptive safety equipment while smoking, nor if they could safely store their own cigarettes or lighters. [...]

Inspectors wroteBased on interview, facility document review, and facility P&P review, the facility failed to ensure the CNAs' performance evaluations were completed every 12 months for the CNAs' competency evaluations reviewed. The lack of CNAs' performance review had the potential for the staff to not maintain competencies to provide the residents with needed and appropriate care and services.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen. * The facility failed to ensure the food preparation equipment was air dried. * The facility failed to ensure the meal trays were in good condition. * The facility failed to ensure the food service spatulas were in good condition. * The facility failed to ensure the food items in the resident refrigerator were labeled and dated. * The facility failed to ensure the backflow prevention of one food preparation sink was maintained. * The facility failed to ensure the door frame of the kitchen walk-in refrigerator was free from residue and in good condition. * The facility failed to ensure the kitchen cleaning equipment were stored off the floor. [...]

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure multiple waste bins were properly maintained. This failure had the potential to cause unsafe and unsanitary conditions in the facility.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of 25 final sampled residents (Resident 101) participated in the development and planning of their care. * Resident 101 was not invited to participate in the care plan conference. This posed the risk of violating Resident 101's rights in choosing the treatment options and making the decisions in care planning.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 25 final sampled residents (Resident 48) who was not a candidate for self-administered medication had an ointment medication at the bedside and self-administered it. * Resident 48 pulled out an Aquaphor Itch Relief Ointment (anti-itch ointment) from her drawer which she self-administered to her feet. Resident 48's Self-Administration of Medication Assessment showed Resident 48 was not a candidate for self-administration of medication. Resident 48 did not have a physician's order to self-administer the Aquaphor Itch Relief Ointment. This failure had the potential for poor health outcomes to Resident 48.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure six of 25 final sampled residents (Residents 57, 75, 727, 777, 779, and 782) had the rights to receive reasonable accommodation of needs and preferences. * The facility failed to ensure Resident 57's call light was within reach. * The facility failed to ensure Residents 75, 727, 777, and 782's call lights were answered in a timely manner. * The facility failed to ensure Resident 779's bariatric mattress had proper fitted sheets. These failures 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 the resident's advanced directive was obtained and maintained in the medical record for one of 25 final sampled residents (Resident 4). This failure had the potential for the resident's decisions regarding her healthcare and treatment options to not be honored.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to report the potential abuse for one of nonsampled resident (Resident 57) when Resident 57 was found with a skin discoloration below the left eye. This failure created the risk for a delay in protecting Resident 57 and delay investigation of the alleged abuse.

Inspectors wroteBased on interview, medical record review, facility document review and facility P&P review, the facility failed to notify one of three closed record sampled residents (Resident 126) and their representative of their transfer/discharge and the reasons for the move in writing. In addition, the facility failed to send a copy of the transfer/discharge to the representative of the Office of the State Long-Term Care Ombudsman (a person who routinely visits the facility and advocated for the residents). These posed the risk for Resident 126 and the representative not aware of the appeal process for discharge.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to accurately complete the MDS for one of 25 final sampled residents (Resident 529). This posed the risk of the resident not receiving an individualized plan of care based on the resident's specific needs. * Resident 529 was a smoker. The facility failed to code the use of tobacco in the admission MDS dated [DATE].

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to develop the plan of care to reflect the individual care needs for six of 25 final sampled residents (Residents 29, 52, 55, 57, 59, and 777). * The facility failed to ensure Resident 29's care plan problem addressing dialysis included Resident 29's fluid restriction. * The facility failed to develop a care plan problem to address Resident 777's dialysis catheter site care. * The facility failed to develop a care plan problem to address Resident 57's skin discoloration below the left eye. * The facility failed to ensure a care plan problem addressing smoking included the safe storage of cigarettes materials for Resident 52. * The facility failed to ensure a care plan problem addressing smoking included the safe storage of cigarettes materials for Resident 55. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure care plans were updated and revised for four of 25 final sampled residents (Residents 42, 59, 100, and 777 ) as evidenced by: *For Resident 100, the care plans for dialysis to administer epoetin (used to treat anemia (a lower than normal number of red blood cells) in people with chronic kidney failure) were not revised timely. * The facility failed to revise the care plan intervention of Resident 59 for the dialysis access care. * The facility failed to revise the care plan of Resident 777 to address the dislodged femoral dialysis catheter. * The facility failed to revise the care plan intervention of Resident 42 for the use of indwelling catheter. These failures had the potential for inadequate treatment and management of residents' medical and health conditions.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide care and services for one of 25 final sampled residents (Resident 48). * Resident 48 did not have the follow-up appointment for an ENT consult for decreased hearing. This failure had the potential for Resident 48's hearing needs to not be met.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure two of 25 final sampled residents (Residents 48 and 69) received adequate care. * The facility failed to ensure a change of condition and care plan problem were documented when Resident 69 was prescribed erythromycin (antibiotic used to treat infections) ointment to both eyes. * The facility failed to ensure Resident 69 with positive ESBL in urine (urinary tract infection) had a contact isolation order. There were no care plans developed to address prescribed antibiotic medication, Bactrim DS (antibiotic used to treat infections), positive ESBL, and contact isolation for positive ESBL. * The facility failed to address a change of condition and notify the physician when Resident 48 was observed having redness and rashes to bilateral feet. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the RNA services for one of 25 final sampled residents (Resident 100). This failure had the potential to negatively affect the residents' health.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 25 final sampled residents (Resident 42) received the appropriate care and services for an indwelling urinary catheter. This failure had the potential for the resident to develop complications associated with the use of indwelling urinary catheter.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to offer or provide adequate and appropriate pain management for two of 25 final sampled residents (Residents 777 and 779). * The facility failed to ensure Resident 777 was administered pain medication per the physician's order. * The facility failed to consistently provide non-pharmacological interventions for pain prior to administration of a narcotic pain medication to Residents 777 and 779. * The facility failed to monitor Resident 779's implanted pain pump. These failures had the potential for not effectively managing these residents' pain.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to implement the fluid restrictions for one of 25 final sampled residents (Resident 29). This failure had the potential to negatively impact Resident 29's health and complication associated with fluid deficit and overload.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the competency of the licensed nurses in assessing the dialysis access site for one of 25 final sampled resident (Resident 59). LVN 9 was unable to demonstrate competency in the assessment of the AV shunt site of Resident 59. This failure had the potential to put residents at risk for care not provided in a safe and competent manner.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide pharmaceutical services for two of 25 final sampled residents (Residents 529 and 779) and one nonsampled resident (Resident 35) to meet the needs of each resident as evidenced by: * The facility failed to ensure Resident 529's oxycodone-acetaminophen (pain medication) was accurately reconciled. The number of tablets of oxycodone-acetaminophen removed showing on the Individual Narcotic Record did not match the number of tablets in the electronic MAR as administered to Resident 529. This failure had the possibility of diversion of controlled medications. [...]

Inspectors wroteBased on interview and medical record review, the facility failed to ensure one of 25 final sampled residents (Resident 4) was free from unnecessary psychotropic medications. * The facility failed to ensure Resident 4's orthostatic blood pressure (measure the blood pressure while laying down or sitting and again upon standing up) was monitored as ordered by the physician related to the use of an antipsychotic medication. This failure had the potential for the resident to experience adverse consequences from the psychotropic medication.

Inspectors wroteBased on observation and interview, the facility failed to ensure the medications and influenza test kits were appropriately stored. * The unopened insulin bottle and insulin pen were stored at room temperature in Medication Cart 1 instead of storing in the refrigerator as per the pharmacy labels. * The facility failed to ensure proper storage of influenza test kits. These failures had the potential to alter the efficacy of the stored medications and cause inaccurate influenza results.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to provide one nonsampled residents (Resident 44) an entree substitute of similar nutritive value when Resident 44 was served a cheese quesadilla for lunch. This failure posed the risk for Resident 44's nutritional needs to not be met.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the policy on resident food brought by visitors was followed. * The facility failed to ensure the staff were aware of the process for storing and discarding the resident food brought by the visitors. * The facility failed to ensure the staff were educated on safe food handling practices when handling the resident food brought in by the visitors. * The facility failed to ensure the policy, guidelines, and safe food handling practices were communicated to the resident's family/visitors who brought the resident food from the outside. These failures had the potential to cause foodborne illness to the residents who received food brought by the visitors.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medical records for two of 25 final sampled residents (Residents 75 and 100) were accurate and complete. * Resident 75's and 100's MARs had multiple entries of medication and treatment missing initials of the license nurses. This failure created the risk of not knowing if the medications administered.