Arbor Glen Care Center

Inspectors wroteBased on interview and record review, the facility failed to administer medications within one hour after the prescribed time for three of three sampled residents (Residents 1, 8, and 9) in accordance with the facility's Policy and Procedure (P&P) titled, Pharmaceutical Services. The deficient practice had the potential to result in the loss of therapeutic drug effects and increased the risk of adverse drug reactions (undesired harmful effect resulting from a medication) to Residents 1, 8, and 9.

Inspectors wroteBased on interview and record review, the facility failed to ensure two (2) of 17 sampled residents' (Resident 1's and Resident 10's) medical records were complete and accurate when Resident 1's and Resident 10's medical records did not contain documentation that the residents were turned and repositioned every two hours in accordance with the residents' care plans. This failure resulted in Resident 1's and Resident 10's medical records containing inaccurate information and had the potential for Resident 1and Resident 10 to receive inappropriate care and treatment.1. [...]

Inspectors wroteBased on interview and record review, the facility failed to promptly notify one (1) of 17 sampled residents' (Resident 2's) primary physician and Resident Representative (RR 1) regarding Resident 2's fall on [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one (1) of 17 sampled residents (Resident 2) received the necessary care and services when Resident 2's vital signs (measurements of the body's basic functions, such as heart rate, breathing rate, oxygen saturation, blood pressure, and temperature) and neuro-check (neurological exam, a check of how well the brain, nerves, and muscles work often performed after a suspected head injury) were monitored every shift for 72 hours after the resident had a fall on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of three sampled residents (Resident 104 and Resident 6), were treated with dignity when:a. On 3/24/2026, Certified Nursing Assistant (CNA) 5 did not close Resident 104's drapes (privacy curtain) all around Resident 104's bed while getting ready to clean up Resident 104 and CNA 5 removed Resident 104's bed sheet exposing Resident 104 from the waist down.b. On 3/27/2026, CNA 7 and CNA 8 did not close Resident 6's drapes all around Resident 6's bed while providing peri care (cleaning and caring of the genital and anal areas) to Resident 6 and exposing Resident 6's back, buttocks, and scrotal (dual-chambered sac of skin and muscle that protects the testes and regulates their temperature for optimal sperm production) area. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary care and services for three of three sampled residents (Residents 7, 56, and 98) when the facility:1. Failed to follow a physician's (health professional who is licensed and trained to practice medicine) order indicating to ear lavage (a medical procedure used to remove excess ear wax [cerumen] or foreign materials from the ear canal with a gentle stream of warm water) for Resident 7 who was hard of hearing.2. Did not complete a fall risk evaluation following Resident 56's third fall on [DATE].3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one kitchen (Kitchen 1) had safe and proper storage practices in accordance with professional standards for food service safety and the facility's policy and procedure (P&P) by failing to:1. Discard a gallon of expired ClassicGourmet [brand name] classic Caesar dressing on or before the expiration date that was stored inside Refrigerator # 3.2. Label and date a large clear plastic storage bin that had ready to eat corn flakes with raisins inside and supplied from the manufacturer's original bulk container.3. Properly store two (2) rectangular pans of facility baked yellow cake left out for cooling. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide specialized rehabilitative services (therapy services that help a resident improve or regain physical, mental, or functional abilities) for one of one sampled resident (Resident 56) when:1. Resident 56's physical therapy (PT-a treatment focused on improving or restoring physical movement and function) evaluation was not completed.2. Resident 56's occupational therapy (OT-a treatment focused on improving the performance of activities required in daily life) evaluation was not completed. This failure had the potential to result in Resident 56's rehabilitative needs not being addressed, leading to a significant physical decline posing a serious risk to the resident's overall health and safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection prevention and control practices by failing to ensure four of four sampled residents' (Resident 72, 80, 16 and 70) personal care item was labeled and stored properly. This deficient practice had the potential to result in cross contamination (the process by which microorganisms are unintentionally transferred from one area/object to another with a harmful effect) and/or the development and transmission of disease (an illness or sickness) and infections for Resident 72, 80, 16 and 70).

Inspectors wroteBased on interview and record review, the facility failed to notify the ombudsman (an advocate for residents of nursing home, board and care centers, and assisted living facilities) of one of one sampled resident's (Resident 9) transfer to an acute hospital (GACH). This deficient practice had the potential to result in the ombudsman not being able to advocate for Resident 9 and could potentially lead to illegal or inappropriate discharge (resident dumping) or loss of bed-hold (keeping a resident's bed available while the resident is temporarily absent/hospitalized ) rights for Resident 9.

Inspectors wroteBased on interview and record review, the facility failed to accurately assess one of three sampled residents (Resident 7's) hearing. Resident 7's Minimum Data Sheet (MDS, a resident assessment and care-screening tool) indicated minimal difficulty, when it was observed Resident 7 had moderate difficulty in hearing. This deficient practice had the potential to result in Resident 7 not receiving appropriate care or treatment services to effectively communicate with others. Cross reference with F656Findings:During a review of Resident 7's Face Sheet (admission record, FS), the FS indicated Resident 7 was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation (irregular heartbeats), dysphagia (difficulty swallowing), and generalized muscle weakness. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop an individualized person-centered care plan (CP) for one of one sampled resident (Resident 7) that addressed Resident 7's moderate difficulty (speaker has to increase volume and speak distinctly) hearing. This failure had the potential to result in unmet individual needs for Resident 7 and the potential to affect Resident 7's physical and psychosocial well-being. Cross reference with F636Findings:During a review of Resident 7's Face Sheet (admission record, FS), the FS indicated Resident 7 was admitted to the facility on [DATE] with diagnoses that included atrial fibrillation (irregular heartbeats), dysphagia (difficulty swallowing), and generalized muscle weakness. During a review of Resident 7's History and Physical (H&P), dated 3/18/2025, the H&P indicated Resident 7 had the capacity to understand and make decisions. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a licensed nursing staff informed one of four sampled residents (Resident 79) of the type of medication being administered during medication administration on 3/26/2026 and as indicated in the facility's Policy and Procedure (P&P), titled Med Pass. This deficient practice had the potential to result in medication errors due to Resident 79 not being encouraged to participate during Resident 79's medication administration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 95), who spoke a dialect from China, was provided a communication tool or resources to effectively ensure Resident 95 communicated Resident 95's needs. This deficient practice had the potential to result in Resident 95's care needs not effectively conveyed to the facility staff, which could lead to a decline in the resident's physical and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 42), who was unable to carry out activities of daily living (ADL - routine tasks activities such as bathing, dressing, and toileting, a person performs daily to care for themselves) was properly groomed. This deficient practice had the potential to impact Resident 42's overall health and could affect Resident 42's psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a low air loss (LAL, mattress that operates using a blower-based pump that was designed to circulate a constant flow of air) mattress was set at intermittent pressure mode (alternating pressure, continuous, automatic inflation and deflation of air cells in a cyclical pattern) for one of four sampled residents (Resident 43). This deficient practice had the potential for Resident 43 to develop new pressure injuries (PI, lesion/wound caused by unrelieved pressure usually over a bony prominence that results in damage of underlying tissue) or delayed healing to Resident 43's existing PI.

Inspectors wroteBased on observation, interview, and record review, the facility failed to supervise two of two sampled residents (Resident 82 and Resident 106) while smoking in the patio's designated smoking area. This failure had the potential to result in injury, accidental burns, and fire hazards to the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure call lights (a device used by a resident to signal the need for assistance) were within reach for two of two sampled residents (Resident 10 and Resident 41). This deficient practice had the potential to result in unmet needs for Resident 10 and Resident 41 due to the residents being unable to call for assistance from staff or alert staff during an emergency.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Certified Nursing Assistant 2 (CNA 2) turned and repositioned one of two sampled residents (Resident 2) with pressure ulcer/injury (localized damage to the skin and/or underlying tissue usually over a bony prominence) in accordance with the resident's plan of care. This deficient practice had the potential for worsening or delaying healing of Resident 2's Stage 4 pressure ulcer (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone).

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pain medication to one of two sampled residents (Resident 2) and let the pain medication take effect prior to continuing with Resident 2's wound care to Resident 2's Stage 4 pressure ulcer (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) and prior to providing a bed bath to Resident 2. This deficient practice resulted in Resident 2 experiencing unrelieved pain for 40 minutes on 2/20/2026.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement proper infection control procedures for one of two sampled residents (Resident 4) when Certified Nursing Assistant 3 (CNA 3) did not change protective gown and performed hand hygiene after providing care to Resident 3 and before providing care to Resident 4. This deficient practice had the potential to spread MDRO infection to Resident 4.

Inspectors wroteBased on interview and record review, the facility failed to ensure physician assessment and continued management of a high-risk medication (drugs that can cause serious harm, injury, or death if used incorrectly) for one of three sampled residents (Resident 5). Resident 5 was on insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication), a high-risk medication, for management of diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and Resident 5's Hemoglobin A1C (Hgb A1C - a blood test which measures a person's average blood sugar levels over the past 2-3 months) laboratory test results indicated Resident 5's HgB A1C was 13.6 percent (normal range is below 5.7 percent). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to promptly respond to call lights (device used by a resident to signal his or her need for assistance from staff) and/or promptly respond to a resident's request for toileting assistance for two of four sampled residents (Residents 6 and 7). This failure had the potential to result in residents (in general) feeling like their concerns were unheard and feeling frustrated.

Inspectors wroteBased on interview and record review, the facility failed to ensure the facility created a Plan of Action form for concerns which 2 of 23 residents (unidentified) expressed during resident council (a formal gathering of residents to discuss shared concerns, improve quality of life, and communicate with management) meetings, according to the facility's Policy and Procedure (P&P) titled, Resident Council Meeting, reviewed 01/2025. This failure had the potential for residents' (in general) concerns to be unheard and had the potential for residents' (in general) needs to be unmet.

Inspectors wroteBased on interview and record review, the facility failed to maintain a complete and accurate medical record for one of three sampled residents (Resident 1) when facility staff (in general) failed to document Resident 1's visit to a physician on 9/4/2025 in Resident 1's medical record. This failure resulted in Resident 1's medical record containing incomplete information and had the potential for Resident 1 to receive inappropriate care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the dignity of one of four sampled residents (Residents 2) when staff failed to promptly respond to Resident 2 ' s call light. This failure had the potential to result in Resident 2 feeling unimportant and disrespected and for Resident 2 ' s needs not being met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 2) who required assistance with activities of daily living (ADLs- tasks of everyday life such as bathing, dressing, and toileting) was provided care timely when staff did not answer Resident 2 ' s call light promptly and assist Resident 2 with incontinence (involuntary loss of urine or feces) care. This failure resulted in Resident 2 to not receive timely assistance with ADL as needed and had the potential to result in skin breakdown and affect Resident 2 ' s well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 of 3 sampled residents (Resident 3) who received enteral feeding (tube feeding, the delivery of nutrients through a feeding tube directly into the stomach) received care and services from staff who were trained and competent in feeding tube management according to the facility ' s policies and procedures (P&P) titled, Gastrostomy Tube. This failure had the potential for Resident 3 and all residents who received tube feeding to not receive appropriate feeding tube nutrition and feeding tube care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate staff provided proper care and maintenance for one of three sampled residents (Resident 3) who received enteral feeding (tube feeding, the delivery of nutrients through a feeding tube directly into the stomach). This failure had the potential for Resident 3 to not receive appropriate feeding tube nutrition and care by trained and competent staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement Enhanced Barrier Precautions (EBP- an infection control strategy in nursing homes that expands the use of personal protective equipment [PPE], specifically gowns and gloves, during high-contact resident care to prevent the spread of infection) for one of 13 sampled residents (Resident 3). This failure had the potential to spread infections to the residents, staff, and visitors that could lead to hospitalization and/or death.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure to provide care and services to prevent and manage pressure ulcers for three of four residents (Resident 32, Resident 62 and Resident 183) by failing to: 1. Ensure Certified Nursing Assistant 1 (CNA 1) turned and repositioned Resident 62 who had a Stage 4 pressure ulcer (ulcer that extends into the muscle and bone and causing extensive damage on the sacrococcyx (the fused sacrum and coccyx. Sacrum is the large, triangular bone at the base of the spine. Coccyx is the triangular arrangement of bone that makes up the very bottom portion of the spine below the sacrum). 2. Ensure Certified Nursing Assistant 2 (CNA 2) turned and repositioned Resident 183, Resident 183 was assessed as high risk for the development of pressure ulcer. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to have sufficient staff to ensure timely incontinence care and dignity was provided for two of two sampled residents (Resident 233 and Resident 39). This failure had the potential for Resident 233 and Resident 39 to experience skin breakdown and loss of dignity. a decline in psychosocial well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement the facility's policy and procedure (P&P) titled, Infection Prevention and Control Program (IPCP) Standard and Transmission-Based Precautions, for nine of nine sampled residents (Residents 42, 235, 236, 234, 23, 61, 237, 40 and 46) by failing to: a. Ensure unlabeled personal toiletries were not stored inside Residents 42, 235, 236 and 234's [NAME] n' [NAME] restroom (a restroom that has two doors and is sandwiched between two bedrooms and is accessible by both bedrooms). b. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement its antibiotic (ABX, medication used to treat infections) stewardship program (efforts that ensure antibiotics are used only when necessary and appropriate) for three of seven sampled residents (Resident 10, Resident 72, and Resident 134) sampled residents. Residents 10, 72, and 134 did not meet McGreer's criteria (infection surveillance checklist to help determine appropriate antibiotic) for antibiotic use. These deficient practices had the potential for unnecessary administration of antibiotics and lead to resistance (when the antibiotic can no longer kill the bacteria [living organism that can cause an infection]) to antibiotics for Residents 10, 72, and 134.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light was within reach for one of one sampled resident (Resident 283). This deficient practice had the potential to result in a delay or the inability for Resident 283 to obtain necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to treat one of one sampled resident (Resident 39) with respect and dignity when Certified Nursing Assistant 4 (CNA 4) was observed saying, not right now, I am busy now to Resident 39 when Resident 39 asked CNA 4 for assistance on 2/6/2025. This deficient practice had the potential to compromise Resident 39's dignity and individuality and result in psychosocial decline to Resident 39.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide reasonable accommodation to meet the resident's needs by failing to ensure the resident's call light system was accessible and functional for one of six sampled residents (Resident 53). This deficient practice had the potential to negatively impact the psychosocial well-being of Resident 53 or result in delayed provision of services.

Inspectors wroteBased on interview and record review, the facility failed to ensure an accurate assessment was completed to reflect the history of falls within the past 3 months of the assessment for one of one sampled resident (Resident 59). This deficient practice had the potential to negatively affect Resident 59's plan of care and delivery of necessary care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 45), who was a newly admitted resident was pre-screened for PASARR (Preadmission Screening and Resident Review - a federal assessment requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care) prior to admission to the facility and a record of the PASARR was retained in Resident 45's medical record. These deficient practices had the potential for Resident 45's mental disorder was not identified and could result in Resident 45 not receiving specialized care and/or rehabilitative services as needed.

Inspectors wroteBased on interview, and record review, the facility failed to revise a care plan (CP) for two of two sampled residents (Resident 59 and 183), by failing to: A. Revise a CP for Resident 59 after the resident sustained a fall on 12/31/2024 and was at risk for recurrent falls. B. Revise a CP for Resident 183 after the resident developed a pressure injury [PI, localized injury to the skin and or underlying tissue usually over a bony prominence as result of pressure or pressure in combination with shear (mechanical force that cause the skin to break off) and/or friction) and when Resident 183 refused to turn and be repositioned. This deficient practice had the potential to result in unmet individualized needs for Residents 59 and 183 and the potential to affect the resident's physical well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure activities was provided to one of two residents (Resident 62). This deficient practice had the potential to affect Resident 62's psychosocial wellbeing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 42), was provided care in accordance with professional standards of practice by failing to: 1. Notify Resident 42's physician when Resident 42 had multiples bowl movements and refused to take Milk of Magnesia suspension (MOM, a laxative, medication used to relieve occasional constipation) when the resident had constipation. 2. Follow Resident 42's physician's orders for Dulcolax suppository (a medication that stimulates bowel movements [bm] designed to be inserted into the anus). These deficient practices resulted in Resident 42 having multiple bm and Resident 42 feeling anxious and miserable. Resident 42 was transferred to the General Acute Care Hospital (GACH) for further evaluation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of two sampled residents' (Resident 233 and Resident 59) environment remained free of accident (refers to any unexpected or unintentional incident, which results or may result in injury or illness to a resident) hazards to prevent a falls (refers to unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force) by failing to: A. Ensure Resident 233's bed always remained in a low position. B. Ensure Resident 59 received staff assistance on 1/31/2025 to prevent Resident 59 from falling. These deficient practices had the potential for Resident 233 who was a risk for fall to sustain a fall and result in injury and resulted in Resident 59 sustaining a fall on 1/31/2025.

Inspectors wroteBased on observation, interview and record review, the facility failed to post oxygen (02 - a colorless, odorless, tasteless gas that's essential for life) signage per facility's policy and procedure (P&P) for one of three sampled residents (Resident 233) when Resident 233 was receiving supplemental continuous oxygen. This deficient practice had the potential for an unsafe environment for Resident 233, other residents, staff and visitors due to the risk of fire related to the use of supplemental 02.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sanitation buckets (bucket 1) in the kitchen had adequate amount of quaternary sanitizing solution (an ammonium solution used for sanitizing surfaces) for the disinfection of key areas in the kitchen utilized to prepare resident's food. This deficient practice placed the residents at increased risk of infections and could have impacted the health and safety of residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Director of Nursing (DON) attended the Quality Assurance Performance Improvement quarterly meeting. This deficient practice had the potential to affect residents' physical, mental and psychosocial well-being.

Inspectors wroteBased on observation and interview, the facility failed to ensure one out of 34 rooms had no more than 4 residents (room [ROOM NUMBER]) in the room. This failure had the potential to result in lack of space and privacy for the residents residing in that room.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the facility's policy and procedure (P&P) titled, Medication Administration: Controlled Medications, for five of five sampled residents (Resident 2, Resident 3, Resident 4, Resident 5, Resident 6) by failing to: 1. Ensure the facility's controlled medication (refers to a substance [narcotics] that is regulated by the government due to its potential for abuse and addiction) count sheets were signed after Licensed Vocational Nurse 1 (LVN 1) administered the controlled medications for Resident 2, Resident 3, Resident 4, Resident 5, and Resident 6. 2. Ensure LVN 1 signed the Medication Administration Record (MAR) after the controlled medications were administered for Resident 4 and Resident 6. These deficient practices had the potential for controlled medications to not be properly accounted for.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a care plan for the use of an abdominal binder (a wide band of elastic or cotton material that fits around the abdomen) for one of eight sampled residents (Resident 1). This deficient practice had the potential for Resident 1 to receive inconsistent care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a sanitary (clean) environment to prevent the spread of infections for 3 of 13 sampled residents (Resident 5, Resident 12, and Resident 13) by failing to ensure Certified Nursing Assistant 3 (CNA 3) and Licensed Vocational Nurse 1 (LVN 1) performed hand hygiene (cleaning hands by either washing them with soap and water, or by using an alcohol-based hand sanitizer) according to the facility's Hand Washing policy and procedure (P&P). These failures had the potential to spread infection to all residents, staff, and visitors in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 of 13 sampled residents (Resident 2) was provided peripherally inserted central catheter (PICC - a thin, flexible tube that's inserted into a vein in the arm and threaded into a large vein near the heart. It is used to administer intravenous (IV) fluids, blood transfusions, chemotherapy, and other drugs, and to draw blood samples) care according to the physician's order and the facility's policy and procedure. This failure had the potential for Resident 2 to develop an infection on Resident 2's PICC site and/or develop sepsis (a life-threatening blood infection).

Inspectors wroteBased on observation, interview and record review, the facility failed to reduce the risk of a fall and injury hazard for Resident 1 (who had a fall with a skin tear at the facility on 7/17/24), by not providing Resident 1 with bilateral floor mats as indicated in Resdient 1's care plan and physician order. This deficient practice had the potential to placed Resident 1 at risk for recurrent falls and injury.

Inspectors wroteBased on interview and record review, the facility failed to provide the care and services for one of six sampled residents (Resident 2) according to the facility's policies and procedures (P&P) titled, Resident Care, Monitoring of, Change of Condition Reporting, and Significant Change of Condition, Response, by failing to: 1. Ensure Licensed Vocational Nurse (LVN) 1 notified Resident 2's Primary Care Provider/Medical Doctor (MD) 1 promptly (quickly/with little or no delay) when LVN 1 noted a lump (growth, swelling, or mass that can appear anywhere on the body) in Resident 2's left breast on 4/17/2024 at 12:15 pm. 2. Ensure LVN 1 and/or assigned licensed nurses (LVNs or Registered Nurses [RNs]) developed a plan of care and implemented interventions to address Resident 2's left breast lump. 3. [...]

Inspectors wroteBased on interview and record review, Certified Nursing Assistant (CNA) 2 and CNA 3 failed to treat one of six sampled residents (Resident 2) with consideration, respect, and full recognition of Resident 2's dignity and individuality according to the facility's policy and procedure (P&P) titled, Resident Rights, by failing to listen and respect Resident 2's request to be turned a certain way in bed during patient care. This failure caused Resident 2 to feel degraded and feel that Resident 2 had no say about her care in the facility.

Inspectors wroteBased on interview and record review, the facility failed to promptly (quickly/with little or no delay; immediately) notify the physician for one of six sampled residents (Resident 2) who experienced a change of condition (COC- a sudden clinically important deviation from a resident/patient's baseline in physical, behavioral, or functional domains) as indicated in the facility's policy and procedure (PP) titled, Change of Condition Reporting, by failing to: 1. Ensure Licensed Vocational Nurse (LVN) 1 notified Resident 2's Primary Care Provider/Medical Doctor (MD) 1 promptly when LVN 1 noted a lump (growth, swelling, or mass that can appear anywhere on the body) in Resident 2's left breast on 4/17/2024 at 12:15 pm. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a care plan (CP) upon a significant change of condition for one of six sampled residents (Resident 2) according to the facility's policy and procedure (P&P) titled, Care Planning, revised 1/2024, by failing to: 1. Ensure Licensed Vocational Nurse (LVN) 1 and/or assigned licensed nurses (LVNs or Registered Nurses [RNs]) developed and implemented a CP when LVN 1 noted a lump (growth, swelling, or mass that can appear anywhere on the body) in Resident 2's left breast on 4/17/2024. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow the facility's policy and procedure (P&P) titled, Reporting Alleged Violations of Abuse, Neglect, Exploitation or Mistreatment, when the facility failed to report an allegation of abuse to the California Department of Public Health (the Department) for one of three sampled residents (Resident 1). This failure violated Resident 1's rights, had the potential to compromise Resident 1's safety, and could subject Resident 1 to potential further abuse.

Inspectors wroteBased on interview and record review, the facility failed to provide sufficient nursing staffing for one of three shifts (the nocturnal shift [NOC- night shift, 11 pm to 7 am]) on 08/24/2024, from 3 am to 7 am, to provide safe and timely nursing care to four of eight sampled residents (Residents 1, 3, 4, and 5). This failure resulted in Residents 1, 3, 4, and 5 to feel unsafe during the NOC shift on 08/24/2024 from 3 am to 7 am, and had the potential to delay the provision of care for the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the indwelling Foley catheter (thin, sterile tube inserted into the bladder to drain urine into a bag outside the body) tubing was free from urine sediments (bacteria and white blood cells are shed into the urine) for one of one sampled resident (Resident 6). This failure had the potential for Resident 6 to receive delay in care and treatment and placed the resident at risk for urinary tract infection (UTI- infection in the urinary system).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 of 10 sampled residents (Resident 7) had the call light within reach. This deficient practice had the potential to result in Resident 7 being unable to summon health care workers for assistance for care and services as needed.

Inspectors wroteBased on interview and record review, the facility failed to provide a dignified existence and self-determination to one of five sampled residents (Resident 1) by failing to: Ensure facility staff showered or provided a full bath (an all-over washing, as given to a person confided to bed, done with a wet sponge or washcloth rather than in a bathtub or shower than includes the washing of hair and or shaving) or sponge bath (an all-over washing, as given to a person confided to bed, done with a wet sponge or washcloth rather than in a bathtub or shower) to Resident 1 on 2/12/2024 which was a designated shower day for Resident 1. This deficient practice had the potential for Resident 1 to develop infection, skin breakdown, and suffer psychosocial (mental, emotional, social, and spiritual effects) harm.

Inspectors wroteBased on interview and record review, the facility failed to maintain the dignity of five of seven sampled residents (Residents 1, 20, 25, 281, and 283): a. For Resident 1, 20, and 25, facility staff failed to promptly respond to call lights (a device used by a resident to signal his or her need for assistance from staff). b. For Resident 281, facility staff failed to promptly respond to Resident 281's call light during the night, to assist Resident 281 to the toilet. c. For Resident 283, the facility failed to assist Resident 283 in getting dressed for the day, in a timely manner. These failures resulted with Resident 281 to feel miserable and like crying and for Resident 283 to feel afraid. The failures had the potential to result in Residents 1, 20, 25, 281, and 283 to feel like their concerns were unheard and feel disrespected.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate was less than 5% (percents) for one of four sampled residents (Resident 26). The medication error rate was 11.76 % due to four medication errors in a total of 34 opportunities observed during the medication administration. The facility failed to: A. Ensure Resident 26's insulin glargine (long-acting insulin [hormone that regulates blood sugar] that keeps blood sugar levels stable during periods of fasting) was properly labeled and available for administration as ordered by the physician. B. Ensure Resident 26's insulin aspart (rapid-acting insulin taken before meals that works quickly to prevent blood sugar from going too high after carbohydrates intake) was available for administration per the physician's insulin sliding scale order. C. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure three of three sampled residents (Resident 26, 38, and 183) had their blood sugar (BG) levels checked and were adminitered insulin (medication used to control sugar in the blood) as indicated in the physician's orders. a. For Resident 26, during medication administration observation on 1/24/2024, insulin glargine (long-acting insulin [hormone that regulates blood sugar] that keeps blood sugar levels stable during periods of fasting) and insulin aspart (rapid-acting insulin taken before meals that works quickly to prevent blood sugar from going too high after carbohydrates intake) were not available for administration. b. For Resident 38, on 1/24/2024, the BG level was not checked prior to meals. c. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all medications were properly labeled and stored as indicated in the facility's policies and procedures (P&P): a. The facility did not properly label Resident 26's insulin glargine pen (long-acting insulin [hormone that regulates blood sugar] that keeps blood sugar levels stable during periods of fasting) in one of three medication carts (Med Cart 3). b. The facility staff did not dispose of expired Epi-Pen (life-saving medication to treat a severe allergic reactions) in one of three medication carts (Med Cart 1). c. The facility did not properly label and store in a designated locked area the discontinued medications or medications of discharged residents. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate documention for three of three sampled residents (Resident 38, 183, and 26) by failing to document the insulin (medication used to lower blood sugar levels) administration as soon as it was administered. This failure had to the potential result in staff and health care providers to use inacurate and insufficient resident information during care planning and a changing status, in addtion, there was a potential to show inaccurate trends in Residents 38, 183, and 26's blood sugar management.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow infection control practices to maintain a safe, sanitary environment for three of three sampled residents (Resident 25, 1, and 181) in accordance with the facility's policies and procedures (P&P) when, a-b.the facility failed to store resident care equipment properly. On 1/22/24, there was an unlabeled bedpan stored on the floor in Resident 1 and Resident 25's shared restroom and the facility did not know which resident the bedpan belonged to. c. For Resident 181, on 1/22/24 the Director of Rehabilitation (DR) exited Resident 181's room without performing hand hygiene. These failures had the potential to result in cross contamination (process by which bacteria can be transferred from one area to another) and/or the development and transmission of disease and infection to Residents 25, 1 and Resident 181.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 284), was provided with a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN, a document that informs the resident they may need to pay out of pocket for their care). This failure had the potential to result in Resident 284 to not be able to make an informed decision about Resident 284's care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a comfortable environment and failed to protect resident (in general) property for two of two sampled residents (Resident 131 and Resident 26) as indicated in the facility policy and procedures (P&P), titled, Hot Water Temperatures, Controlling and Personal Belonging, Inventory of, when, a. For Resident 131, the facility staff gave Resident 131 a bed bath (an all-over wash given to a person in bed) with water that was not hot enough or comfortable for Resident 131. b. For Resident 26, Resident 26's personalized blanket went missing and the blanket was not added to Resident 26's inventory list. These failures resulted in Resident 131 to experience an uncomfortable environment and had the potential to affect Resident 131's health and safety. [...]

Inspectors wroteBased on interview and record review, the facility failed to conduct a comprehensive and accurate assessment, for two of two sampled residents (Resident 181 and 61) when, a. For Resident 181's admission Minimum Data Set (MDS, an assessment and screening tool), dated 1/2/24, indicated Resident 181 had minimal difficulty hearing (when a person speaks softly, or a setting is noisy) when Resident 181 had difficulty hearing and was hard of hearing. b. For Resident 61, the MDS was not completed accurately. This failure resulted in inaccurate assessments of Resident 181's hearing and Resident 61 and had the potential to result in physical and psychosocial declines to Resident 181 and could potentially result in Resident 181 and 61 to not receive appropriate care and services based on the resident's preferences, goals of care, functional-health status, strengths, and needs.

Inspectors wroteBased on interviews and record review, the facility failed to develop and implement a baseline care plan within 48 hours of admission for the physician's orders for medications used to treat anxiety disorder (anxiety, persistent or excessive worry about activities or events, including routine and ordinary issues), psychosis (mental condition wherein one loses some contact with reality), and major depressive disorder (depression, persistently low or depressed mood and loss of interest in activities that brought joy previously, interfering with daily life) for one of one sampled resident (Resident 131). This failure had the potential to lead to inaccurate or inconsistent provision of treatments and services to Resident 131.

Inspectors wroteBased on interview and record review, the facility failed to implement a comprehensive plan of care for one of one sampled resident (Resident 181) when: 1. Resident 181 was hard of hearing and there were no alternative communication tools like a communication board at Resident 181's bedside as indicated in Resident 181's care plan (CP). This failure resulted in no individualized care to Resident 181 and did not maintain Resident 181's highest practical physical and mental well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of one sampled resident's (Resident 59) care plan (CP, provides direction on the type of nursing care an individual needs that include goals of treatment, specific nursing interventions [actions, treatments, procedures, or activities designed to meet an objective] and an evaluation plan) was revised in accordance with the facility's policies and procedures (P&P) titled, Comprehensive Person-Centered Care Planning. This failure had the potential to result in Resident 59, who had a change in condition, to receive inadequate care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 20 sampled residents (Resident 26) was provided with activities that met the resident's interests and supported the resident's physical, mental, and psychosocial well-being. This failure had the potential to cause a decline in Resident 26's physical, mental, social, and emotional well-being.

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide care and services to meet the residents' physical, mental, and psychosocial needs for two of two sampled residents (Residents 181 and 185) by failing to ensure: a. Resident 181 who was hard of hearing was provided audiology (hearing) services. b. Resident 185's order for urine sample for culture and analysis was carried out as ordered by the physician. These failures had the potential to result in the delay of necessary care and services for Residents 181 and 185.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure two of two sampled residents (Resident 70 and Resident 59) were provided proper treatment to promote the prevention of pressure ulcer/injury (PU/PI, refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) development by failing to ensure the low air loss mattress (LAL, special type of mattress used for both the prevention and treatment of PU/PI) was set correctly. This failure could result in the development of PU/PI for Resident 70 and Resident 59 due to incorrect LAL setting.

Inspectors wroteBased on observation, interview and, record review the facility failed to ensure, for one of two sampled residents (Resident 59), was free of accident (any unexpected or unintentional incident, which results or may result in injury or illness to a resident) hazards by failing to ensure Resident 59's bed remained in a low position when Resident 59 had a history of falls (refers to unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force e.g., resident pushes another resident). This failure could potentially result in Resident 59 falling and sustaining injuries.

Inspectors wroteBased on observation, interview, and record review the facility failed to manage pain and follow its policy and procedure to consult physician for pain not relieved by current pain medication orders for one of two residents (Resident 185). As a result, Resident 185's pain was unrelieved. These failures caused Resident 185 physical and emotional distress and failed to maintain Resident 185's highest practical physical, mental, and psychosocial well-being.

Inspectors wroteBased on interviews and record review, the facility failed to ensure, one of one sampled resident (Resident 40), who received hemodialysis (dialysis, process of filtering the blood of an individual whose kidneys are impaired) received care and services consistent with Resident 40's care plans and the facility's policy and procedures (P&P). This failure had the potential to cause a decline in Resident 40's physiological and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a system of accurate acquisition, receipt, dispensing of all routine drugs for one of 4 sampled residents (Resident 26) was in place with documentation readily available for review. This failure had the potential to lead to a decline in Resident 26's well-being due to missed medications and possible drug diversion (transfer of a resident's prescribed medication to another individual) related to unaccounted medications. Cross Reference with F759, F760, and F761.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of one sampled resident (Resident 282), who received a psychotropic drug (any drug that affects brain activities associated with mental processes and behavior), was monitored for adverse consequences (unwanted, uncomfortable, or dangerous effects) as indicated in the facility's Policy and Procedure (P&P), titled, Psychotropic Drug Use. This failure had the potential to result in Resident 282 to experience adverse consequences from administration of psychotropic drugs and the potential to result in a physical decline to Resident 282.

Inspectors wroteBased on interview and record review, the facility failed to, for one of three sampled residents (Resident 38), provide the Agreement To Arbitrate Disputes Related To Medical Malpractice Binding Arbitration Agreement (Binding Arbitration Agreement), in a language Resident 38 understood when the facility asked Resident 38 to enter into an agreement for binding arbitration (involves the submission of a dispute to a neutral party who hears the ca12se and makes a decision). This failure had the potential to result in Resident 38 to not be able to make an informed decision and/or his rights to be denied.