Anaheim Terrace Care Center

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary services to attain or maintain the highest practicable well-being for five of 19 final sampled residents (Residents 4, 9, 11, 31, and 47). * The facility failed to follow the physician's order to administer the metoprolol (medications to treat high blood pressure) when Residents 4's systolic blood pressure (SBP) was above 110 mmHg and pulse rate above 55 beats per minute. This failure had the potential for Resident 4 to develop adverse effects from untreated hypertension, including cardiovascular complications. * The facility failed to notify the physician when Resident 9's blood sugar was more than 400 mmHg, as per the physician's order. [...]

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 six of 19 final sampled residents (Residents 4, 31, 47, 52, 62, and 91) reviewed for pain management. * The facility failed to ensure to provide nonpharmacological interventions prior administration of hydrocodone with acetaminophen (a strong prescription medication used to manage moderate to severe pain) to Residents 31. In addition, the hydrocodone with acetaminophen medication was administered when the resident's pain level did not meet the ordered parameters for severe pain. * The facility failed to ensure Resident 62 was assessed for pain and provided with nonpharmacological interventions prior to administration of the hydrocodone with acetaminophen medication. [...]

Inspectors wroteBased on observation, interview, facility document review and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen. * The facility failed to ensure the cutting boards were kept in a sanitary condition, with smooth, cleanable surface. * The facility failed to ensure the toaster used to warm bread for the residents was kept in a sanitary condition. * The facility failed to ensure kitchen equipment and utensils were stored and maintained in a sanitary condition. * The facility failed to ensure proper labeling and dating of food stored in the refrigerator. These failures had the potential to result in foodborne illnesses for the 89 residents who consumed food prepared in the facility's kitchen.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to maintain infection control practices. * The facility failed to ensure RN 1 performed appropriate hand hygiene during an intravenous (IV) medication administration observation. * The facility failed to ensure LVN 6 performed appropriate hand hygiene between oral and ophthalmic routes during a medication administration observation. * The facility failed to show consistent and accurate documentation of its testing protocols for Legionella and other opportunistic pathogens in building water systems for the kitchen water temperatures for February 2026. * The facility failed to ensure the staff performed appropriate hand hygiene after touching a soiled linen cart and before entering Resident 80's room to provide care. These failures placed the residents at risk for infection and disease transmission.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure a resident representative was provided for one of 19 final sampled residents (Resident 6) reviewed for resident rights. * The facility failed to ensure Resident 6, who was unable to make her own decisions, was provided with a resident representative or a public resident representative through The Office of the Long-Term Care Patient Representative (OLTCPR) as required by AFL 23-18. This failure placed Resident 6 at risk for not receiving adequate representation during care and treatment decisionsFindings: [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure residents and/or resident representative were provided with the right to self-determination for one of 19 final sampled residents (Resident 9). * The facility failed to ensure the informed consent for psychotropic medication buspirone (antianxiety) and escitalopram (antidepressant) for Resident 9 included the indication of use, manifested behavior, and nonpharmacological interventions that could address the behavior related to the use of the psychotropic medication. In addition, the informed consent forms for buspirone and escitalopram were not signed by the physician. Furthermore, the facility failed to ensure informed consent was obtained prior to administering the Ativan (antianxiety) medication to Resident 9. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medications were safely administered for one of 94 residents (Resident 105). * Resident 105 had Visine Red Eye Hydrating Comfort eye drops (reduces redness of the eyes) on the nightstand beside the resident. This failure had the potential for the resident to inaccurately self-administer the medications, develop adverse reactions, and negatively affect the resident's well-being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of five final sampled residents (Resident 9) reviewed for the unnecessary medications was free from the unnecessary psychotropic medications. * The facility failed to ensure the PRN psychotropic medication ordered for Resident 9 was limited to 14 days as required. The physician did not provide documentation justifying the continued use of the PRN psychotropic medication beyond 14 days when Ativan (antianxiety) 0.5 mg was ordered PRN for 30 days. This failure had the potential to place Resident 9 at risk for adverse drug effects, inappropriate medication use, and a decline in their overall health and well being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure a safe and effective transition of care when a resident was transferred to the acute care hospital for one of three residents (Resident 102) reviewed for closed records. * The facility failed to ensure for a documented evidence the required information was communicated to the receiving provider, including contact information of the practitioner responsible for the resident's care, resident's representative information, advance directive information, and any special instructions or precautions for ongoing care, as appropriate. This failure had the potential to result in incomplete or delayed care, miscommunication of the resident's medical needs, and an increased risk of adverse outcomes during the transition to the acute care hospital.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the recommendations from the PASRR Level II determination were incorporated into the resident's care for one of two final sampled residents (Resident 5) reviewed for PASRR. * The facility failed to incorporate the Level II PASRR recommendations into the assessment and care planning for Resident 5. This failure had the potential to result in Resident 5 not receiving adequate care as recommended by the PASRR Level II determination conducted by the state-designated authority.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services related to GT feeding for one of three residents (nonsampled Resident 48) reviewed for tube feedings. * The facility failed to ensure Residents 48 received the complete dose of the GT enteral feeding as ordered by the physician. This failure had the potential to result in unmet nutritional needs and place Resident 48 nutritional at risk for adverse outcomes, including weight loss and/or dehydration.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of one final sampled resident (Resident 109) reviewed for IV therapy was properly monitored. * The facility failed to ensure Resident 109's midline catheter to the right upper arm was measured upon admission and after dressing changes, as per the facility's P&P. This failure had the potential to result in inadequate monitoring and care for Resident 109, who was receiving IV medications.

Inspectors wroteBased on observation, interview, medical record, and facility P&P review, the facility failed to ensure the appropriate respiratory care was provided for one of one final sampled resident (Resident 40) reviewed for respiratory care and one nonsampled resident (Resident 74). * The facility failed to ensure Resident 40's CPAP humidifier, and filter were cleaned weekly; mask, nasal pillow and tubing were cleaned daily, and headgear (strap) was washed as needed, as per facility policy. * The facility failed to ensure Resident 74's BiPAP humidifier and filter were cleaned weekly; mask, nasal pillow and tubing were cleaned daily, and headgear (strap) was washed as needed, as per facility policy. In addition, the facility failed to ensure Resident 74's oxygen nasal cannula was properly stored in a bag when not in use. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the pharmaceutical services were safely provided for one of seven residents (Resident 62) observed during the medication administration. * The facility failed to ensure RN 1 performed safe intravenous (IV) medication techniques when RN 1 flushed Resident 62's PICC line without removing an air bubble from the normal saline flush syringe. * The facility failed to ensure Resident 62's physician's order for the IV vancomycin (antibiotic) 1 gram/200 ml matched the IV vancomycin 1 gram/250 ml dispensed by the pharmacy. These failures posed a risk for negative health outcomes and compromised the safe delivery of IV therapy for Resident 62.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to store the disposed drugs and biologicals in a safe manner. * The facility failed to ensure the medications placed in the medication disposal bin in Medication Room A were properly destroyed and disposed medication tablets were not left whole. This failure posed a risk for medication diversion.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medical record for one of 19 final sampled residents (Resident 31) was complete and accurately documented. * The facility failed to ensure Resident 31's blood pressure access site was accurately documented in the resident's medical record. This failure had the potential to result in the resident's care needs not being met due to inaccurate medical information.

Inspectors wroteBased on interview and facility document review, the facility failed to ensure the glucometer on Medication Cart A was calibrated and the quality control testing was performed. * The facility failed to ensure the glucometer for Medication Cart A was calibrated and the quality control testing was performed daily in [DATE]. This failure had the potential for the residents requiring blood glucose checks to have inaccurate readings.

Inspectors wroteBased on interview and closed medical record review, the facility failed to provide the necessary treatment and services to maintain the highest practicable well-being for one of three sampled residents (Resident 1). * The facility failed to ensure Resident 1's change of condition was monitored every shift for at least 72 hours. This failure had the potential to negatively affect Resident 1's health and well-being and the potential risk of not providing Resident 1 with appropriate and individualized care.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of eight sampled residents' (Resident 5) medical record were complete and readily accessible upon request, in accordance with facility's P&P. * The facility was unable to provide Resident 5's medical record, which included the physician's orders, assessments, progress notes, and discharge plan documentation. This failure had resulted in the facility not being able to show Resident 5's discharge planning and teaching was provided to the resident and the resident's family member, to ensure a safe discharge for the resident.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure the food safety and sanitation guidelines were followed when: * The facility failed to ensure the food preparation equipment was air dried. * The facility failed to ensure the kitchen equipment and utensils were maintained in a sanitary condition. * The facility failed to ensure safe storage of food items. These failures had the potential to result in foodborne illnesses for residents receiving kitchen services.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to obtain the informed consent prior to administering the new or increased psychotropic medications for two of six final sampled residents (Residents 10 and 30) reviewed for the informed consent. * Resident 30's informed consent was completed after the resident had started the psychotropic medication. * The facility failed to ensure Resident 10's informed consent was obtained prior to administering the quetiapine fumarate (antipsychotic medication) for Resident 10. These failures had the potential for the residents not being fully informed of the medications and the potential effects of the medications.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the safe self-administration of the medication for one of 21 final sampled residents (Resident 27). * A bottle of artificial tears eye drop (medication to temporarily relieve dry, irritated eyes) was kept at Resident 27's bedside table. Resident 27 was not assessed to ensure the resident was safe to self-administer the medication. This failure had the potential to negatively impact the resident's physiological well-being and the potential for the resident to administer the medications inaccurately.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the physician was notified timely for one of three residents (Resident 22) reviewed for hospitalizations. * The facility failed to notify the physician or an alternate physician timely to obtain orders for Resident 22's change in condition. Additionally, Resident 22's radiology reports showed severe colonic distention from megacolon or ileus, chronic large bowel obstruction not excluded and mild bibasilar air space disease possible aspiration or developing consolidation. When Resident 22's physician was notified, an order to transfer Resident 22 to an acute care hospital for further evaluation and treatment was documented seven hours after the radiology report was transmitted to the facility. These failures had the potential to delay the medical interventions for Resident 22.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide reasonable care for the protection of the resident's personal property from loss or theft for one of one final sample resident (Resident 51) reviewed for personal property. * Resident 51's personal belonging was not listed in the inventory form. 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 ensure two of five final sampled residents (Residents 10 and 22) reviewed for unnecessary medications were free from unnecessary psychotropic medications. * The facility failed to ensure Resident 10's orthostatic blood pressure was accurately monitored as ordered by the physician and per the care plan for the use of the psychotropic medications. In addition, the facility failed to implement the nonpharmacological interventions for Resident 10's use of the lorazepam (antianxiety), aripiprazole (antipsychotic), duloxetine (antidepressant), and quetiapine (antipsychotic) medications. * The facility failed to ensure Resident 22's orthostatic blood pressure was accurately monitored as ordered by the physician and per the care plan for the use of the Seroquel (antipsychotic) medication. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the notice of discharge and discharge summary documentation for one of three sampled residents (Resident 90) reviewed for closed records. This failure had the potential for Resident 90 to have an inappropriate discharge.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the PASARR was accurate and updated for one of four final sampled residents reviewed for PASARR (Resident 27). Resident 27 had serious mental illness on admission and had developed the new serious mental illness diagnoses after the initial admission to the facility. This failure had the potential for Resident 27 to be inappropriately placed in the facility and not receive the treatment and services to meet the resident's needs.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure a comprehensive care plan was developed for two of 21 final sampled residents (Residents 9 and 19) and failed to implement the care plan for one nonsampled resident (Resident 42). * The facility failed to to develop a comprehensive person-centered care plan to address Resident 9's use of Namenda (medication used for cognitive loss). * The facility failed to develop a comprehensive person-centered care plan to address Resident 19's depressive signs and symptoms. * The facility failed to implement Resident 42's fall risk care plan for the use of the bilateral floor mats. These failures had the potential risk of not providing appropriate, consistent, and individualized care to the residents.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure a physician's order for the orthostatic blood pressure monitoring while standing was clarified for one of 21 final sampled residents (Resident 31). This failure placed the resident at risk of receiving services not appropriate for his functional level.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure two nonsampled residents (Residents 25 and 42) remained free from accident hazards. * The facility failed to ensure the bilateral floor mats were implemented in accordance with the physician's order for Resident 42. * The facility failed to ensure Resident 25 had a physician's order prior to going out on pass. These failures had the potential to place the residents at risk for injury.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure two of two final sampled residents (Residents 61 and 493) and one nonsampled resident (Resident 59) reviewed for respiratory care were provided the appropriate respiratory care. * The facility failed to ensure Resident 59's oxygen order was carried out as ordered by the physician. * The facility failed to ensure Resident 61's oxygen order was carried out as ordered by the physician. * The facility failed to ensure Resident 493 received oxygen administration as ordered by the physician. These failures had the potential to affect the respiratory health and well-being of the residents in the facility.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the appropriate pain management for three of three final sampled residents (Residents 10, 30, and 45) reviewed for pain management. * The facility failed to accurately document the monitoring of pain for Resident 45 and administer the pain medications according to the physician's order. In addition, the facility failed to ensure the non-pharmacological interventions for pain were provided to Resident 45 prior to the administration of the pain medications as per the physician's order. * Resident 10 was administered pain medication outside of the ordered pain level parameters. * Residents 10 and 30's pain level was not monitored and documented as ordered. [...]

Inspectors wroteBased on observation, interview, facility document review, medical record review, and facility P&P review, the facility failed to ensure the ongoing assessment before, during, and after dialysis treatments for two of two final sampled residents (Residents 45 and 61) reviewed for dialysis was conducted as evidence by: * The facility failed to ensure Resident 45's Hemodialysis Communication Records were complete, and ensure accurate documentation for the monitoring for Resident 45's fluid restriction. In addition, the facility failed to ensure Resident 45 was administered the blood pressure medications after dialysis as per the physician's orders. * The facility failed to ensure Resident 61's Hemodialysis Communication Records were complete and accurate. These failures had the potential of not identifying negative outcomes for dialysis residents.

Inspectors wroteBased on interview, medical record review and facility P&P review, the facility failed to provide the pharmacy services to meet the resident needs for one of 21 final sampled residents (Resident 22), and two nonsampled residents (Residents 70 and 74). * Residents 70 and 74's controlled medication log did not match the MAR. * The facility failed to ensure the BP medication was held as per the physician's ordered hold parameters for Resident 22. These failures had the potential for poor health outcomes related to a potential unstable BP, and a delay in identifying potential diversion of the controlled medications.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 5.13%. One of three licensed nurses (LVN 1) was found to have made errors during the medication administration observation. * LVN 1 failed to administer the complete dose for two of Resident 22's medications when significant residual of the medications were observed in the medication cups after administering the zinc (supplement) medication and vitamin D3 (supplement) medication via GT to Resident 22. This failure had the potential to negatively affect the resident's health conditions and posed the risk for possible complications or delay in interventions.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to store the drugs and biologicals in a safe manner for two of two medications rooms (Medication Rooms A and B) and three of three medication carts (Medication Carts A, B, and C). * The facility failed to remove the expired medications after the discard after or use-by date. * The facility failed to ensure proper labeling of the eye drop medication with the opened date. * The facility failed to remove the discontinued medications from the medication cart for Residents 10 and 50. * The facility failed to ensure the orally administered medications were stored separately from externally used medications. These failures had a potential to negatively impact residents' physiological well-being and posed the risk of unauthorized access, drug diversion, and medication administration errors; [...]

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the menu was followed when preparing food for the residents. * The facility failed to ensure [NAME] 1 followed the recipe when preparing pureed spaghetti. This failure had the potential for not providing nutritional meals to meet the needs of the residents who were on pureed diet.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to implement their P&P to ensure proper storage of food in the residents' refrigerator as evidenced by: * Residents' refrigerator for food brought from the outside was not maintained in a proper temperature. In addition, the food items were in the residents' refrigerator not labeled with the current date and use by dates as per the facility's P&P. These failures had the potential to result in foodborne illnesses in a highly susceptible resident population.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to properly dispose of the unused items. This failure had the potential to attract rodents and pests that carried a disease.

Inspectors wrote3. Medical record review for Resident 3 was initiated on 5/18/25. Resident 3 was admitted to the facility on [DATE]. On 5/20/25 at 1032 hours, an interview and concurrent medical record review for Resident 3 was conducted with the ADON. A review of Resident 3's EHR was conducted with the ADON. Resident 3's EHR contained Resident 343's PASRR Level 1 screening. The ADON verified Resident 343's PASRR Level 1 screening was uploaded to Resident 3's EHR in error. Based on interview, medical record review and facility P&P review, the facility failed to ensure the complete and accurate medical records for four of 21 final sampled residents (Residents 3, 9, 10, and 19). * The facility failed to ensure Residents 9 and 19's MAR documentation for months of April and May 2025 were accurate regarding monitoring for the side effects for apixaban use (a medication used to prevent blood clots). [...]

Inspectors wroteBased on interview, and facility document review, the facility failed to ensure the QAPI committee implemented and monitored the effectiveness of their plan of correction for improvement of repeated deficient practice cited at F552, F812, and F883. This failure had the potential to affect the quality of care for all the residents in the facility.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the appropriate infection control practices designed to provide the safe and sanitary environment were implemented as evidenced by: * The facility failed to ensure the basins found inside the shared restrooms in Rooms A, B, C, and D were properly labeled and stored. * The facility failed to ensure Resident 595's personal food items maintained infection control. These failures had the potential to spread communicable diseases to the vulnerable residents in the facility.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure one of five final sampled residents (Resident 12) reviewed for influenza vaccinations was offered the influenza vaccination. This failure placed Resident 12 at risk for increased risk of infection and the transmission of influenza.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure one of five final sampled residents (Resident 12) reviewed for COVID-19 vaccination was offered the COVID-19 vaccination. This failure placed Resident 12 at risk for increased risk of infection and transmission of COVID-19.

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 ensure two of 13 sampled residents (Residents 8 and 13) attained and maintained the highest practicable physical well-being. * On 12/22/24, Resident 8 requested to continue the Ciprodex Otic suspension (used to treat middle ear infections) for continued ear pain after completing the seven-day treatment on 12/20/24. Resident 8 received the requested Ciprodex Otic suspension on 1/7/25, 16 days later. * The facility to ensure Resident 13's ceftriaxone sodium (antibiotic) intravenous medication was administered as per the physician's order. These failures had the potential to negatively affect residents' health condition and well- being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to provide the pharmaceutical services for one of 13 sampled residents (Resident 8) to meet the needs of each resident as evidenced by: * The facility failed to ensure the medication was administered as ordered to Resident 8. This failure had the potential for poor health outcome to Resident 8.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure three of three sampled residents (Resident 3, 4, and 5) reviewed for the use of respiratory care equipment was provided with the appropriate respiratory care. * The facility failed to ensure Resident 3's oxygen tubing was changed weekly and the CPAP mask was stored in a dated set-up bag when not in use. * The facility failed to ensure Resident 4's Yankauer tip suction was clean and stored according to the facility' P&P. * The facility failed to ensure Resident 5's oxygen tubing was stored in a bag and changed weekly as ordered by MD.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of sevensampled residents (Residents 6) could self-administer the medications safely. * Resident 6 had a bottle of sealed Motrin (medication to relieve pain) 200 mg, a plastic medication cup containing one tablet of Oscal 500/200 with vitamin D (supplement), and two capsules of Docu Soft (stool softener) 100 mg inside the drawer of Resident 6's bedside table for self-administration. Resident 6 was not assessed for self-administration of medications. This failure had the potential to negatively impact the resident's physiological well-being, and administer the medications inaccurately.

Inspectors wroteBased on interview, medical record review, and facility document review, the facility failed to ensure one of seven sampled residents (Resident 2) was free from the physical abuse by another resident. * Resident 2 was hit on the left shoulder and left side of the face by Resident 1. This failure had the potential to negatively impact the resident's well-being.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to promote the dignity and respect for one of seven sampled residents (Resident 2). * CNA 1 was observed standing over Resident 2 while assisting the resident to eat her meal. This failure posed the risk of not treating the resident with respect.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the call light was accessible for one of sevensampled Residents (Resident 6). * Resident 6's call light was not within her reach. This failure had the potential to negatively impact Resident 6's psychosocial well-being.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure the oversight of food service operations when the facility did not employ a full-time qualified individual, defined as 35 hours per week, to manage and oversee food operation services for the skilled nursing facility. This failure had the potential to jeopardize the health and well-being of the 82 residents who received food prepared in the kitchen.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the food safety and sanitation requirements were met in the kitchen when: * The facility failed to properly monitor for Time/Temperature Control for Safety (TCS) foods (food that require time and temperature controls to limit the growth of illness causing bacteria) to ensure proper cool down process was followed, as per the facility's P&P. * The facility failed to ensure the refrigerated pasta salad was labeled with a prepared date and a use by date, as per the facility's P&P. * The facility failed to label and properly cover the thawing meat in the refrigerator. * The facility failed to ensure the food past the use-by date was discarded. * The facility failed to properly air-dry the kitchen equipment. [...]

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to establish and maintain the infection control program and practices designed to help prevent the development and transmission of diseases and infections as evidenced by: * The facility failed to ensure the EBP (Enhanced Barrier Precautions) was practiced for Resident 71. * The facility failed to ensure hand hygiene was performed after adjusting the resident's bed control using a gloved hand and proceeding to perform care for Resident 8. * The licensed nurse failed to ensure a contaminated equipment was not disinfected prior to use on Resident 793. * The facility failed to ensure infection control was maintained in the laundry room. * The facility failed to ensure the staff and visitors followed the contact precautions before entering Resident 93's room. [...]

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the antibiotics were prescribed and administered to the residents under the guidance of their antibiotic stewardship program. * The facility failed to monitor and address the use of antibiotics when the resident's condition did not meet the McGeer's criteria (a set of specific definitions to identify true infections in long term nursing facilities) for six nonsampled residents (Residents 38, 63, 71, 593, 594, and 595). * The facility failed to ensure their antibiotic surveillance tracking forms included outcome and adverse events during the months of January 2024 through May 2024. These failures had the potential for antibiotics to be used when it was not indicated and the development of antibiotic-resistant bacteria.

Inspectors wroteBased on observation, interview, equipment instruction manual review, and facility P&P review, the facility failed to maintain the essential equipment in safe operating condition. * The facility failed to ensure the ice machine was cleaned and sanitized according to the manufacturer's specification. This failure had the potential for the equipment to not function in the way it was intended, which could cause food-borne illnesses for the residents.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of five final sampled residents (Resident 55) reviewed for psychotropic use was informed of the use of psychotropic medications (medication affecting brain activities associated with mental processes and behavior). * The facility failed to ensure Resident 55's informed consent was obtained prior to administering the increased dosage of mirtazapine (antidepressant medication). This failure had the potential for Resident 55 to not be informed of the medication and potential side effects of mirtazapine.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the reasonable accommodations to meet the needs for two of 22 final sampled residents (Residents 5 and 55). * The facility failed to ensure Resident 5's head of bed was elevated to allow the resident to reach her meal tray. * The facility failed to ensure Resident 55's call light was within the resident's reach. These failures had the potential to negatively impact the residents' psychosocial well-being or result in a delay to receive care.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to provide two nonsampled residents (Residents 394 and 395) with the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN) Form CMS-10055. This failure had the potential for not allowing the residents or their representatives to make informed decisions regarding their healthcare.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the privacy was provided for three of 22 final sampled residents (Residents 3, 8, and 244). * The privacy curtain was not pulled completely in Resident 8's room when the license nurse administered the medications via GT. Additionally, Resident 8's window had the missing blind slats showing a walkway outside the window during the medication administration via GT. * The computer screen on Medication Cart 3 was left unattended showing Resident 3 and other residents' names and care information. * The computer screen was left on unattended with no privacy screen in Nursing Station 2 showing Resident 244's personal information. These failures had the potential to negatively affect the dignity of the residents and violate the resident's rights to privacy.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to maintain a clean and homelike environment for four of 22 final sampled residents (Residents 14, 65, 74, and 75) and two nonsampled residents (Residents 8 and 71). * Residents 65 and 74 complained about the condition of the carpet in the resident hallways throughout the facility, stating the carpets were dirty. * Two resident's rooms (Residents 14 and 75) were observed with missing paint and scrapes on the walls. * Resident 8's window was observed with missing blind slats. * Resident 71's room was observed with an improperly hung curtain. These failures had the potential to negatively impact the residents' quality of life.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to follow up on the grievance for one of 22 final sampled residents (Resident 25). This failure had the potential for violating the resident's rights to have their grievances resolved.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to notify the resident's representatives of the transfer and reasons for the transfer to the acute care hospital in writing and send a copy of the notice of transfer to the representative of the Office of the State Long-Term Care (LTC) Ombudsman for two of three sampled residents (Residents 55 and 72) reviewed for hospitalization. This failure posed the risk of the resident's representatives not being aware of their appeal rights and the 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 interview, medical record review, and facility P&P review, the facility failed to ensure the resident or the resident's representative was provided a written bed hold policy upon transfer to the acute care hospital for two of three sampled residents (Resident 55 and 72) reviewed for hospitalization. This failure had the potential for the resident or the resident's representative to not be informed of their rights to return to the facility following a hospitalization.

Inspectors wroteBased on interview and medical record review, the facility failed to coordinate an assessment with Pre-admission Screening and Resident Review (PASRR) program for one of 22 final sampled residents (Resident 15) when the resident had a newly evident mental disorder for level II review. This failure posed the risk for Resident 15 not receiving the necessary specialized services specific to treat mental illness and had the potential for inappropriate placement in a long-term nursing home.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the level 1 PASRR Screening was conducted after an acute care hospital discharge exemption lapsed for one of four residents (Resident 65) reviewed for PASRR. * Resident 65's Level I PASRR Screening dated 4/3/24, showed Resident 65 had a diagnosed mental illness and had been prescribed psychotropic medications. Resident 65's Level 1 Screening was negative, and a Level II mental health evaluation referral was not required due to an exempted hospital discharge. Further review of Resident 65's Level 1 PASRR Screening dated 4/3/24, showed if Resident 65 remained in the facility longer than 30 days, the facility should resubmit a new Level 1 PASRR Screening on the 31st day. However, the facility failed to resubmit a new Level 1 PASRR Screening when Resident 65 had remained in the facility longer than 30 days. [...]

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 three of 22 final sampled residents (Residents 25 and 93) attained and maintained their highest practicable well-being. * The facility failed to ensure Resident 93's medication order for Insulin Regular Human (Regular Insulin is a short-acting type of insulin) Injection Solution per sliding scale was administered as ordered by the physician. This failure posed risk for Resident 93 to have hyperglycemic episode and to receive unnecessary short acting insulin dose. * Resident 25's change in skin integrity were not assessed and documented. This failure posed the risk of Resident 25 not receiving appropriate care.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of one resident (Resident 25) reviewed for accident hazards remained free from accident hazards. * The facility failed to ensure two persons transferred Resident 25 with the mechanical lift. This failure had the potential for injury to Resident 25.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure one of three sampled residents (Resident 8) reviewed for GT care received adequate care as evidenced by: * The facility failed to ensure the GT patency and placement were properly checked before the medication was administered for Resident 8. This failure had the potential for negative outcomes for the residents with GT.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one sampled resident (Resident 93) reviewed for IV therapy was administered parenteral flushes in accordance with the physician's order. * The facility failed to flush Resident 93's IV every 12 hours as ordered by the physician. This failure posed the risk for complications related to the IV therapy.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure one sampled residents (Resident 35) reviewed for dialysis treatment received the dialysis treatment at the prescribed time. * Resident 35's transportation issues were not followed up on with the resident's insurance carrier. This failure had the potential for negative health outcomes for the resident.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the pharmaceutical services including accurate acquiring, receiving, dispensing, and record keeping were maintained to meet the needs of each resident as evidenced by: * The facility failed to ensure the medications removed from the emergency kit were replaced in a timely manner. * The facility failed to ensure the controlled drug count reconciliation logs were properly accounted for and documented. These failures had the potential for not having the medications available for use in case of emergency and drug diversion.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure one of 22 final sampled resident (Resident 25) was free from the unnecessary medications. * The facility failed to clarify Resident 25's physician's order for no other narcotics and muscle relaxants while on methadone (narcotic). Resident 25 was prescribed narcotics pain medications and muscle relaxant with methadone. This failure had the potential for Resident 25 to receive unnecessary medications and develop significant adverse effects, and risk adverse effects from prolonged use of medication.

Inspectors wroteBased on interview, medical record review, and facility P& P review, the facility failed to ensure one of 22 final sampled residents (Resident 15) was free from the unnecessary psychotropic medications (medication that affects the brain activity). * The facility failed to ensure the Psychotropic Medication Administration Disclosure (informed consent) was completed prior to the administration of Resident 15's psychotropic medications. This failure posed the risk of not evaluating the need and effectiveness of Resident 15's psychotropic medications use

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the facility's medication error rate was below 5%. * The facility's medication error rate was 16.12%. One of three licensed nurses (LVN 3) was observed administering the medications to one of 22 final sampled residents (Resident 8) and was found to have errors. The facility failed to ensure Resident 8 received the prescribed medications as ordered. This failure had the potential for the resident to not receive the effective therapeutic effects of the medications and may negatively affect the resident's health.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 22 final sampled resident (Resident 8) was free from the significant medication errors. This failure placed Resident 8 at risk for medical complications.

Inspectors wroteBased on observation, interview, medical record review, facility P&P review, the facility failed to ensure the medications were labeled and stored safely, securely, and properly. * The facility failed to ensure the medications were stored and labeled properly. * The facility failed to ensure the discontinued medications were removed from the medication cart. * The facility failed to ensure the oral medications were stored separate from externally used medications. These failures had the potential for medication errors.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to offer and provide education for COVID-19, influenza, and pneumococcal immunizations for three of 22 final sampled residents (Resident 2, 15, and 75). * The facility failed to provide education and offer the COVID-19 and influenza immunizations to Resident 75. * The facility failed to offer and provide education for PCV 15/20 (PCV 15 protects against two additional serotypes and PCV 20 protects against seven additional serotypes involved in cases of invasive pneumococcal disease (IPD) and pneumonia) for Residents 2, 15, and 75. These failures increased the risk for residents to be inadequately vaccinated for COVID-19, influenza, and pneumococcal disease and not be informed of its associated complications.

Inspectors wroteBased on interview, facility document review, and facility P&P review, the facility failed to maintain the documentation if the staff received the COVID-19 vaccinations, were provided the education regarding the benefits and risks of COVID-19 vaccines, and were offered to receive the COVID-19 vaccine. This failure placed the staff and residents at risk of COVID-19.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the baseline care plan for one of 22 final sampled resident (Resident 55) was initiated upon admission. * The facility failed to ensure Resident 55's baseline care plan included the necessary information to properly care for the resident using anticoagulant medication, necessary interventions to prevent bleeding. This failure had the potential for Resident 55 not receiving necessary resident-centered care.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the comprehensive care plan was developed for one of 22 final sampled residents (Resident 393). * The facility failed to develop the comprehensive resident-centered care plan to address the use of oxygen for Resident 393. This failure placed the resident at risk of not being provided appropriate, consistent, and individualized care.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the oxygen therapy equipment was stored in a sanitary manner for one of two sampled residents reviewed for oxygen therapy (Resident 393). * Resident 393's nasal cannula was observed lying on the floor. This failure posed the risk for equipment contamination and respiratory complications.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure two of four garbage dumpsters with lids were properly closed. This failure had the potential to attract pests/rodents that carry diseases.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the privacy for one sampled resident (Resident 4) was provided during care. * The privacy curtain was not pulled while providing ADL care to Resident 4. This failure had the potential to violate the resident's rights to privacy.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to notify Resident1 's family of the resolution of the theft and loss filed report. This failure had the potential to impact Resident 1's well-being and the risk of violating the resident's rights.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to establish and maintain the infection control program and practices designed to help prevent the development and transmission of diseases and infections for two of eight nonsampled residents (Residents G and H). * The facility failed to ensure Residents G and H's urinal bottles were stored in a sanitary manner. This failure had the potential for increased risk of infection and compromising the residents' medical conditions.