Ararat Nursing Facility

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices for one of three sampled residents (Resident 1) by failing to maintain complete and accurate documentation when Resident 1's care plan did not correctly indicate the correct year of the fall. This failure resulted in Resident 1's medical records containing inaccurate information, which had the potential to negatively affect Resident 1's care in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent a fall and injury for one of four sampled residents (Resident 1), who had severely impaired cognition (resident had lost the ability to think, learn, remember, or make decisions to the point that resident cannot live independently and require full-time supervision or help with daily tasks like eating and dressing), identified as high risk for falls, and had history of falls. The facility failed to ensure two or more nursing staff assisted Resident 1 when turning in bed from one side to the other side during resident care. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide care and services in accordance with professional standards of practice for one of four sampled residents (Resident 2). The facility failed to ensure that Resident 2's witnessed fall on 5/25/2026, which resulted in a subarachnoid hemorrhage (a serious type of brain bleed), was reported to the State Survey Agency (SSA) within 24 hours as required by the facility's policy and procedure, titled Unusual Occurrence Reporting. This deficient practice had the potential for delayed oversight, inadequate monitoring, and potential unmet resident medical needs following a serious injury.

Inspectors wroteBased on interview and record review, the facility failed to ensure the medical records for one of four sampled residents (Resident 3) were maintained in accordance with accepted professional standards and practice, complete, and accurately documented by failing to ensure licensed nurses documented the correct change in condition (COC - when there is a sudden change in a resident's condition) date on Resident 3's medical record. This deficient practice resulted in inaccurate information on Residents 3's medical records and had the potential for delayed and inaccurate medical interventions.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free from significant medication error (one which causes the resident discomfort or jeopardizes his or her health and safety) when Registered Nurse (RN) 1 failed to resume Resident 1's apixaban (a generic name of a blood thinner medication used to prevent blood clots) on 5/28/2026 as ordered by the Medical Doctor (MD). On 5/27/2026, the MD gave an order to RN 1 to hold Resident 1's apixaban on that night (5/27/2026) because of nose bleeding but to resume it the next day (5/28/2026). Resident 1 did not receive the apixaban medication from 5/28/2026 through 6/1/2026. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure professional standards of practice were followed for one of three sampled residents (Resident 3) when Certified Nurse Assistant (CNA) 1 found Resident 3 on her knees next to her roommate's bed on 5/15/2025. The facility failed to: 1. Complete Resident 3's Change of Condition (COC) assessment. 2. Monitor Resident 3 for 72 hours after the fall. 3. Conduct neuro checks on Resident 3. 4. Implement interventions to prevent Resident 3 from further falls. These failures had the potential to result in delayed care and services following Resident 3's fall.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a person-centered care plan (a tool that ensures residents receive personalized, comprehensive, and goal-oriented care in a nursing home setting) for four of nine sampled residents (Residents 3, 4, 6, and 8) by failing to:1. Implement Resident 3's care plan on risk of anti-hypertensive medication (medications used to treat hypertension [HTN-high blood pressure]).2. Develop a care plan for Resident 4's use of hydrogel (promotes wound healing by maintaining a moist environment, cooling the skin, and softening dead tissue to allow the body to naturally clear it away).3. Implement Resident 6's care plan on enhanced barrier precaution (EBP- an infection control method used in nursing homes to prevent the spread of hard-to-treat germs, like antibiotic-resistant bacteria).4. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents received care consistent with professional standards of practice for two of nine sampled residents (Residents 1 and 9) by failing to:1. Ensure the Physician was notified of Resident 1's blood sugar over 250 milligrams (mg- metric unit of measurement, used for medication dosage and/or amount) per deciliter (dl- a metric unit of volume equal to one-tenth of a liter) on 4/17/2026, to 4/19/2026, as per physician order.2. Ensure Resident 9's fluid restriction of one liter per day was followed as per physician order. These failures had the potential to place Resident 1 at risk for hyperglycemia (high blood sugar) and for Resident 9 at risk for fluid overload.

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents received care consistent with professional standards of practice to prevent pressure injuries (localized damage to the skin and/or underlying tissue usually over a bony prominence) for three of nine sampled residents (Residents 3, 4, and 6) by failing to:1. Ensure Treatment Nurse 1 (TN 1) provided wound treatment to Resident 3's pressure injuries on 5/14/2026.2. Ensure TN 1 assessed Resident 3's skin accurately on 5/10/2026.3. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that pain management was provided to residents who require such services, consistent with professional standards of practice for one of four sampled residents (Resident 9) by failing to ensure nurses administer hydrocodone (medication used to treat severe and persistent pain) and morphine (a strong pain-relief medicine that can cause life-threatening breathing problems) for severe pain level as per physician order. These failures had the potential to result in Resident 9's sedation (state of calmness, relaxation, or sleepiness caused by certain drugs) that could lead to slow and shallow breathing.

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) for three of five sampled residents (Residents 3, 5, and 6) by failing to:1. Ensure Licensed Vocational Nurse 4 (LVN 4) and LVN 5 follow physician order to hold (to temporarily pause or skip a dose as instructed by a healthcare professional) metoprolol (medication used to treat hypertension [HTN- high blood pressure]) for Resident 3's systolic blood pressure (sbp- the top or first number in a blood pressure reading. It measures the maximum pressure the blood exerts against the artery walls when the heart beats and pumps blood throughout the body) below 120-millimeters of mercury (mmHg-standard unit of measurement for pressure).2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe provision of pharmaceutical services for four of nine sampled residents (Residents 4, 6, 10, and 11) during treatment cart storage observation by failing to:1. Ensure Resident 4's nystatin cream (medication used to treat skin infections caused by yeast) was labeled with an open date.2. Ensure Resident 6's Silver Silvadene cream (medication used to prevent, manage, and treat burn wound infections) was labeled with an open date.3. Ensure Resident 10's Santyl (medication used to clean dead, damaged tissue from severe burns and chronic skin ulcers [a small open sore or wound generally found in the stomach or on the skin]) was labeled with an open date.4. Ensure Resident 11's Dakins solution (diluted bleach used to kill germs without hurting a healing wound) was labeled with an open date. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain accurate and complete medical record for three of nine sampled residents (Residents 3, 8, and 9) by failing to:1. Ensure accurate documentation of Resident 3's location of pressure ulcer (localized damage to the skin and/or underlying tissue usually over a bony prominence) on 5/8/2026.2. Ensure accurate documentation of Resident 8's location of pressure ulcer in the weekly Skin Checks on 4/23/2026, 4/30/2026, and 5/7/2026.3. Ensure accurate documentation of Resident 8's right heel deep tissue injury (DTI-purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure and/or shear) on 5/2026 Treatment Administration Record (TAR).4. Ensure accurate documentation of Resident 9's weekly Skin Check on 4/16/2026. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its infection control measures for two of seven sampled residents (Residents 4 and 6) by failing to:1. Ensure Resident 4's oxygen tubing (flexible tubing that carries oxygen from an oxygen source to the user) was not touching the floor.2. Ensure Treatment Nurse 1 (TN 1) wore gloves when applying new foam dressing to Resident 4's stage two pressure injury (Partial-thickness loss of skin, presenting as a shallow open sore or wound).3. Ensure Certified Nursing Assistant 1 (CNA 1) wore gown when providing bed bath to Resident 6 who was on enhanced barrier precaution (EBP- an infection control method used in nursing homes to prevent the spread of hard-to-treat germs, like antibiotic-resistant bacteria). These failures had the potential to spread and expose other residents to infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure the medical records of one of three sampled residents (Resident 1) was maintained in accordance with accepted professional standards and practice, complete, and accurately documented by failing to:1. Ensure Registered Nurse (RN) 1 documented the level of care provided to Resident 1 while the resident was in the facility. RN 1 documented the level of care and assessment she provided to Resident 1 on 2/10/2026. Resident 1 had a change of condition (COC) on 2/9/2026.2. Ensure social service staff documented the level of care provided to Resident 1 while the resident was in the facility. Social service staff documented Resident 1 was transferred to the General Acute Care Hospital (GACH) 1 on 2/9/2026. Resident 1 was transferred to GACH 1 on 2/10/2026. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure confidential personal information for one of four sampled residents (Resident 4) was protected. The medical records of Resident 4 were left unattended on the medication cart computer. This deficient practice had the potential to violate Resident 4's rights for privacy and confidentiality of personal and medical records.

Inspectors wroteBased on interview and record review, the facility failed to ensure a comprehensive, person-centered care plan with measurable objectives and interventions for one of three sampled residents (Resident 1) was created and implemented. The facility failed to develop and implement an individualized care plan with interventions addressing Resident 1's change of condition (COC) on 2/9/2026. This deficient practice had placed Resident 1 at risk for not receiving the necessary services and assistance that can result in resident injury or serious condition such as worsening of Resident 1's right hip fracture and pain.

Inspectors wroteBased on interview and record review, the facility failed to follow professional standards of practice for one of three sampled residents (Resident 1) by failing to:1. Ensure licensed nurses monitored Resident 1's medical status after the resident's change of condition (COC) on 2/9/2026. Resident 1's COC status was not monitored on 2/9/2026, 11 p.m. to 7 a.m. shift.2. Ensure Registered Nurse (RN) 1 assessed Resident 1's right lower extremity after the resident complained of right hip pain. These deficient practices had the potential to place Resident 1 at risk for undetected and worsening medical conditions which could negatively impact the residents' health and safety.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1), who had a history of multiple falls in the facility (12/20/2024 and 9/30/2025) and required partial/moderate assistance (helper does less than half the effort) from facility staff with bed mobility (the ability to roll from lying on back to left and right side, and return to lying on back on the bed), remained free from accidents by failing to:1. Initiate the facility's Falling Star Program (a resident safety initiative that uses a visual symbol, like a falling star, to identify residents at high risk for falls in healthcare settings) on 6/24/2025 when Resident 1 was identified as being at higher risk for falls following a fall incident on 12/20/2024. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the medical records for one of four sampled residents (Resident 1) were maintained in accordance with accepted professional standards and practice, complete, and accurately documented by failing to ensure accurate documentation of Fall Risk Assessment (a tool to identify residents at high risk of falling by evaluating factors such as medical conditions, vision, balance, mobility, medications) form. This deficient practice had the potential for inaccurate medical interventions for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to protect the right of one of three sampled residents (Resident 1) to be free from physical restraint (is defined as any manual method, physical or mechanical device, equipment, or material that meets all of the following criteria: is attached or adjacent to the resident's body; cannot be removed easily by the resident; and restricts the resident's freedom of movement or normal access to his/her body). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Medical Doctor (MD) and the Resident Representative (RR) of one of three sampled residents (Resident 1) were notified when on 1/14/2026 at 3 a.m. Certified Nursing Assistant (CNA) 1 who was assigned to Resident 1 allegedly tied Resident 1's hands together at the wrist with a scarf while Resident 1 was in her bed in her (Resident 1) room. This deficient practice had the potential to negatively affect the care and services provided to Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to implement its Abuse Prevention and Prohibition Program Policy and Procedures (P&P) by failing to report the alleged abuse to the State Survey Agency (SSA), and local law enforcement, in accordance with the facility's policy no later than two (2) hours after the allegation occurred for one of three sampled residents (Resident 1) when on 1/14/2026 at 2:50 a.m. Licensed Vocation Nurse (LVN) 1, observed Resident 1 with her wrists bound. This deficient practice had the potential to result in unidentified abuse and placed Resident 1 at risk for further abuse.

Inspectors wroteBased on interview and record review, the facility failed to take precautionary measures to provide protection to one of three sampled Residents (Resident 1) when, on 1/14/2026 at 3 a.m. Certified Nursing Assistant (CNA) 1 who was assigned to Resident 1 tied Resident 1's hands together at the wrist with a scarf while Resident 1 was in bed in her (Resident 1) room. CNA 1 was able to continue to work with Resident 1 and all other residents in the facility until she clocked out on 1/14/2026 at 7:16 a.m. This deficient practice had the potential to place Resident 1 and other residents at risk for further abuse.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive person-centered care plan (a document designed to facilitate communication among members of the care team that summarizes a resident's health conditions, specific care needs, and current treatments) for one of three sample residents (Resident 1) to address the use of restraints when on 1/14/2026 at 3 a.m. Certified Nursing Assistant (CNA) 1 who was assigned to Resident 1 tied Resident 1's hands together at the wrist with a scarf while Resident 1 was in bed in her (Resident 1) room. This deficient practice had the potential to negatively affect the care and services provided to Resident 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) receive treatment and care in accordance with professional standards of practice when on 1/14/2026 at 3 a.m. Certified Nursing Assistant (CNA) 1 who was assigned to Resident 1 tied Resident 1's hands together at the wrist with a scarf while Resident 1 was in bed in her (Resident 1) room, the facility failed to:1. Failed to create a Change of Condition (COC) Evaluation for the alleged physical abuse2. Failed to start 72-hour monitoring (a watch period where staff closely observe a resident for three days to make sure the new health problem does not get worse) after Resident 1 had a COC.This deficient practice had the potential to negatively affect Resident 1's plan of care and delivery of necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure interventions to prevent falls were in place for one of three sampled residents (Resident 3) when Resident 3 had a fall on 11/19/2025 by failing to: 1. Ensure the Situational Background Assessment Recommendation (SBAR - a structured communication tool used primarily in healthcare for concise, clear updates, especially during handoffs or critical situations, ensuring all team members understand the resident's status and needs) Communication Form, dated 11/19/2025, was complete and accurate for Resident 3's Fall. 2. Ensure the Incident Note (IN - a formal, factual document that records any unplanned or unusual event that affects a resident, visitor, or staff member's safety or well-being) for Resident 3's fall on 11/19/2025 was complete and accurate. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of an employee-to-resident verbal abuse (harsh and insulting language directed at a person) and physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) within two hours to the State Survey Agency (SSA) for one of three sampled residents (Resident 1). Certified Nursing Assistant (CNA) 1 reported an allegation of abuse to the Director of Nursing (DON) that allegedly occurred on 8/5/2025, committed by Life Enrichment Coordinator (LEC) 1 towards Resident 1. The facility reported the allegation of abuse to the SSA on 8/29/2025, 24 days after the allegation of abuse was made. This deficient practice had the potential to result in unidentified abuse and failure to protect other residents from abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) received treatment and care to attain or maintain the highest practicable physical well-being, when the facility failed to: 1. Complete Resident 1's admission Assessment upon his re-admission to the facility after being transferred to the General Acute Care Hospital (GACH) 1 due to a fall incident. 2. Complete Resident 1's neurological checks for 72 hours post-fall in accordance with the facility's policy and procedure. These deficient practices had the potential to result in Resident 1 receiving inadequate care.

Inspectors wroteBased on interview and record review, the facility failed to complete a background check for three of three sampled employee files (Licensed Vocational Nurse 1 or LVN1, Registered Nurse 1 or RN1, and Certified Nurse Assistant 1 or CNA1). This deficient practice has the potential to place residents at risk for abuse, neglect, exploitation, or misappropriation of resident property.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) for one of six sampled residents (Resident 1) when on 7/25/2025 at approximately 2:30 p.m., Resident 2 threw a four-ounce (oz - a unit of measurement) thickened flavored water cup at Resident 1, inside Room A (Resident 1 and Resident 2's shared room), hitting Resident 1 on the left lower lip. This deficient practice resulted in Resident 1 being subjected to physical abuse by Resident 2 while under the care of the facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) for one of three sampled residents (Resident 224) when on 6/28/2025 at 2:45 p.m., Certified Nursing Assistant 11 (CNA 11) witnessed Resident 45 approached Resident 224 and hit Resident 224 on the head and right lower extremity (RLE - right side of the lower part of the human body) with a single point cane (a mobility aid with a single tip that provides basic support and balance assistance for individuals with minor mobility issues). This deficient practice resulted in Resident 224 being subjected to physical abuse by Resident 45 while under the care of the facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure three of five sampled residents (Resident 2, 19, 27) reviewed under unnecessary medication, were afforded the right to informed consent for the use of psychotherapeutic medications (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) by failing to: 1. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure residents were free from unnecessary (any medication in excessive dose, excessive duration, without adequate indication for its use and monitoring) use of psychotherapeutic drug (any medication capable of affecting the mind, emotions, and behavior) in accordance with facility policy and procedures for three (3) of six (6) sampled residents (Residents 2, 19 and 27) by failing to ensure: 1. Resident 2 had specific, measurable target behaviors monitored related to the use of clonazepam (a psychotropic medication used to treat anxiety). As a result, Resident 2 was not monitored for specific behavior with the use of clonazepam, starting 7/11/2025. 2. The use of clonazepam was limited to the use of as needed for 14 days or indicate a specific duration of use. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a tool that ensures residents receive personalized, comprehensive, and goal-oriented care in a nursing home setting) for four of the five sampled residents (Residents 117, and 106, 72 and 224) by failing to: 1. Ensure a care plan was developed for Resident 117's diagnosis of pneumonia (lung infection). 2. Ensure a care plan was developed for Resident 106's use of azithromycin (antibiotic medication used to treat infection). 3. Ensure a care plan was developed for Resident 72's refusal to remove the wheelchair on top of the floor mat (a cushioned floor pad designed to help prevent injury should a person fall). 4. Ensure a care plan was developed timely for Resident 224's involvement on a resident-to-resident altercation. [...]

Inspectors wroteBased on interview and record review, the facility's licensed nursing staff failed to provide care in accordance with professional standards to one of five sampled residents (Resident 6) reviewed for unnecessary medications by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (sq, beneath the skin) insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) administration sites. The deficient practice had the potential for adverse effect (unwanted, unintended result) of the same site subcutaneous administration of insulin such as excessive bruising, lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin).

Inspectors wroteBased on interview and record review, the facility failed to ensure residents with pressure ulcers/injury (a skin and tissue injury caused by prolonged pressure on the skin, often over bony areas) receive necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for one of three sampled residents (Resident 15) by failing to ensure weekly wound assessment was done for Resident 15's stage 2 pressure injury (it involves a break in the skin's outer layer [epidermis] and some damage to the underlying layer [dermis] on the coccyx (the last bone at the bottom [base] of the spine). The deficient practices had the potential for delay of necessary care and services and worsening of pressure injury to residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respiratory care was provided to residents consistent with professional standards of practice for three of four sampled residents (Resident 53, 72, and 114), reviewed for Respiratory care by failing to: -Ensure Resident 53's oxygen concentrator (a medical device that provides supplemental oxygen) was turned on to administer as needed (PRN) oxygen on 7/14 and 7/15/2025. -Ensure Resident 72's nebulizer (a small machine that turns liquid medicine into a mist that can be easily inhaled) tubing and mask was off of the floor. -Ensure Resident 114's nasal cannula (a simple, two-pronged device that delivers extra oxygen to the nose) tubing was not touching the floor. These deficient practices had the potential for residents to develop breathing complications and respiratory infections.

Inspectors wroteBased on interview and record review the facility failed to ensure sulfamethoxazole trimethoprim (antibiotic medication used to treat infection) was administered on 7/13/2025, at 9 a.m., per physician's order for one of five sampled residents (Resident 44). The facility also failed to reconcile (comparing medication activity to supporting documentation) six medication emergency kits (eKITs) for July 2025, in three of three medication rooms (Southwest Station, Southeast Station, East Station). These deficient practices had the potential for residents to experience medication errors, worsening of infection, and increased the opportunity for Controlled Medication diversion (CM - medications which have a potential for abuse, the transfer of a CM or other medication from a lawful to an unlawful channel of distribution or use).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five percent (% - one per hundred). Two medication errors out of 26 total opportunities contributed to an overall medication error rate of 7.69 % affecting two of three residents observed for medication administration (Residents 215 and 106). The medication errors were as follows: 1. Resident 215 did not receive Senna Plus (a combination medication containing senna [a laxative] with docusate [a stool softener] used for constipation) as ordered by Resident 215's physician. Instead, Resident 215 received senna tablet. 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure three of five sampled residents (Resident 6, Resident 106 and Resident 207) were free of significant medication errors. For Resident 6, the insulin administration sites were not rotated per standard of care. For Resident 106, the azithromycin (an antibiotic medication used to treat infections) was not administered timely, per physician's order on 7/16/2025, and Resident 207 received nine doses of expired fluticasone and salmeterol (a combination medication used to treat breathing disorders) inhalation powder Diskus (inhaler device used to deliver medication to the lungs). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe provision of pharmaceutical services by failing: a. To ensure there were no expired hand sanitizer on the resident's bedside table for one of two sampled residents (Resident 72) observed during resident screening. The expiration date of the hand sanitizer is 3/2021. This deficient practice had the potential for Resident 72 to use an alcohol-based hand sanitizer past its efficacy state decreasing the effect of killing bacteria or viruses on the resident's hands that can lead to resident illnesses. b. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen, reviewed during the Kitchen task by failing to: 1. Ensure food items in Walk-in Refrigerator 1 were labeled per facility policy. 2. Ensure food items in Walk-in Refrigerator 1, were properly covered with tight sealed lids per facility policy. 3. Ensure expired food items in Walk-in Refrigerator 1 and in the food preparation area were discarded per facility policy. 4. Ensure the sanitization buckets were maintained per the manufacturer guidelines with the recommended concentration level of chemicals. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain complete and accurate medical record in accordance with accepted professional standards for 11 of 75 sampled residents, including five of five sampled residents (Residents 44, 106, 117,188, and 96) reviewed for infection control, 6 of 244 sampled residents (Resident 48, 121, 140, 146, 159, and 240) receiving Restorative Nursing Aide ([RNA] nursing aide program that helps residents to maintain their function and joint mobility) services, by failing to: 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement appropriate infection control practices for one of six sampled residents (Residents 21) reviewed under the Nutrition care area by failing to: 1. Implement Enhanced Barrier Precautions (EBP, sometimes referred to as enhanced standard precautions, an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDRO, microorganisms, mainly bacteria, that are resistant to one or more classes of antibiotics] that uses targeted gown and glove use during high contact resident care activities) for Resident 21 during indwelling catheter (a flexible tube placed in the bladder to drain urine) care (the act of cleaning the catheter and area around the catheter). 2. [...]

Inspectors wroteBased on interview, and record review, the facility failed to implement its policy for antibiotic (medication used to treat infection) stewardship (efforts in doctors' offices, hospitals, long-term care facilities, and other health care settings to ensure that antibiotics are used only when necessary and appropriate, means prescribing the right drug at the right dose at the right time for the right duration) program and infection prevention and control program for four of five sampled residents (Residents 188, 117, 60, and 44) by: 1. Failing to monitor Resident 188 for the adverse effects (undesired or harmful effects) of cefdinir (antibiotic medication used to treat infection) on the following dates and times: a. 7 a.m., to 3 p.m. on 6/26/2025, and 6/27/2025. b. 3 p.m., to 11 p.m., on 6/29/2025. c.11 p.m., to 7 a.m. on 6/27/2025, 67/28/2025, and 6/29/2025. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Infection Preventionist performed the duties of the position by failing to implement the antibiotic (medication used to treat infection) stewardship program (efforts in doctors' offices, hospitals, long-term care facilities, and other health care settings to ensure that antibiotics are used only when necessary and appropriate, means prescribing the right drug at the right dose at the right time for the right duration) and the infection prevention and control program for four of five sampled residents (Residents 188, 117,106, and 44) by: 1. Failing to completely fill out the Infection Control Surveillance log (a documented record used to systematically track and analyze healthcare-associated infections and other infectious diseases within a healthcare facility), dated 6/2025, for Resident 188, 117 and 106. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the decision of the resident representative were given the same consideration as if the resident made the decision themselves for one of seven sampled residents (Resident 102) reviewed for accidents by failing to assess and implement Resident Representative (RR) 1's request for a least restrictive form of physical restraint (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the resident's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) for safety. This deficient practice had denied the right of the resident representative to advocate for the resident who was deemed incompetent to make medical decisions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep the call light (an alerting device for nurses or other nursing personnel to assist a patient when in need) within reach of the resident for three of the three sampled residents (Residents 125, 113 and 74) reviewed under the area of accommodation. The deficient practice had the potential to result in the residents being unable to summon health care workers for help as needed.

Inspectors wroteBased an observation, interview, and record review, the facility failed to ensure that nine of nine residents (Residents 59, 73, 116, 119, 123, 131, 135, 150 and 232) who attended the Resident Council Meeting (gathering of residents, typically in a long-term care or public housing setting, where they discuss issues, concerns, and suggestions related to their living environment and quality of life) on 7/15/2025, were aware of the availability and location of the facility's latest survey results. This failure had the potential for the residents and their legal representatives not to be fully informed of the facility's deficient practices and how they were corrected.

Inspectors wroteBased on observation, interview, and record review, the facility failed to notify the primary physician and responsible party of a significant change in condition (major decline or improvement in a resident's status that will not resolve itself without intervention) for one of six sampled residents (Resident 21) reviewed under the Nutrition care area by failing to notify the physician and family regarding significant weight loss per the facility policy and procedure (P&P) when the resident had a weight loss of greater than 5 pounds (lbs. - a unit of measurement for mass) in 30 days. This failure had the potential to result in a delay in care and services and a further decline of Resident 21.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, comfortable, and homelike environment for one (1) of two (2) sampled residents (Resident 27) reviewed under the environmental task by failing to ensure Resident 27's floor mat (a cushioned floor pad designed to help prevent injury should a person fall) was free from rips and disrepair. This deficient practice had the potential to negatively affect the residents' quality of life. [...]

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of staff to resident abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) immediately, but no later than two hours after the allegation was made to the State Survey Agency (CDPH - California Department of Public Health), the Ombudsman (a resident advocate), and local law enforcement (LLE) in accordance with federal and state law for one of three sampled residents (Resident 16) reviewed under the Abuse care area. This deficient practice had the potential to result in unidentified abuse in the facility and failure to protect residents from harm from abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of 13 sampled residents (Resident 21 and Resident 20) were provided care in accordance with professional standards of practice. For Resident 21 (who was dependent on staff for eating), after the breakfast dining observation, the head-of-bed (HOB) was not elevated which caused an increased risk to Resident 21 for aspiration (when food or liquid goes into the airway instead of the esophagus). For Resident 20, the 72-hour daily shift charting was incomplete when the resident had a change in condition regarding weight loss which caused a potential for Resident 20's oral intake to go unmonitored and further weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide range of motion ([ROM] full movement potential of a joint) exercises to one of five sampled residents (Resident 240) with positioning and mobility (ability to move) concerns by failing to provide active assistive range of motion ([AAROM] use of muscles surrounding the joint to perform the exercise but requires some help from a person or equipment) exercises to Resident 240's right ankle and left leg in accordance with the physician's order and care plan. This failure had the potential for Resident 240 to develop weakness and ROM limitations.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received necessary care and services to prevent accidents for two of seven sampled residents (Resident 72 and 4). For Resident 72, who had repeated falls, the floor mat (a cushioned floor pad designed to help prevent injury should a person fall) had furniture or medical equipment on top of it. For Resident 4, who had a high risk of fall, there was no fall risk assessment completed after the resident fell on 4/24/2025. These deficient practices caused an increased the risk of accidents and fall with injury.

Inspectors wroteBased on observation, interview and record review, the facility failed to effectively manage a resident's pain for one of six sampled residents (Resident 21) reviewed during the nutrition care area by failing to ensure Treatment Nurse (TN) 2 assessed for pain before, during, and after indwelling catheter (a flexible tube placed in the bladder to drain urine) care (the act of cleaning) when the resident displayed facial grimacing/moaning on 7/17/2025. This deficient practice resulted in Resident 21's undetected pain after catheter care, potentially resulting in a negative effect on the resident's quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility did not have sufficient staff to provide Restorative Nursing Assistant ([RNA] nursing aide program that helps residents to maintain their function and joint mobility) services to 244 residents, including Resident 159, on 7/15/2025. This deficient practice had the potential for the residents to develop limitations in range of motion ([ROM] full movement potential of a joint) and mobility (ability to move).

Inspectors wroteBased on observation, interview, and record review, the facility failed to perform competency skills evaluations (systematic process that evaluated an individual's skill and knowledge) for three of 13 Restorative Nursing Assistants ([RNA] certified nursing aide program that helps residents to maintain their function and joint mobility [ability to move]; RNA 4, RNA 5, and RNA 6) prior to providing RNA services, including the provision of feeding assistance, the provision of range of motion ([ROM] full movement potential of a joint) exercises, application of splints (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion), and the provision of ambulation (the act of walking). [...]

Inspectors wroteBased on interview and record review, the facility failed to act upon the recommendations of the consultant pharmacist for two of six sampled residents (Residents 27 and 19) reviewed for Unnecessary Medications, Psychotropic (medications capable of affecting the mind, emotions, and behavior) Medications, and Medication Regimen Review (MRR-a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) care area by: 1. Failing to follow-up with Resident 27's physician regarding the consultant pharmacist's MRR recommendation to add Eliquis (also known as apixaban - a type of blood thinner medication to prevent blood clots). This deficient practice had the potential to place Resident 27 at risk for ineffective treatment or adverse effects. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from unnecessary psychotropic medication (medications that affect the mind, emotions, and behavior) for one of three sampled residents (Residents 1) by failing to:1. Provide ongoing re-evaluation of the need for psychotropic medication by failing to ensure PRN (given as needed or requested) risperidone (Risperdal-a psychotropic medication used to treat mental health conditions such as schizophrenia [(a mental illness that is characterized by disturbances in thoughts] ) was ordered with an end date (time at which a medication will no longer be dispensed and will be required to be re-prescribed).2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sample residents (Resident 1), who had moderate impaired cognition (a stage where individuals experience noticeable and significant difficulties in functions like memory, language, and problem-solving, affecting their ability to manage daily activities independently), was free from sexual abuse (any sexual activity that occurs without consent [permission]), by Resident 2 (Resident 1's roommate) on 6/20/2025 by failing to: 1. Protect Resident 1 from Resident 2 when Certified Nursing Assistant (CNA) 1 and Licensed Vocational Nurse (LVN) 1 witnessed Resident 2, topless with breasts uncovered, was at the head of Resident 1's bed leaning on top of Resident 1 who was lying on her (Resident 1) bed. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a care plan was created for a resident who was high risk for fall for one of four sampled resident (Resident 2). This deficient practice had the potential to a delay in/or lack of delivery of care and services to Resident 2.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a person-centered care plan for four of five sampled residents (Residents 1, 2, 3 and 4) by: 1. Failing to ensure a care plan was develop timely for Resident 1 ' s impulsive behavior of getting up unassisted. 2. Failing to ensure a care plan was develop for Resident 2 ' s diagnosis of osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D). 3. Failing to ensure a care plan was develop for Resident 3 ' s behavior of throwing himself (Resident 3) on the floor. 4. Failing to ensure a care plan was develop for Resident 4 ' s diagnosis of osteoporosis. 5. Failing to ensure a care plan was timely develop for Resident 4 ' s behavior of banging the call light on the table. 6. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents received care consistent with professional standards of practice for two of four sampled residents (Resident 1 and Resident 2) by: 1. Failing to ensure vital signs (measurements that indicate the status of a person's body's vital functions and are used to assess overall health) were taken when Resident 1 fell on 5/21/2025. 2. Failing to ensure Resident 1 ' s neurochecks (neurological assessments that nurses perform to monitor a patient's neurological status, especially when a patient has a condition that could affect their brain or nervous system function) were assessed after the falls on 10/16/2024, 12/31/2024 and 5/21/2025 as indicated in the facility ' s Neurological Assessment policy. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) for two of four sampled residents (Residents 1 and 4) by: 1. Failing to ensure Resident 1 ' s physician order to administer cephalexin (antibiotic medication that treats infection [harmful germs have entered your body and are causing problems]) for five days was followed. 2. Failing to ensure Resident 1 ' s physician order was followed for Humulin R (medication used to manage blood sugar level) administration. 3. Failing to ensure 12 medications of Resident 4 ' s were not provided to Family Member (FM 2) without a physician order. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain accurate and complete medical records for three of five sampled residents (Residents 4, 3, and 2) by: 1. Failing to document 12 medications provided to Resident 4 ' s Family Member 2 (FM2) when FM 2 requested the medications on 5/5/2025. 2. Failing to accurately document Resident 3 ' s behavior of throwing himself on the floor from 5/6/2025 to 5/24/2025. 3. Failing to document Resident 2 ' s vital signs (basic measurements that indicate how well your body is functioning) when Resident 2 had a fall incident on 5/21/2025. These failures had the potential to cause confusion in care and the medical records containing inaccurate documentation.

Inspectors wroteBased on interview and record review, the facility failed to ensure that one of the four sampled residents (Resident 4), who was unable to carry out activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) received the necessary services to maintain good grooming and personal hygiene. This failure had the potential to negatively affect Resident 4' s self-esteem and wellbeing and placed Resident 4 at risk of infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure that one of four sampled residents (Resident 2) who had an indwelling urinary catheter (a flexible plastic tube inserted into the bladder that remains there to provide continuous urinary drainage) received proper care and services by failing to ensure Resident 2 ' s urine color and consistency was assessed per physician order. This failure had the potential to result in urinary tract infection (UTI- an infection in the bladder/urinary tract) and had potential to lead to urosepsis (a potentially life-threatening complication of urinary tract infection).

Inspectors wroteBased on interview and record review, the facility failed to administer pain medication for one of four sampled residents (Resident 2) as per physician ' s order to administer Tylenol (medication used to treat pain) as needed for pain when Resident 2 had an incident of fall on 5/21/2025 and had a pain level of six out of ten using the pain scale (a tool used to help people describe and quantify their pain). This failure had the potential to negatively affect the Resident 2 ' s physical comfort and had the potential to increase the pain level and result in an unmanageable pain.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Director of Nursing (DON) has an active Registered Nurse (RN) License while working in the capacity as the full-time DON in the facility. On [DATE], during an onsite visit, the DON's license was expired since [DATE]. This deficient practice had the potential to affect the delivery of care and services to the residents.

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) and verbal abuse (the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or to their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability) for two of six sampled residents (Resident 1 and Resident 3) when: 1. On 5/9/2025 at 1:30 p.m., Resident 1 and Resident 2, who were both inside Room A (Resident 1 and Resident 2's shared room), were observed by Certified Nursing Assistant (CNA) 1, when Resident 2 made a fist with his left hand and punched Resident 1 on Resident 1's lower right abdomen, then Resident 2 used verbal profanity towards Resident 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement its policy and procedure (P&P) titled, Abuse Prevention and Prohibition Program, by failing to report a physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) to the State Survey Agency (SSA) no later than two hours for one of six sample residents (Resident 5) when on 5/18/2025 at 10:15 a.m. Resident 5 reported to Registered Nurse (RN) 1, that Certified Nursing Assistant (CNA) 2 had handled her roughly. The facility reported the allegation of abuse to the SSA on 5/18/2025 at 2:48 p.m. This deficient practice had the potential to result in unidentified abuse and place Resident 5 at risk for further abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents, Resident 1, had the right to be treated with dignity and respect by Restorative Nurse Assistant 1 (RNA 1) who was heard by Visitor 1 (V 1) telling Resident 1, Do you want to end up in the grave like your wife? This deficient practice placed Resident 1 at risk of feeling sad, hopeless or humiliated.

Inspectors wroteBased on interview and record review, the facility failed to protect a resident's right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) for one of eight sampled residents (Resident 1) when on 3/12/2025, at around 5:45 p.m. Resident 2 scratched Resident 1's right upper nose during a physical altercation (refers to a confrontation or fight involving physical contact or force) in the dining room. This deficient practice resulted in Resident 1 being subjected to physical abuse by Resident 2 while under the care of the facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a written or electronic record containing all the information the resident needs to effectively manage their own health) for one of eight sampled residents (Resident 4) by failing to ensure Resident 4 had a care plan regarding Resident 4's bluish discoloration below the knee and foot on 3/22/2025. This deficient practice had the potential to result in a delay in or lack of delivery of care and services to Resident 4.

Inspectors wroteBased on interview and record review, the facility failed to follow the physician's order and follow pain management policy for three of eight sampled residents (Residents 1, 2, and 5) by: 1. Failing to ensure Licensed Vocational Nurse 10 (LVN 10) document the time Tylenol (medication used to treat pain and fever) was given to Resident 1 on 3/9/2025. 2. Failing to ensure LVN 10 document Resident 1 ' s pain level before Tylenol administration on 3/9/2025. 3. Failing to ensure LVN 5 document pain level and reassess Residents 2 ' s pain level after Tylenol administration on 3/9/2025 at 9 a.m. 4. Failing to ensure physician's order for Norco (medication used to treat pain) was followed for Resident 5. These deficient practices had the potential to negatively affect the residents' (Residents 1, 2, and 5) physical comfort and had the potential to not manage residents' pain.

Inspectors wroteBased on interview and record review, the facility failed to maintain accurate and complete medical records for four of eight sampled residents (Residents 1, 2, 3, and 8) by failing to ensure monitoring for the use of an anticoagulant (medication used to treat and prevent blood clot) was documented in Residents 1, 2, 3 and 8 ' s Medication Administration Record (MAR-a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 3/2025. This deficient practice had the potential to cause confusion in the residents' (Residents 1, 2, 3, and 8) care and medical records containing inaccurate documentation.

Inspectors wroteBased on interview and record review, the facility failed to ensure the medical records of one of four sampled residents (Resident 3) were maintained in accordance with accepted professional standards and practice, complete, and accurately documented by failing to: 1. Ensure Licensed Nurses documented the specific and detailed descriptions of Resident 3's left hip discoloration in the resident's medical records. 2. Ensure Licensed Nurses documented the level of care provided to Resident 3 after the resident's change of condition (COC). 3. Ensure Licensed Nurses' signatures were indicated on Resident 3's Medication Administration Record (MAR). These deficient practices resulted in inaccurate information on Resident 3's medical records and had the potential for delayed and inaccurate medical interventions.

Inspectors wroteBased on interview and record review, the facility failed to maintain accurate and complete medical records for four of four sampled residents (Resident 1, 2, 3, and 4) by failing to ensure monitoring for use of anticoagulant (medication used to treat and prevent blood clot) was documented in Residents 1, 2, 3, and 4's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) dated 2/2025. These deficient practices had the potential to cause confusion in care and the medical records containing inaccurate documentation.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive care plan for two of four sampled residents (Resident 1 and Resident 2) by: 1. Failing to ensure a care plan was created when Resident 1 had a left shin (on the front of the lower leg, between the knee and ankle joints) discoloration (a change to the original color) on 2/9/2025. 2. Failing to ensure a care plan was created when Resident 2 had a right upper inner arm bruise (discoloration of the skin that occurs when the small blood vessels break and leak blood) on 2/10/2025. These deficient practices had the potential for delayed provision of necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sampled residents (Resident 3), who was assessed as high risk for falls, had intermittent (not happening regularly or continuously) confusion, and required two-person staff assistance was free from falls and injury in accordance with Resident 3's care plan (a document that outlines the specific healthcare and support needs of a resident, along with strategies and interventions to address those needs), by failing to: 1. Provide Resident 3 with the required two-person staff assistance for the use of a mechanical lift (a device used to assist with transfers of residents who require support for mobility) when on 1/24/2025 at 9:30 a.m. Certified Nursing Assistant 1 (CNA 1) transferred Resident 3, by himself, from the wheelchair to the shower bench. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure three of six sample residents (Resident 1, Resident 2, and Resident 3) were identified on the facility ' s fall prevention program by failing to complete the Shift Report and the Resident Transfers Audit Tool as indicated on the facility ' s previous Plan Of Correction (POC). This deficient practice had the potential to increase the residents ' (Residents 1, 2, and 3) risks for falls that can lead to injuries.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the physician and family or resident representative were notified for one of four sampled residents (Resident 1) when Resident 1 had a change in condition. This deficient practice had the potential for delayed medical interventions for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sampled resident's (Resident 3) medical records were maintained in accordance with accepted professional standards and practice, complete, and accurately documented by failing to ensure Medication Administration Record (MAR)s were not signed later. On 2/6/2025, the facility provided Resident 3's MAR, dated 1/1/2025 to 1/31/2025, the MAR indicated Resident 3's Tylenol (a brand name for acetaminophen [medication used to relieve mild to moderate pain]) 325 milligrams (mg - unit of measurement) did not have a licensed nurse signature on 1/24/2025. On 2/7/2025, Resident 3's MAR without a licensed nurse signature had later been signed. This deficient practice had the potential for inaccurate information on Resident 3's medical record and had the potential for inaccurate medical interventions for Resident 3.

Inspectors wroteBased on interview and record review, the facility failed to implement infection control measures for one of three sampled residents (Resident 2) by failing to ensure Resident 2 was included in the line list report (a table that organizes information about people or cases of disease during an outbreak investigation) submitted to the Public Health Nurse (PHN) for possible exposure to scabies (a contagious skin condition caused by microscopic [so small as to visible only with microscope] mites [tiny bugs] burrowing [made a hole] into the skin. This deficient practice resulted to incomplete line listing report submitted to the PHN and had the potential for spread of infection among residents and staff.

Inspectors wroteBased on interview and record review, the facility failed to prevent a fall and injury for one of three sampled residents (Resident 1), who was identified as a high fall risk, with unsteady standing and walking balance, with decreased muscular coordination requiring use of assistive device (a tool or piece of equipment that helps a person with disability perform tasks and activities such as a walker [a device that helps a person maintain balance and stability while walking]) and needed supervision to prevent falls and injuries. The facility failed to: a. Provide an assistive device for safe ambulation (the ability to walk from one place to another safely or move around independently). b. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled resident's (Resident 1) comprehensive, person-centered care plan with measurable objectives and interventions were implemented addressing: 1. Resident 1's fall risk status not identified by Certified Nursing Assistant 1 (CNA 1), CNA 2, and Restorative Nursing Assistant 1 (RNA 1). 2. Resident 1's need for an assistive device (a tool or piece of equipment that helps a person with disability perform tasks and activities) during ambulation (the ability to walk or move around independently). 3. Resident 1's unspecified abnormalities on gait and mobility as identified by the physical therapist (PT). As a result, on 10/29/2024 at 7:08 a.m., Resident 1 had a fall and sustained a left hip fracture. Resident 1 was admitted to General Acute Care Hospital 1 (GACH 1) and underwent a major surgical intervention.

Inspectors wroteBased on interview and record review, the facility failed to ensure that one of three sampled residents (Resident 1) was free from physical restraint when he was placed on a wheelchair against the wall and placing a bed horizontally across in front of him. Resident 1 was noted with a white bed sheet across his stomach area and tied to the back of the wheelchair. This deficient practice had the potential to inhibit Resident 1's freedom of movement or activity.

Inspectors wroteBased on interview and record review, the facility failed notify the primary physician (PP) of a significant change of condition (major decline or improvement in a resident's status that will not resolve itself without intervention) for one of three sampled residents (Resident 1) by: 1. Failing to ensure the PP was notified on 9/26/2024, when Resident 1 was prescribed (to tell somebody to take a particular medicine or have a particular treatment) with permethrin cream (medication used to treat scabies [a contagious skin condition caused by mites burrowing into the skin and laying eggs characterized by intense itching and a rash of small red bumps and blisters])by the dermatologist (a doctor who has special training to diagnose and treat skin problems). 2. Failing to ensure the PP was notified on 10/7/2024 when Resident 1 tested positive for scabies. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) for one of three sampled residents (Resident 1) by failing to follow the physician's order for permethrin cream (medication used to treat scabies [a contagious skin condition caused by mites burrowing into the skin and laying eggs characterized by intense itching and a rash of small red bumps and blisters]) treatment to Resident 1. This deficient practice resulted in the delay of Resident 1's treatment and had the potential for the spread of scabies (an itchy rash due to mites that live under your skin) among residents and staff.

Inspectors wroteBased on interview and record review, the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one of three sampled residents (Resident 1). This deficient practice had the potential to result in confusion in the care and services rendered to Resident 1 and resulted in inaccurate information entered into Resident 1's medical record.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement infection control measures for one of three sampled residents (Resident 1), who tested positive for scabies (a contagious skin condition caused by microscopic [so small as to visible only with microscope] mites [tiny bugs] burrowing [made a hole] into the skin) by failing to ensure a contact isolation (a safety measure as certain germs can be spread by contact) signage was posted outside Resident 1's room. This deficient practice had the potential for staff to be unaware of the necessary infection control measures to observe when caring for Resident 1 and increase the risk of the spread of infection among residents and staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that two of eight residents (Resident 2 and Resident 1) who had a urinary catheter (a flexible plastic tube inserted into the bladder that remains there to provide continuous urinary drainage) received proper care and services by: 1. Failing to ensure Treatment Nurse 1 (TN 1) notified physician of sediments (urine becomes more concentrated, allowing substances like salts and minerals to precipitate and form) and blood in Resident 2 ' s urine on 10/2/2024 as per facility ' s policy and procedure. 2. Failing to ensure TN 1 obtain an order for urinary irrigation (flushing of the bladder with sterile fluid to prevent clots [gel-like clumps of blood] and blood retention) before flushing Resident 2 ' s urinary catheter. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its infection control policy for three of eight sampled residents (Resident 3, 1, and 2) by: 1. Failing to ensure Physical Therapist Assistant (PTA 1) and Occupational Therapist (OT 1) wore gowns while repositioning Resident 3, who was placed on Enhanced Barrier Precautions (EBP- an infection control method that uses personal protective equipment [PPE- equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses] to reduce the spread of multidrug-resistant organisms [MDROs- microorganisms, mainly bacteria, that are resistant to one or more classes of antimicrobial agents, such as antibiotics] between residents in skilled nursing facilities). 2. Failing to ensure Resident 1 ' s oxygen tubing did not touch the floor. 3. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) received care consistent with professional standards of practice to prevent pressure ulcers (PU, a localized injury to the skin and or underlying tissue usually over a bony prominence as a result of pressure, or pressure in combination with shear) by: 1. Failing to measure Resident 1 ' s pressure ulcer upon readmission on [DATE] and 9/25/2024. 2. Failing to assess and document Resident 1 ' s weekly wound assessment. 3. Failing to assess and complete Resident 1 ' s weekly Skin Integrity Sheet. These deficient practices placed Resident 1 at risk for the development and worsening of pressure ulcers.

Inspectors wroteBased on interview and record review, the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one of three sampled residents (Resident 1). This deficient practice had the potential to result in confusion in the care and services rendered to Resident 1 and resulted in inaccurate information entered into Resident 1's clinical record.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control measures for one of three sampled residents (Resident 3) and four of five sampled staff (Director of Nursing [DON], Licensed Vocational Nurse 1 [LVN 1], Restorative Nursing Assistant 1 [RNA 1] and RNA 2) when the facility had Coronavirus Disease 2019 (COVID-19, highly contagious respiratory disease is thought to spread from person to person through droplets released when an infected person coughs, sneezes or talks) positive residents by; a. Failing to ensure DON wore N95 mask (is a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) with lower strap secured behind the neck while walking in the hallway. b. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a person-centered care plan with measurable objectives and timeframes for one of three sampled residents (Resident 3) by failing to develop a care plan that addressed Resident 3's Enhanced Barrier Precaution (EBP- an infection control intervention designed to reduce transmission [transfer] of multidrug-resistant organisms [MDRO- bacteria that have become resistant to certain antibiotics that can no longer be used to control or kill the bacteria]). This deficient practice had the potential to negatively impact Resident 3's over-all health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure four of four sampled residents (Residents 119, 139, 141, and 34) with limited range of motion ([ROM] full movement potential of a joint [where two bones meet]) and mobility (ability to move) received treatment and services to prevent further decline in ROM, by failing to: 1. Accurately complete Joint Mobility Assessments (JMA, brief assessment of a resident's range of motion in both arms and both legs) for Residents 119, 139, 141, and 34 in accordance with the facility's policy titled, Joint Mobility Assessment, revised on 5/1/2018 and reviewed on 1/29/2024. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the facility's Registered Nurses (RNs) and Restorative Nursing Assistants ([RNA], certified nursing aide program that helps residents to maintain their function and joint mobility) were competent in providing assessments and services affecting four of four sampled residents (Residents 119, 139, 141, and 34) with limited range of motion ([ROM] full movement potential of a joint [where two bones meet]) and mobility (ability to move), by failing to: 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen by failing to: a. Ensure one (1) food item in the walk-in refrigerator and three (3) food items in the reach-in refrigerator had a label. b. Ensure the bulk condiment container lid had no chips and scratches. c. Ensure four (4) dented cans were not stored with non-dented cans. d. Ensure one storage rack was not six (6) inches ([in.] unit of measurement) above the floor. e. Ensure [NAME] 1 was not wearing two gold bracelets while scooping food and Dietary Aide 1 (DA 1) was not wearing a watch while scooping soup during lunch trayline. f. Ensure Yogurts were at 58.5 degrees Fahrenheit ([°F], degree of temperature), 57.2°F and 58.2°F. g. Ensure eight resident's trays had no cracks and chips. h. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to have an updated policy regarding the use and storage of food brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption when the policy did not include the facility's responsibility for storing food brought in by family and other visitors. This deficient practice had the potential to cause a decrease food intake resulting in unintentional (without trying) weight loss, frustrations, and psychosocial harm to 239 of 239 facility residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose garbage and refuse properly by not maintaining the trash area free from trash, soiled gloves, soiled tissue papers, a plastic bag of trash on the floor and other dirt debris. This deficient practice had a potential to attract birds, flies, insects, pests and possibly spread infection to 239 of 239 facility residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to report and monitor changes of condition ([COC] major decline or improvement in a resident's status that will not resolve itself without intervention) for two of four sampled residents (Resident 119 and Resident 139) with limited range of motion ([ROM] full movement potential of a joint [where two bones meet]) and mobility (ability to move) concerns by failing to: 1. Report Resident 119's decline in ROM to both arms and legs during Restorative Nursing Assistant ([RNA] certified nursing aide program that helps residents to maintain their function and joint mobility) sessions in accordance with the facility's job description titled, Restorative Nursing Assistant, revised 10/2011, and policy tilted, Change of Condition Notification, revised 1/1/2017 and reviewed 1/29/2024. 2. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents were treated with respect and dignity including the right to be free from physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the resident's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) for four of five sampled residents (Residents 38, 190, 2, and 109) investigated during review of physical restraints care area by failing to: 1. Complete a Physical Restraint Assessment Form, obtain a physician order, and obtain an informed consent from the resident or the resident representative prior to placing the bed against the wall as a restraint for Residents 38, 109, 2, and 109. 2. [...]

Inspectors wroted. During a review of Resident 38's admission Record, the admission record indicated the facility admitted the resident on 2/28/2023, with diagnoses that included age-related osteoporosis (a condition in which there is a decrease in the amount and thickness of bone tissue), ataxia (involves a lack of muscle coordination and control), and the presence of right artificial shoulder joint (removes damaged areas of bone and replaces them with parts made of metal and plastic [implants]). During a review of Resident 38's History and Physical (H&P), dated 1/27/2024, indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 38's MDS, dated [DATE], indicated Resident 38 had the ability to make self-understood and to understand others. [...]

Inspectors wroteBased on interview and record review, the facility's licensed nursing staff failed to provide care in accordance with professional standards for two (2) out of 2 sampled residents (Residents 43 and 211) investigated under the insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (SQ - beneath the skin) insulin administration sites. These deficient practices had the potential to result in adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin such as lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin).

Inspectors wrotec. During a review of Resident 139's admission Record indicated the facility admitted the resident on 4/28/2021, with diagnoses that included pressure-induced deep tissue damage (condition that affects the underlying layers of skin, muscle, and other soft tissues) of the left heel, muscle wasting and atrophy (a wasting away or progressive decline, typically of a body part, organ, or tissue), and peripheral vascular disease (a common condition in which narrowed arteries reduce blood flow to the arms or legs). During a review of Resident 139's History and Physical (H&P), dated 4/1/2024, the H & P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 139's MDS, dated [DATE], indicated the resident usually makes self-understood and understands others. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the resident environment was free of accident hazards for eight of ten sampled residents (Residents 227, 38, 14, 55, 148, 177, 213, and 43) investigated under care area accidents by failing to ensure: 1. Resident 227's Areds 2 (supplement for age related macular degeneration) was not left at the bedside for the resident to self-administer. The deficient practice had the potential to place Resident 227 at risk for adverse effect (a harmful or abnormal result) of taking medications. 2. Residents 38 was not left in a wheelchair with a bedside table on top of a fall mat (used to cushion fall impact) to eat breakfast. [...]

Inspectors wroteb. During a review of Resident 211's admission Record, the admission record indicated the facility admitted the resident on 8/22/2022, with diagnoses that included type 2 diabetes mellitus (a disease that occurs when the blood glucose, also called blood sugar, is too high) with diabetic chronic kidney disease (a type of kidney disease caused by diabetes) and Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks). During a review of Resident 211's History and Physical (H&P), dated 8/11/2023, indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 211's Order Summary Report, indicated an order for: [...]

Inspectors wrotee. During a review of Resident 13's admission Record indicated the facility admitted the resident on 3/28/2020, with diagnoses that included paroxysmal atrial fibrillation (a fast, irregular heartbeat that only lasts a few hours or days) and history of malignant neoplasm of the brain (a cancerous growth in the brain that grows quickly and invades healthy brain tissue). During a review of Resident 13's History and Physical (H&P), dated 4/27/2024, the H & P indicated the resident had fluctuating capacity to understand and make decisions. During a review of Resident 13's MDS, dated [DATE], indicated the resident sometimes had the ability to make self-understood and understand others. The MDS indicated the resident had impaired vision and was totally dependent on mobility and activities of daily living (ADLs). [...]

Inspectors wroteBased on interview and record review the facility failed to implement its policy and procedure on Coronavirus Disease 2019 (COVID-19 -a highly contagious disease spread from person to person through droplets released when an infected person coughs, sneezes, or talks) vaccination (the act of introducing a vaccine [a substance that stimulates the body's immune system to fight disease]) by failing to provide documentation an informed consent was obtained from the residents or the resident's representative and education was provided on the risk and benefits of the vaccine prior to vaccination for three of five sampled residents (Residents 174, 80, and 98) investigated under the infection control task. This deficient practice violated the resident or resident representative's right to make an informed decision.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignity in a manner that promotes maintenance or enhancement of his or her quality of life by failing to ensure Certified Nursing Assistant 8 (CNA 8) sat at eye level while providing feeding assistance for one of one residents (Resident 109) reviewed under the Dignity care area. This deficient practice had the potential to result in a decrease in psychosocial well-being and a lack of awareness of the resident's ability to safely swallow resulting in choking.

Inspectors wrote2. During a review of Resident 227's admission Record, the admission record indicated the facility admitted Resident 227 on 12/26/2023, with diagnoses that included glaucoma (a group of eye diseases that can cause vision loss and blindness by damaging a nerve in the back of the eye called optic nerve) and dysphagia (difficulty swallowing). During a review of Resident 227's Care Plan titled, Family Education related to resident's safe feeding/eating precautions, initiated on 5/16/2024, indicated to instruct visitors that either feeding or resident eating with visitor should be under close supervision of staff. During a review of Resident 227's H&P, dated 5/22/2024, indicated Resident 227 had the capacity to understand and make decisions. During a review of Resident 227's MDS, dated [DATE], indicated Resident 227 had the ability to make self-understood and understand others. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide reasonable accommodation of resident needs and preferences by failing to ensure the call light (an alerting device for nurses or other nursing personnel to assist a resident when in need) was within reach for two of two sampled residents (Resident 159 and 14) reviewed under the Environment task. This deficient practice had the potential to result in the delay of care and services and possible injury to residents when they are unable to summon health care workers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately and safely provide or obtain pharmaceutical services, including the provision of routine medications, for two of two sampled residents reviewed during a general observation and investigated under residents' rights (Resident 177 and Resident 227) by failing to: 1. Obtain a physician's order for Resident 177's bottle of saline spray (a mixture of salt and water that is sprayed into the nose) present on the resident's bedside table. 2. Obtain a physician's order for the use of Areds 2 (supplement for age-related macular degeneration [an eye disease that can blur the central vision]) observed at the bed side taken by Resident 227 on 8/6/2024. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Consultant Pharmacist's (CP) recommendation for July 2024's Medication Regimen Review (MRR) (a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) note was reviewed, addressed or carried out as per facility policy and procedure for one of five sampled residents (Resident 79). The deficient practice had the potential to result in the increased risk of receiving medication that was not optimal for Resident 79's medical condition, that would not maintain the resident's highest level of physical, mental and psychosocial well-being and/or increase the risk of adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have) from the medication therapy. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one (1) of five (5) sampled residents (Resident 79) drug regimen was free from the use of unnecessary (any medication in excessive dose, excessive duration, without adequate monitoring) psychotropic (any medication capable of affecting the mind, emotions, and behavior) medications in accordance with the facility policy and procedure by failing to provide a detailed clinical rationale for continuing Trazadone (a psychotropic medication used for depression [also referred to as antidepressant] and insomnia [inability to sleep]) as originally prescribed on 6/18/2023 for Resident 79. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Label one Latanoprost (a medication used to treat glaucoma [a condition of increased pressure in the eyeball]) eye drop bottle for Resident 122, with an open date in accordance with facility requirements and manufacturer's requirements in one of four inspected medication carts (Medication Cart North Middle East.) 2. Dedicate a refrigerator for medication storage only for one of six inspected medication refrigerators (Medication Refrigerator in ADMIN office hallway.) 3. [...]

Inspectors wroteBased on interview and record review the facility failed to implement its policy and procedure on influenza (an infection of the nose, throat and lungs, which are a part of the respiratory system) and pneumonia (an infection that affects one or both lungs) vaccine (a substance that stimulates the body's immune system to fight disease) administration by failing to provide documentation an informed consent was obtained from the resident or the resident representative and education was provided to the resident or the resident's representative regarding the benefits and potential side effects of the vaccine for two of five sampled residents (Residents 174 and 98) investigated under infection control task. This deficient practice violated the resident or responsible party's right to make an informed decision.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a safe environment for one of two sampled residents (Resident 41) investigated during review of the environment task by failing to ensure Resident 41 did not plug an extension cord (an electrical outlet that contains two wires: a neutral wire and a hot wire) into a two-prong wall outlet to charge Resident 41's cellphone. This deficient practice had the potential to result in safety hazards including electrical shock and fire.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately assess functional limitation (limited ability to move a joint that interferes with daily functioning) in range of motion ([ROM] full movement potential of a joint [where two bones meet]) for one of four sampled residents (Resident 34) with limited ROM and mobility (ability to move). This failure provided inaccurate information to the Federal database.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was free from neglect (the failure to provide healthcare services necessary to avoid physical harm, pain, mental anguish, or emotional distress) for one of seven residents (Resident 1), who had impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses), at high risk for falls, and was diagnosed with parkinsonism (brain conditions that cause slowed movements, stiffness and tremors), by failing to: 1. Provide Resident 1 with the required two-person staff assistance for the use of a mechanical lift (a device used to assist with transfers of individuals who require support for mobility) in weighing Resident 1 on 6/1/2024 at around 11 a.m. 2. Ensure Certified Nursing Assistant 1 (CNA 1) did not leave Resident 1 unattended. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of seven residents (Resident 1), who was with impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses), was high risk for falls, and was diagnosed with parkinsonism (brain conditions that cause slowed movements, stiffness, and tremors), was free from accidents, by failing to: 1. Provide Resident 1 with the required two-person staff assistance for the use of a mechanical lift (a device used to assist with transfers of individuals who require support for mobility) in weighing Resident 1 on 6/1/2024 at around 11 a.m. 2. Ensure Certified Nursing Assistant 1 (CNA 1) did not leave Resident 1 unattended. On 6/1/2024 at around 11 a.m., CNA 1, by herself, brought a mechanical lift inside Resident 1's room to weigh Resident 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide safe eating practices for four of ten sampled residents (Resident 1, Resident 2, Resident 3, and Resident 4) who were on aspiration precaution (precautions followed to prevent aspiration [food or liquid goes into the airway instead of the stomach]) by: 1. Failing to ensure Family Member 1 (FM 1) was provided education and training before being allowed to assist with Resident 1 ' s meals. 2. Failing to monitor and supervise Resident 1 while FM 1 was assisting Resident 1 with dinner on 3/9/2024. 3. Failing to provide Resident 1 with a Restorative Nursing Assistant (RNA) to assist Resident 1 in eating during dinner on 3/9/2024. 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement comprehensive, person-centered care plan (contains relevant information about a resident ' s health conditions, goals of treatment, specific actions that must be performed, and a plan for evaluation) with measurable objectives and interventions addressing the training on aspiration precautions (precautions followed to prevent aspiration [food or liquid goes into the airway instead of the stomach]) to the family members of three of ten sampled residents (Resident 1, Resident 2, and Resident 3) with dysphagia (swallowing difficulties). These deficient practices had the potential for failure to deliver the necessary care and services and placed Residents 2 and 3 at risk for aspiration which had the potential to cause serious harm and death. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two of six sampled residents (Resident 3 and Resident 4) were included in the list of residents assisted by a Restorative Nursing Assistant (RNA) during dinner on 6/23/2024. This deficient practice had the potential to result in Resident 3 and Resident 4 ' s not being assisted during meal and had a potential to negatively impact the residents ' physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident with urinary indwelling catheter (a flexible plastic tube inserted into the bladder that helps provide continuous urinary drainage) received proper care and services that included to anchor (secure) the urinary catheter tubing to resident ' s thigh for one of three sampled residents (Resident 8). This deficient practice had the potential to result in urinary catheter dislodgement (forcefully pulled out of a secure position) causing urethral (the tube through which urine leaves the body) tearing that may result in pain and bleeding.

Inspectors wroteBased on interview and record review, the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for five of ten sampled residents (Resident 1, Resident 2, Resident 3, Resident 4, and Resident 10) by failing to ensure staff documented in the physician ' s order sheet, the time the physician ' s orders were received. This deficient practice resulted in incomplete medical information entered in the residents' medical record.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident was free from any significant medication error for one of three sampled residents (Resident 1). There was no documented evidence that Licensed Vocational Nurse 1 (LVN 1) and LVN 2 administered metoprolol tartrate (medication used to treat high blood pressure) on 4/14/2024 and 4/15/2024 at 8 p.m., as per physician ' s order, to Resident 1. This deficient practice had the potential to result in uncontrolled elevated blood pressure.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide dignity when on 4/8/2024 the Restorative Nursing Assistant 2 (RNA 2) failed to assist a resident with their meals at eye-level for one out of five sampled residents (Resident 5). This deficient practice had the potential to affect Resident 5's self-worth.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled resident (Resident 2) was free of any significant medication error when Licensed Vocational Nurse failed to administer metoprolol tartrate (medication that works by relaxing blood vessels and slowing heart rate to improve blood flow and decrease blood pressure [the pressure of blood pushing against the walls of your arteries]) to Resident 2 as prescribed for four out of four days. This deficient practice had the potential for Resident 2 ' s blood pressure to be elevated.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a comprehensive, person-centered care plan with measurable objectives and interventions for three of three sampled residents (Resident 1, Resident 2, and Resident 3). The facility failed to develop and implement individualized care plan interventions addressing: 1. Resident 1 ' s restlessness and constant episodes of standing up from the wheelchair as stated by Life Enrichment Coordinator 1 (LEC 1) and Licensed Vocational Nurse 1 (LVN 1). As a result, on 1/16/2024 at 11 a.m., Resident 1 fell out of the wheelchair hitting the floor left shoulder first. Resident 1 was transferred to General Acute Care Hospital 1 (GACH 1) where the resident was diagnosed with left shoulder traumatic fracture (broken bone). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of three sampled residents (Residents 1, Resident 2, and Resident 3) received the necessary care to prevent falls. The facility failed to: 1. Ensure Resident 1 was monitored for behaviors of restlessness and constant episodes of standing up from the wheelchair. As a result, on 1/16/2024 at 11 a.m., Resident 1 fell out of the wheelchair hitting the floor, left shoulder first. Resident 1 was transferred to General Acute Care Hospital 1 (GACH 1) where the resident was diagnosed with left shoulder traumatic fracture (broken bone). Resident 1 required a left shoulder arthroplasty (a surgical procedures that removes damaged areas of the bone and replace them with parts made of metal and plastic). 2. [...]

Inspectors wroteBased on interview and record review, the licensed nursing staff failed to communicate to the primary doctor and the diagnostic imaging center (describes a variety of non-invasive methods of looking inside the body to help determine the causes of an injury or an illness, and to confirm a diagnosis) the presence of a cardiac pacemaker (a device used to control an irregular heart rhythm) on a resident undergoing a magnetic resonance imaging (MRI, a non-invasive imaging technology that produces three dimensional detailed anatomical images) of the left wrist without contrast (chemical substances used in MRI scans) to one of three sampled residents (Resident 1). The deficient practice had the potential for the pacemaker of Resident 1 to malfunction once exposed to the magnetic field of the MRI imaging machine that poses a threat to Resident 1 ' s well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care in a manner that maintained or enhanced a resident's dignity and respect in full recognition of their individuality by staff standing over the resident while assisting during a meal for two of three sampled residents (Resident 171 and Resident 220). This deficient practice had the potential to affect the residents' self-worth and self-esteem.

Inspectors wroteBased on observation, interview, record review, the facility failed to ensure the residents' safety for three of three sampled residents (Resident 65, Resident 66 and Resident 171) by: 1. Failing to ensure LVN 4 disposed a lancet (small devices that provides a way to take blood samples) used on Resident 65 in a designated sharps container (a container that can be filled with used medical needles and all categories of sharps waste, before being disposed of safely) rather than a trash can. 2. Failing to ensure facility staff did not leave medications for Resident 66 and Resident 171 unattended. These deficient practices had the potential to result in injury and/or harm to residents and/or staff through needle prick (an accidental puncture of the skin with an unsterilized needle) and through the ingestion of unattended medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Administer 4 doses of Advair (fluticasone-salmeterol, a purple circular inhaler device that administers medication to a resident to aide in breathing) between the dates, 10/16/2021 and 10/21/2021, to one of two sampled residents (Resident 19) investigated on breathing treatment medications. 2. Administer 14 doses of albuterol (an inhaled medication used to treat breathing problems) between the dates 10/16/2021 and 10/21/2021, to one of two sampled residents (Resident 192) investigated on breathing treatment medications. The deficient practice of failing to administer medications in accordance with physician's orders increased the risk that Resident 19 and 192 could have experienced serious health complications such as respiratory arrest (the inability to breathe).

Inspectors wroteBased on observation, interview, and record review, the kitchen staff failed to ensure the proper storage, preparation, and distribution of food was done under sanitary conditions for 236 of 237 residents by: 1. Failing to ensure two packages of frozen alfredo sauce were labeled with the date received by the facility. 2. Failing to ensure one package of sliced bread was labeled with the date received by the facility. 3. Failing to ensure one bag of frozen pastry dough was labeled with an expiration date. 4. Failing to discard one large bag of expired carrots stored in the kitchen refrigerator and readily accessible for use in preparing meals. [...]

Inspectors wroteb. During an observation on 10/20/2021 at 1:20 p.m., observed four to six staff members drank coffee and ate cookies in nursing station [NAME] 1. An electric coffee maker, four to six full cups of coffee, and a package of cookies were located on the nursing station's computer and charting work surface area. Two to four staff members removed the cups of coffee and the package of cookies and quickly walked away. During an interview, on 10/20/2021, at 1:22 p.m., with Certified Nursing Assistant 5 (CNA 5), she stated she and her coworkers were drinking Armenian coffee and eating cookies in the nursing station. CNA 5 stated it was against the facility policy to eat in the nursing station and she apologized. CNA 5 stated staff should only eat in the staff lounge. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of one sampled resident (Resident 19), did not self-administer (take medications without supervision from a licensed nurse) their medications unless the interdisciplinary team ([IDT]- a team of individuals from multiple medical disciplines tasked with providing a clinical plan of care for a resident) determined it was clinically safe, and appropriate to do so. This deficient practice increased the risk of Resident 19 omitting medications or taking them incorrectly which could negatively impact health and well-being.

Inspectors wroteBased on observation, interview, and record review, the nursing staff failed to ensure the call light button was within reach of the residents while they were sitting in the wheelchair next to the bed for two of two sampled residents (Resident 184 and Resident 95) at high risk for falls. This deficient practice had the potential to result in residents not being able to summon health care workers for assistance as needed that may include urgent care.

Inspectors wroteBased on observation, interview, and record review, Licensed Vocational Nurse 6 (LVN 6) failed to notify the resident's physician about a medication refusal for one of two sampled residents (Resident 192) investigated addressing prescribed breathing treatments. Resident 192 refused to take albuterol sulfate (an inhaled medication used to treat breathing problems) on two separate occasions with LVN 6, who did not notify Resident 192's physician of the refusal. This had the potential for Resident 192 to have a decline in health and increased breathing problems.

Inspectors wroteBased on observation, interview and record review facility failed to ensure that Licensed Vocational Nurse 4 did not first sign the Medication Administration Record (MAR-flowsheet that indicates medications given to a resident) prior to administering insulin (medication used to decrease levels of sugar in the blood) for one of three sampled residents (Resident 65). This deficient practice placed Resident 65 at risk for unsafe patient care. It can lead to a lack in continuity of care, the inability to evaluate the appropriateness of the care delivered

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five percent (%). A total of three medication errors were observed out of 25 total opportunities, medication error rate 12%, affecting one out of three sampled residents (Resident 66). This deficient practice of administering medications contrary to accepted professional standards had the potential to negatively affect the health and well-being of Resident 66.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that the daily medication room thermometer readings were monitored and recorded in a room temperature log in the Central Supply Office to assure a safe temperature range for medication storage for one of one storage room for over the counter (OTC) floor stock medications at the facility. This deficient practice had the potential for harm to residents due to the potential loss of strength of the drugs, and the potential for the residents to receive ineffective drug dosages. Findings During an observation of the facility's Central Supply office on 10/21/2021, at 11:15 a.m., observed that there was no room thermometer or temperature monitoring log. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS - a standardized assessment and care screening tool) accurately reflected Resident 246's discharge status, for one out of three residents (Resident 246) investigated for closed record review. This deficient practice had the potential to inaccurately reflect Resident 246's care assessment and care planning.