Artesia Palms Care Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services to one of eight sampled residents (Resident 167) with limited range of motion ([ROM] full movement potential of a joint) and mobility concerns by failing to provide passive range of motion ([PROM] movement of a joint through the range of motion with no effort from person) and to apply both hand rolls (soft roll positioned in the palm of the hand and fastened with a strap) and the right elbow extension (straightening) splint (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion) from 12/25/2025 to 1/1/2026. This failure had the potential to result in a decline in ROM to both of Resident 167's arms.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the manufacturer's specifications (detailed documents outlining the technical requirements, performance standards, and physical characteristics of a product) of a rollator walker (four-wheeled mobility aid with a frame, handlebars, hand brakes, and a built-in seat) for one of five sampled residents for accidents (Resident 13). This failure resulted in Resident 13 experiencing a fall from the rollator walker on 5/27/2026.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide accurate and complete documentation for two of 35 sampled residents (Resident 13 and Resident 46) by failing to:a. Provide accurate documentation of Resident 13's fall which occurred while sitting in a rollator walker (four-wheeled mobility aid with a frame, handlebars, hand brakes, and a built-in seat) on 5/27/2026. b. Determine Resident 46's decision making capacity (the ability to make decisions regarding health care and related treatment choice) upon admission. These failures had the potential to prevent the facility from determining the cause of Resident 13's fall and to prevent additional falls. These failures also had the potential to prevent Resident 46 and/or the responsible party from making decisions regarding Resident 46's care.

Inspectors wroteBased on interview and record review, the facility failed to ensure facility staff accurately documented in the clinical record for one of five sampled residents (Resident 1) when Resident 1 had multiple prior attempts to elope (an unauthorized departure of a patient from an around-the-clock care setting) from the facility, but documentation indicated he did not attempt to elope. This failure of inaccurate documentation posed a risk for staff not identifying Resident 1 as an elopement risk, which could delay timely interventions and place Resident 1 at risk for injury or death due to unsupervised exit from the facility.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure:26 residents on pureed diet (foods that do not require chewing and are easily swallowed. All food should be smooth and pureed to the consistency of pudding) received pureed textured bread a form that meets their needs and in accordance with the international Dysphagia Diet Initiative-level 4 (IDDSI -a framework made up of levels and describes food textures and drink thickness) level Four (pureed foods and extremely thick drinks) when the texture of the pureed bread was lumpy and liquid seeping out, not smooth and had small pieces of bread crust present requiring chewing before swallowing. This failure had the potential to result in meal dissatisfaction and increased choking risk for 26 out of 166 residents who received the pureed bread from the facility kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light was within reach for one of eight sampled residents (Resident 154). This deficient practice had the potential for a delay of care for Resident 154.

Inspectors wroteBased on interview and record review, the facility failed to ensure psychotropic medication (medications that affect brain activities associated with mental processes and behavior) was not used unnecessarily for one of three sampled residents (Resident 7) by failing to define and monitor resident specific, measurable target behaviors related to the use of Seroquel [an atypical antipsychotic that's used to improve mood, thoughts, and behaviors for people with schizophrenia (a mental illness that is characterized by disturbances in thought) and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs)] For Resident 7. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure minimum data set (MDS a resident assessment tool) assessments were coded accurately for two of 35 sampled resident (Resident 2 and Resident 20). -The facility failed to ensure Resident 20 who has a diagnosis of diabetes mellitus (DM a condition where the body can not process sugar normally and may lead to poor wound healing) was coded accurately.-The facility failed to ensure Resident 2's treatment for DM was coded accurately. These failures had the potential for Resident 2 and Resident 20 not receiving an individualized plan of care based on the resident's specific needs and treatment.a. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for one of three sampled residents (Resident 10) by failing to identify triggers of trauma (a very upsetting or harmful experience that can affect a person's mind or body) and develop individualized interventions for Resident 10. These failures had the potential to result in Resident 10's needs not being met, affecting the residents' mental and physical well being.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for one of three sampled residents (Resident 7) related to failing to revise and update fall prevention interventions recommended during the Interdisciplinary team (IDT-a group of different experts who work together to help the residents with complex needs) meeting regarding actual fall incidents 8/6/2025 and 8/30/2025 for Resident 7. These failures had the potential to result in Resident 7 and 10's needs not being met, affecting the residents' well-being, and poor patient outcomes.

Inspectors wroteBased on interview and record review, the facility failed to ensure monitoring orders were completed and documented as 'complete' as ordered by the physician for one of 35 sampled resident (Resident 47). This deficient practice had the potential to result in unmet medical needs and increased risk of adverse health outcomes for Resident 47.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of five residents (Resident 37) was provided with floor mats on each side of the bed, as ordered by the physician. This failure put Resident 37 at a higher risk for injury in the event of a fall. During a review of Resident 37's admission Record, the admission record documented the facility readmitted Resident 37 on 7/23/2025, with diagnoses including muscle weakness and paranoid schizophrenia (a mental disorder characterized by delusions and auditory hallucinations). During a review of Resident 37's Minimum Data Set ([MDS] a resident assessment tool), dated 10/2/2025, the MDS documented Resident 37 had moderate cognitive (thought process) impairment and transfers were not attempted due to medical condition. [...]

Inspectors wroteBased on interview, and record review, the facility failed to Identify and to intervene in one of three sampled residents' (Resident 10) history of trauma (a very upsetting or harmful experience that can affect a person's mind or body) and triggers which may cause re-traumatization (a person encounters a new event or stimulus that triggers them to re-experience the intense stress, emotional distress, and even flashbacks of a previous traumatic event as if it were happening again). This failure had the potential to result in Resident 10 experiencing unnecessary re-traumatization.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 17 of 91 resident rooms' met the requirements of 80 square feet ([sq. ft.] a unit of area measurement) per residents in multi-bed resident rooms and 100 sq. ft for each single bed resident room. This deficient practice had the potential to result in inadequate provision of safe nursing care, and privacy for the residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure Certified Nursing Assistant (CNA) 1, who discovered a resident on the floor, following an unwitnessed fall (8/21/2025), reported the resident's fall and did not place the resident back in bed prior to a licensed nurse's assessment for one of three sampled residents (Resident 1) reviewed for falls. When the facility was made aware of Resident 1's unwitnessed fall, they failed to conduct a neurological (a series of simple tests to see how well your brain, spinal cord, and nerves are working) assessment, per their policy and procedure (P/P) titled, Neurological Assessment (Routine). These deficient practices resulted in a delay in care (assessment, pain management, evaluation) and transfer to a General Acute Care Hospital (GACH) on 8/22/2025 for continued evaluation and treatment. [...]

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from physical abuse by one of three sampled residents (Resident 1), when Resident 1 punched Resident 2 in the face on 10/31/2025. This deficient practice resulted in Resident 2 sustaining a left periorbital (area around the eye socket) discoloration, discoloration on the bridge (bony, elevated area between the eyebrows and the tip of the nose) of his nose, a left eyebrow skin tear, and a left dorsal (backside) fifth digit (finger) skin tear. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sampled residents, who had a history of wandering into other residents' rooms, was free from physical abuse for one of four sampled residents (Resident 233). The facility failed to: 1. Provide Resident 233 with 1:1 (staff member provides dedicated, individualized attention to a single resident) monitoring to prevent him from wandering into Resident 23's room per untitled Care Plan dated 5/12/2025. 2. Implement the facility's policy and procedure (P&P), titled, Resident Rights, dated January 2025, that indicated the facility would protect a resident's right to be free from abuse. As a result of these deficient practices Resident 23 struck Resident 233 on the face. [...]

Inspectors wroteBased on interview, record review, the facility failed to ensure residents received their mail in a timely manner, including mail delivery on Saturdays for seven of eleven residents (Residents 75, 76, 115, 122, 166, 191, and 212) who attended the resident council meeting (scheduled gathering of residents in a long-term care facility, where they discuss issues related to their quality of life). This deficient practice had the potential for violating their right to communicate promptly with individuals within and outside the facility.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure there were adequate indications for the use of Abilify and Risperdal (antipsychotic medications used to treat mental illness) by failing to identify and document the use of non-pharmacological interventions (attempts to modify resident behavior without the use of medications) in two of five residents sampled for unnecessary medications (Resident 179 and 209.) 2. Ensure Abilify was necessary to treat a specific condition as diagnosed and documented in the medical record in one of five residents sampled for unnecessary medications (Resident 179.) 3. [...]

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 when: 1. Nutritional supplement labeled store frozen with manufactures instructions to use within 14 day of thawing were not monitored for the date they were thawed to ensure expired shakes were discarded after this time frame. Three boxes each with 50 single serve cartons of strawberry flavored nutrition supplements, two boxes of vanilla flavored nutrition supplements, 10 boxes of chocolate flavored nutrition supplements and one box containing 17 single serve cartons of chocolate and strawberry flavor supplements were stored in the reach in refrigerator with no thaw date. This deficient practice had the potential to result in food borne illness in 33 residents who are on nutrition supplements at the facility. 2. [...]

Inspectors wroteBased on interview and record review the facility failed to developed a person centered care plan for two of 25 sampled residents (Residents 68 and 205). This deficient practice had the potential for the resident's care needs not to be addressed related to the use of clonazepam.

Inspectors wroteBased on interview and record review, the facility failed to revise the comprehensive care plan for accidents one of seven sample residents (Resident 156), when a care plan was not updated for Resident 156 after the resident experienced a fall. This had the potential for serious harm, including additional falls or injures, due to the facility's failure to reassess and respond to the resident's change in condition.

Inspectors wroteBased on interview and record review, the facility failed to ensure a new diagnosis of schizophrenia (a mental illness characterized by hallucinations [hearing or seeing things that are not there] or delusions [firmly held beliefs that are untrue despite evidence otherwise]) was based on evidence-based criteria (such as the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition [DSM-5] criteria) consistent with professional standards affecting one of five residents sampled for unnecessary medications (Resident 209.) This deficient practice of failing to use evidence-based criteria consistent with professional standards to make a new diagnosis of schizophrenia increased the risk that Resident 209 could have experienced adverse effects (unwanted or dangerous medication-related side effects) related to psychotropic medication (medications that affect brain activities associated [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 129) who was incontinent (unable to voluntarily control retention of urine or feces in the body) of bowel and bladder, was provided a retraining and/or toileting program to regain the resident's normal bowel and bladder function as much as possible, by failing to identify Resident 129 as a candidate for retraining program. This failure had a potential to result in Resident 129's permanent inability to regain control of bowel and bladder function and can lead to a loss of dignity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of five sampled residents (Resident 111 and Resident 168) who received enteral feeding (nutrition delivered using the gut) through a gastrostomy tube (GT - a tube inserted through a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) received the appropriate treatment and services by: A. Failing to ensure sufficient fluid was provided as physician ordered for Resident 111. B. Failing to ensure Resident 168 was positioned safely at 45 degrees during the enteral feeding via GT. [...]

Inspectors wroteBased on interview, and record review, the facility failed to provide care for use of a Continuous Positive Airway Pressure, (CPAP a machine used to deliver a stream of pressurized air through a mask to keep the airways open during sleep, preventing pauses in breathing) as per the manufacturer's recommendation for one of one sampled resident (Resident 205) by failing to change the CPAP mask cushion every month, and clean the CPAP machine and supplies per the manufacture's guidelines. These deficient practices had the potential to affect the quality and cleanliness of the CPAP machine and supplies and may result in the growth of bacteria affecting the respiratory health and well-being of Resident 205.

Inspectors wroteBased on interview and record review the facility failed to ensure a performance review for two of seven Certified Nurse Assistants (CNA 3 and CNA 4) were completed at least once every 12 months. This deficient practice had the potential to result in poor resident health outcomes.

Inspectors wroteBased on interview and record review, the facility failed to follow up on the denture referral for one of three sampled residents (Resident 182). This failure resulted in delivery of care and services and had a potential risk for weight loss for Resident 182.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store one open bottle of gabapentin solution (a medication used to treat nerve pain) in the refrigerator as required by the manufacturer's specifications affecting Resident 46 in one of five inspected medication carts (Villa Cart South.) This deficient practice of failing to store medication according to the manufacturers' requirements increased the risk that Resident 46 could have received medication that had become ineffective or toxic due to improper storage possibly leading to health complications resulting in hospitalization or death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the trash stored in the dumpster area was maintained in sanitary manner. a. One of 10 garbage dumpster cover was broken, and trash bin was not closed. The floor area around the trash dumpsters was not clean, there were disposable plastic spoons, paper and debris. This deficient practice had the potential for harborage and feeding of pests.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control practices for one sampled resident (Resident 168) and one nonsampled resident (Resident 80) by failing to: 1) Ensure Certified Nursing Assistant (CNA) 1 performed hand hygiene when entering and leaving Resident 168's room who was placed on Enhanced Barrier Precautions (EBP, infection control practices that use personal protective equipment [PPE] to reduce the spread of multidrug-resistant organisms [MDROs]), and to ensure Licensed Vocational Nurse (LVN) 1 performed hand hygiene when entering Resident 168's room. 2) Ensure Laundry Aide (LA) 1 performed hand hygiene when entering and leaving Resident 80's who was on EBP room, and to ensure LA 1 fully covered the residents' personal clothing during transportation to another area of the facility from Resident 80's room. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to conduct a bed inspection to identify areas of possible entrapment for one of two sampled residents (Resident 205). This deficient practice had the potential to negatively impact the resident resulting in possible entrapment, serious injury, and death.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 41 of 91 resident rooms met the requirements of 80 square feet ([sq. ft.] a unit of area measurement) per residents in multi-bed resident rooms and 100 sq. ft for each single bed resident room. This deficient practice had the potential to result in an inadequate provision of safe nursing care, and privacy for the residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of nine sampled residents (Resident 1 and Resident 2), who were assessed at risk for elopement (the act of leaving a facility unsupervised and without prior authorization), received supervision to prevent elopement from the facility. These deficient practices resulted in Resident 1 and Resident 2 eloping from the facility on 5/18/2025 at approximately 12 p.m. without staff awareness. Resident 1 and Resident 2 were located by Resident 1's Family Member (FM) 1 approximately 20 miles from the facility on 5/19/2025 at approximately 3 p.m. (approximately 27 hours after they were believed to have eloped from the facility). Both residents were transported to a General Acute Care Hospital (GACH) for evaluation and treatment, where they remained for four days. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide training related to resident elopement (the act of leaving a facility unsupervised and without prior authorization) for eight of eight sampled employees (Certified Nursing Assistants [CNA] 1, 8, 9, 10, 11, 12 and 13 and a Restorative Nursing Assistant (RNA 1) on hire and/or annually, as indicated in their Facility Assessment. This deficient practice resulted in CNA 1 and Receptionist (RCP) 1 allowing two residents (Resident 1 and Resident 2) to enter the facility's lobby area from a locked location and then wander (a situation in which a resident leaves the premises of a safe area without the facility's knowledge and supervision, if necessary, would be considered and elopement) through the facility's front door on 5/18/2025.

Inspectors wroteBased on interview, and record review, the facility failed to ensure a written notice Based on interview, and record review, the facility failed to ensure a written copy of the bed hold notice was created and provided to two of two sampled resident's (Residents 1 and 2) responsible parties (RP 1 and RP 2) within 24 hours of transferring Resident 1 and Resident 2 to a General Acute Care Hospital (GACH). This deficient practice resulted in the incomplete status of Resident 1 and Resident 2's bed hold availability and no documented notice provided to RP 1 and RP 2.

Inspectors wroteBased on interview, and record review, the facility failed to ensure neurological (relating to disorders of the nervous system) assessments was completed, per protocol, for one of three sampled residents (Resident 3), after Resident 3 experienced a fall and hit his head. This deficient practice resulted in an incomplete/incorrect neurological assessment of Resident 3 and had the potential for a change of condition (COC) to go unnoticed which could lead to a delay in evaluation and care.

Inspectors wroteBased on interview and record review, the facility failed to create and document a Nursing Fall Assessment when one of three sampled residents (Resident 3) experienced a fall and injury to his left eyebrow. This deficient practice resulted in no documented interventions for Resident 3 following his fall and left eyebrow injury and had the potential for care not to be rendered and/or monitored.

Inspectors wroteBased on interview, and record review, the facility ' s licensed nurses failed to ensure informed consents were obtained from residents or their Responsible Party (RP) prior to administering antipsychotic medications (medication used to treat serious mental health conditions) and/or they failed to ensure informed consents were obtained by the resident ' s provider and not licensed nurses for three of seven sampled residents (Residents 1, 5, and 6). This deficient practice resulted in the administration of anti-psychotic medications to Residents 1, 5, and 6 prior to them being informed of the medications risk versus benefits, alternative treatment and opportunity to refuse. This deficient practice had the potential for the residents to receive unnecessary medications. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that for one of three sampled residents (Resident 1) who was prescribed and administered anti-psychotic medication (a class of drugs used to treat psychosis [an abnormal condition of the mind that results in difficulties telling what is real and what is not], that the medication was prescribed and administered for appropriate indications for use, detailed evidence of behaviors were documented, non-pharmacological interventions (any type of healthcare action that does not involve the use of medication) were attempted and evaluated prior to the administration/continuance of the medication, adverse reactions associated with the use of the medication, i.e., weight gain, an increase in cholesterol and dizziness were monitored, documented and evaluated, and a comprehensive evaluation was conducted to determine [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were protected from abuse in the smoking patio area when Resident 54 hit Resident 11 on the nose. As a result of this failure, Resident 11 sustained a nosebleed and had to be sent out to the hospital for further evaluation and treatment.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident, who was diagnosed with atrial fibrillation ([Afib] abnormally fast heartbeat that may lead to blood clots) and received Warfarin (a medication used to prevent blood clots from forming) was free from significant medication errors for one of three sampled residents (Resident 1). The facility failed to: 1. Ensure Resident 1's Warfarin was administered as ordered by Resident 1's physician's Nurse Practitioner (NP). 2. Ensure licensed nurses did not administer multiple orders of duplicate therapy of Warfarin to Resident 1 on 11/21/2024, 11/22/2024, 11/23/2024, 11/25/2024 11/29/2024, 11/30/2024, 12/1/2024, 12/2/2024, 12/9/2024 and 12/10/2024 that included a dose of Warfarin that should have been discontinued on 11/19/2024. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Medication Regimen Review ([MRR] a thorough check of all the medications a patient is taking, done by a healthcare professional, to ensure they are safe, effective, and appropriate for their current health conditions) was conducted by the facility's Consulting Pharmacist (CP) for one of three sampled residents (Resident 1), to include a review of Warfarin (a medication used to prevent blood clots from forming), as well as Resident 1's labs. This deficient practice resulted in administration of unnecessary doses of Warfarin to Resident 1, placing Resident 1 at risk for adverse side effects of Warfarin, such as abnormal bleeding and/or excessive bruising.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure facility staff notified the physician within four hours of receiving critical (values that are significantly outside the normal range) laboratory (labs) and/or the Medical Director (MD) if there was no response by the physician for one of three sampled residents (Resident 1). This deficient practice resulted in the facility's nursing staff receiving no instructions from Resident 1's physician related to Resident 1's critically high International Normalized Ratio ([INR] a blood test that measures how long it takes for blood to clot) results. This deficient practice had the potential to result in the need to significantly alter treatment.

Inspectors wroteBased on interview, and record review, the facility failed to clarify an order for aspirin ([ASA] a medication used for mild pain relief and preventions of blood clots [a gel-like substance that forms when blood hardens from a liquid to a solid]) resulting in a discrepancy that was not clarified by licensed nursing staff for three months, for one of three sampled residents (Resident 1). Resident 1's physician ordered ASA, 81 milligrams ([mg] a metric unit of measurement, used for medication dosage and/or amount) by mouth, but the facility documented ASA 1 mg by mouth. As a result of this deficient practice Resident 1's ASA order was documented as follows: [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure pain medication prescribed to one of eight sampled residents (Resident 5) had a specified indication for use on Resident 1's physician's order, the reason pain medication was administered was specified on Resident 1's medication administration record ([MAR] a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) and the effectiveness of the pain medication was documented These deficient practices resulted in the inability to determine what the pain medication was ordered for, the location of Resident 1's pain, and/or the effectiveness of the pain medication administration. [...]

Inspectors wroteBased on interview and record review, the facility failed to accurately document medication administration in the medical record for one out of eight residents (Resident 5). This deficient practice resulted in inaccurate documentation of the care provided to Resident 5 after he sustained a fall with injury on 10/14/2024. This deficient practice had the potential for non-continuity of Resident 5's care by other health care providers.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of six sampled residents (Resident 6) who had a diagnosis of legal blindness (inability to see) was supervised during mealtime (eating). This deficient practice resulted in Resident 6 feeling neglected, unsatisfied, and undignified when food particles fell on her clothing, accessories, and on the floor while eating, which had the potential to negatively affect her psychosocial and emotional well-being.

Inspectors wroteBased on interview and record review, the facility failed to readmit a resident, who was transferred to a General Acute Care Hospital (GACH) on [DATE] for evaluation and treatment due to behavioral symptoms, agitation, aggression, and psychosis (mental disorder, disconnection from reality) and was ready to return to the facility from the GACH for one of three sampled residents (Resident 1). This deficient practice resulted in Resident 1 remaining at the GACH (as of [DATE]) after Resident 1 was ready to be discharged back to the facility on [DATE] but was denied readmission. Resident 1 has remained at the GACH unnecessarily for additional six days, placing Resident 1 at risk for confusion, disorientation and psychosocial harm related to being displaced from the facility, a place that was considered Resident 1's home since initial admission on [DATE].

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 87 )was positioned properly by a nursing staff during resident care by failing to identify and recognize a bedside drawer located next to the resident's bed as a potential hazard to resident's safety during care which led to resident hitting the nightstand during repositioning. This failure placed Resident 87 at risk for fall and serious injury.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident who had poor safety awareness with a history of an unwitnessed fall from a wheelchair on 1/2/2024, and who required staff supervision with transfers from bed to a wheelchair, did not fall during unassisted and an unsupervised transfers from bed to a wheelchair sustained an injury for one of three sampled residents (Resident 1). The facility failed to: 1. Revise Resident 1's care plan after Resident 1's fall on 1/2/2024 and develop comprehensive person-centered interventions to address Resident 1's poor safety awareness and Resident 1's noncompliance when asking for assistance prior to getting out of bed. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure, a resident, who lacked the capacity to understand and make decisions, was not discharged from the facility against medical advice ([AMA] choosing to leave the hospital before the treating physician recommends discharge) for one of 141 residents (Resident 1). The facility failed to: 1. Ensure Resident 1 was competent to make a decision to leave the facility and sign out AMA. 2. Ensure Resident 1 had a valid Out On Pass ([OOP] temporary permission given to a resident to leave the facility for a specified amount of time) and AMA order on 4/19/2024, the day Resident 1 wanted to leave. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of one resident's (Resident 1) primary care doctor (MD) and responsible party (RP) was informed of Resident 1 oral intake of less than 50 percent, in forty-two meal intakes, from 12/22/2023 to 1/5/2024. This deficient practice had the potential to result in a delay of care and services that can result in further weight loss for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure a quarterly Interdisciplinary ([IDT] team members from different departments working together, with a common purpose, to set goals, make decisions that ensure residents receive the best care) Care Conference meeting, involving one of six sampled residents (Resident 1) and their responsible party (RP), was held on 11/2023. This deficient practice violated Resident 1 and RP 1's right to be an active participant to discuss the resident's plan of care and services with the IDT and potentially delayed the discussion of needed care and services.

Inspectors wroteBased on interview and record review, the facility failed to weigh one of six sampled residents (Resident 1) weekly between 12/19/2023 to 1/10/2024 as indicated in the resident's care plan. This deficient practice had the potential to result in further weight loss.

Inspectors wroteBased on interview, and record review, the facility failed to ensure two housekeeping (HK 1 and HK 2) staff, who were contracted by the facility from an outside agency, did not verbally abuse one of three sampled residents (Resident 1). These deficient practice resulted in HK 1 and HK 2 following Resident 1 from his room, accusing him (Resident 1) of lying, calling Resident 1 names, and impeding Registered Nurse Supervisor 1's (RNS 1) investigation, when Resident 1 accused HK 1 and HK 2 of verbal abuse against him. HK 1 and HK 2 were escorted out of the facility by a local police agency, who were called because of HK 1 and HK 2's aggressive behavior towards Resident 1 and RNS 1. These deficient practices had the potential to subject residents, staff, and visitors to fear, abuse and harm.

Inspectors wroteBased on interview, and record review, the facility failed to ensure abuse training was provided to two housekeeping staff (HK 1 and HK 2), who were contracted by the facility via a outside housekeeping agency. These deficient practices resulted in HK 1 and HK 2 being unaware of the abuse regulations provided to staff at the facility, which resulted in a verbal altercation with a resident (Resident 1) who resided at the facility. This deficient practice had the potential to subject residents, staff, and visitors to fear, abuse and harm.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident, who was depended on staff for activities of daily living (ADL), was not subjected to a physical abuse from another resident for one of three sampled residents (Resident 1). The facility failed to: 1. Ensure a certified nursing assistant (CNA 1) monitored the East hallway as assigned to timely intervene to prevent Resident 2 from physically abusing Resident 1 and ensure residents safety. [...]

Inspectors wroteBased on interview and record review, the facility failed to protect one of one resident (Resident 2) from Resident 1 by keeping the residents (Resident 1 and 2) as roommates after allegations of Resident 1 having physical/ verbal aggression towards Resident 2 was reported on 8/27/2023 at 7:44 a.m. This deficient practice resulted in Resident 1 subjecting Resident 2 to preventable verbal abuse in the form of name calling the day after the incident (8/28/2023) and it placed Resident 2 at high risk for other forms of abuse.

Inspectors wroteBased on interview and record review, the facility failed to implement its abuse prevention policy by failing to report the occurrence of an alleged resident-to-resident altercation to the state survey agency (California Department of Public Health [CDPH]) within 2 hours after the allegation occurred for two of two sample residents (Resident 1 and 2) on 8/27/2023 at 7:44 a.m. This deficient practice had the potential for other abuse incidents to go unreported placing other residents at risk for abuse.