Autumn Creek Post Acute

Inspectors wroteBased on interview and record review, the facility failed to implement resident specific fall prevention interventions recommended by the Interdisciplinary Team (IDT) after a fall for two of three sampled residents (Resident 1 and 2). This failure has the potential to place all residents at risk of falls and injuries.

Inspectors wroteBased on interview and record review, the facility failed to ensure that care plans were updated and individualized for three of three sampled residents (Resident 1, Resident 2, and Resident 3) when interventions were not specific to the care needs of the resident. This had the potential for residents to not receive the interventions that were consistent with their care needs and have a negative impact on their physical and emotional well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure that changes in residents health status were reported for one of five sampled residents when Resident 1's Responsible Party (person designated to make healthcare decisions when the resident is unable to) was not notified of changes in her wound. This resulted in the resident's representative being unaware of changes and unable to fully participate in advocating for and making choice's on Resident 1's behalf.

Inspectors wroteBased on interview and record review, the facility failed to report an alleged violation involving a resident fall resulting in a head injury and right hip fracture to the required state agency for one of four sampled residents (Resident 1). This failure had the potential to delay investigation and corrective actions, placing all residents at risk for ongoing safety hazards and preventable injury.

Inspectors wroteBased on observation and interview the facility failed to ensure that all resident hallways were kept free of hazards during deep cleaning of resident rooms. This resulted in both sides of the hallway being obstruction, representing both a safety hazard for residents as well as a potential fire hazard due to the obstructed exit. This had the potential to negatively impact the safety and well being of all residents. During an observation on 5/5/26 at 11:05 am the hallway on Station # 2 was reviewed. The hallway contained rooms 12 - 20. Both sides of the hallway were lined with equipment and resident items against the walls. Outside of room [ROOM NUMBER] was a paper sign that indicated room [ROOM NUMBER] scheduled for deep clean may 15 at 9 am a staff member was observed inside the room cleaning. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement safe discharge plan for one sampled resident (Resident 1) when the Interdisciplinary Team (IDT, a team composed of nursing, social work, and therapy who develop resident plan of care) did not ensure Caregiver (CG) had training and services were arrange before returning home. This resulted in Resident 1 falling in the facility parking lot on 3/6/26 at 2 pm, when the resident was dropped by the CG during a transfer from the wheelchair to the car.

Inspectors wroteBased on interview and record review, the facility failed to ensure all allegations of abuse were reported within 2 hours to the State Survey Agency in accordance with State Law for one sampled resident (Resident 1). This failure had the potential to put Resident 1 at risk for continued abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure sufficient competent staffing to meet the needs for three of four sampled residents (Residents 1, 2 and 3) when dependent residents required assistance with toileting waited a long time when call light initiated. This failure resulted in residents having unrelieved discomfort, emotional distress, and feelings of and neglect.

Inspectors wroteBased on interview and record review, the facility failed to develop an initial person-centered care plan related to diabetes (blood sugar disease) for one of three residents (Resident 1). This failure had the potential to place Resident 1 at risk for not receiving the appropriate interventions and goals related to their diagnoses.

Inspectors wroteBased on interview and record review, the facility failed to ensure Nurse's Aides (NA, in training) were state certified prior to hiring and had competencies to provide direct resident care independently. This had the potential for all residents to not have their care needs met and at risk for injury when nine uncertified Nurse's Aides provided unsupervised direct resident care. Refer to F839.

Inspectors wroteBased on interview and record review the Governing Body failed to provide oversight to a facility's Administration to ensure nine nurse's aides were state certified and had the competencies required prior to providing care to residents independently. This had the potential to put all residents at risk of injury and harm and to not receive quality of care when nine Nurse's Assistants (NA, in training not certified by state) were hired prior to becoming state certified to practice as Certified Nursing Assistants (CNA, certified by state). Refer to F728.

Inspectors wroteBased on interview and record review the facility did not ensure one out of three sampled residents (Resident 1) was provided with Physician ordered medications when Registered Nurse (RN) B did not transcribe (copy from a written order and entered into the electronic medical record, EMR) the Physician's orders. This failure had the potential to cause a decline in health status.

Inspectors wroteBased on interview and record review, the facility failed to report an abuse allegation for Resident 1 within the required timeframe when a Certified Nursing Assistant (CNA 1) was witnessed shoving him back forcefully into his wheelchair. This failure had the potential to put all residents at continued risk for abuse by staff.

Inspectors wroteBased on interview and record review, the facility failed to ensure Resident Representative (RP) had the right to retrieve the resident's personal belongings, when the RP of one of five sampled residents (Resident 5) was not given personal property back to them following the death of Resident 5. This failure by the facility had the potential to impact further property transfers, if not corrected. During a review of facility policy titled Personal Property, dated [DATE], indicated that the facility is required to ensure they take reasonable steps to protect resident's personal property, and the facility will return inventoried personal items to residents or their representative upon discharge in a timely manner, and take reasonable steps to safeguard the belongings in the interim. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one of two residents (Resident 1) sampled for falls. Resident 1 had four unwitnessed falls in seven days, three occurring after an indwelling catheter (a soft tube that is inserted into the bladder and allows urine to drain into a collection bag) was not replaced and contributed to Resident 1's falls by her attempting to toilet herself. Key failures included:Care Plan was not updated with new interventions to prevent further falls, despite the facility's fall policy requiring increased observation and structured routine for residents with two or more falls in a week. [...]

Inspectors wroteBased on interview and record review the facility failed to notify the Responsible Party (RP- the person who is responsible for making health care decisions for a resident) of falls and a change of condition for one of two residents (Resident 1) sampled for falls, when Resident 1 had four unwitnessed falls, her indwelling catheter (a soft tube that is inserted into the bladder and allows urine to drain into a collection bag) fell out and was not replaced, a change in condition due to a head injury, was transferred to an emergency department (ED) and the RP was not notified. Refer to F689. This failure prevented the family from knowing about Resident 1's falls, condition changes, and transfer to the emergency department, hindering their ability to make informed decisions and participate in Resident 1's care. Findings. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure an injury of unknown origin and major accident for one of two residents (Resident 1) sampled for falls, was reported to the California Department of Health (CDPH) when Resident 1 had a bruise and bump on her head of unknown origin, unwitnessed falls, and a change in condition which sent Resident 1 to the hospital and eventually die due to a brain bleed. This failure to report had the potential for delaying investigations into injuries of unknown origin by facility and required reporting agencies to be able to rule out abuse. FindingsA review of the facility's policy and procedure (P&P) titled Unusual Occurrence Reporting dated [DATE], indicated The Facility reports the following events by phone and in writing to the appropriate State or Federal agencies (California Department of Health, CDPH) c. Other Occurrences. ii. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure one of two sampled residents (Resident 1), who was admitted with an indwelling catheter (a soft tube that is inserted into the bladder and allows urine to drain into a collection bag), had care and services to maintain normal bladder function when Resident 1('s): Did not have an assessment for the need of an indwelling catheter. Indwelling catheter was discontinued without a physician's order. Was not provided bladder training to restore normal bladder function after the indwelling catheter was removed. Did not have a care plan created with interventions concerning her bowel and bladder function. These failures caused Resident 1 to get up and down to the bathroom many times without assistance and have multiple falls.

Inspectors wroteThis requirement was not met when a staff member reportedly spoke to a resident (Resident 1) using profane language and with a disrespectful tone. This had the potential to cause the resident to feel unsafe or that his environment was not home-like. Review of Resident 1's medical record indicated that he was admitted to the facility for Parkinson's Disease (a gradual worsening of coordination and movement caused by diseased brain cells), cognitive communication deficit (trouble speaking and thinking), depression and dementia (age related decline in brain function). A review of Resident 1's Basic Interview for Mental Status (BIMS) performed on 5/28/25 indicated his cognitive (thinking, memory) function was 12 on a scale of one to 15, or moderate cognitive impairment (lessened ability to think and remember). [...]

Inspectors wroteBased on observation and interview this requirement was not met when one of three sampled medication carts were left unlocked and unattended. This had the potential for unauthorized access including nearby residents with dementia, and the potential for harm. In an observation on 8/18/25 at 3:15 PM, one of three sampled treatment carts on nursing station 4 was observed to be unattended and unlocked. Drawers were opened and inspected; accessible supplies and medicines included six, 1-ml hypodermic syringes, and a 12-ounce bottle of what was labeled to be povidone iodine whose plastic top was broken off with brown residue visible on the cap. Residents were observed to be sitting in wheelchairs in the hallway directly adjacent to nursing station 4. No staff stopped or intervened as the drawer was inspected. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement Advance Directive (AD - a legal document that outlines a person's wishes for medical treatment in case they become unable to make their own decisions due to illness or injury) for one of three sampled resident's (Resident 1)This had the potential for Resident 1 to receive medical treatments that were against his wishes and negatively impact his quality of life. During a record review of facility policy titled, Advance Directives, revised 12/1/13, indicated Upon admission, the admission Staff of designee will obtain a copy of a resident's AD. A copy of the resident's AD will be included in the resident's medical record. Facility policy also indicated if a resident does not have an AD, the facility will provide the resident and/or resident's next of kin with information about AD upon request. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the physician's orders were appropriate for one of three sample residents (Resident 1) when Medical Director (MD) based Resident 1's ability to make healthcare decisions on a diagnosis of cerebral palsy (neurological disorders that affect movement, posture, and muscle tone) with no further explanation. This failure increased the potential for an inadequate medical evaluation of Resident 1 which could potentially result in unidentified or unmet medical and care needs. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a plan of care to prevent pressure injuries (damage to the skin and underlying tissue, usually over a bony prominence, caused by prolonged pressure or pressure) for one of four sampled residents (Resident 4) when:1. Resident 4 developed a pressure injury on the sacrum (bony structure located at the base of the back), that progressed to osteomyelitis (an infection of the bone).2. Resident 4 developed pressure injuries on left calf, right and left heels from wearing therapeutic moon boots (maintains proper alignment of foot and ankle from turning inward and outward) brought in from his home. This system failure resulted in Resident 4 developing multiple pressure injuries, wound deterioration, subsequent serious life-threatening infection, and unnecessary pain.

Inspectors wroteBased on interview, observation and record review, the facility failed to meet this requirement when nursing staff failed to develop nursing care plans (a roadmap of care to be provided) for two of 9 sampled residents (Residents 1 and 2) who were involved in resident-to-resident altercations. This had the potential for additional resident-to-resident altercations, injury, and to negatively impact residents' sense of security and well-being. A review of the facility's medical record indicated that Resident 1 was admitted on [DATE] for conditions that included stroke, morbid obesity (life-threatening weight gain), anxiety, chronic pain, and a history of alcohol abuse. A review of Resident 1's Basic Interview for Mental Status (BIMS), a test for memory and brain function, indicated that her score was 5, cognitively impaired (reduced ability to think and act). [...]

Inspectors wroteBased on interview, observation and record review, the facility failed to meet this requirement when two of six medication carts were observed to be unlocked, with medication accessible, while unattended by nursing staff. This had the potential to result in residents, unlicensed staff, and visitors to have unauthorized access to prescribed medications and their misuse. On 7/15/25 at 10:03 AM, two medication carts were observed to be unlocked and openable at the facility's Nursing Station Three. Topical medications and creams were observed to be accessible to residents with dementia (loss of memory and ability to think). Surveyor opened the cart and was unquestioned and unobserved by nearby staff. [...]

Inspectors wroteBased on Interview, observation and record review, the facility failed to meet this requirement when the care plan for a resident who had nine falls was not followed and the resident did not have a fall mat beside the bed. This had the potential to contribute to additional falls and injuries.

Inspectors wroteBased on observation, interview, and record review, the facility did not follow their infection prevention protocol when Certified Nurses Assistant (CNA 1) failed to wear the appropriate personal protective equipment (PPE) when in a room with a resident that was COVID positive. This failure had the potential to spread COVID-19 to other residents.

Inspectors wroteBased on observation, interview, record and facility policy review, the facility failed to ensure that call lights (an electronic sound and light communication device in the residents room that allows a resident to alert staff when they need help), was available for use and within the residents' reach for three of five residents sampled for call lights being within their reach. (Residents 1, 2, and 12) This failure had the potential for the residents not to be able to alert staff that they needed help which could lead to unmet needs, falls, and emotional frustration for the residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure an infection control program was implemented by Infection Preventionist (IP) to reduce the spread of infection in the facility for three of the three sampled residents (Resident 1, 2, and 3) when: 1. Resident 1 was tested positive for Multidrug-resistant organisms (MDROs - microorganisms or germs, such as bacteria or fungi, that are resistant to one or more classes of antimicrobial agents) in the urine (on 3/21/25) and wound (on 3/31/25). Resident 1 continued residing in a shared room (ROOM A) with two other residents (Resident 2, 3). 2. Resident 2 was transferred to ROOM A on 3/25/25, where Resident 1 resided. These failures had the potential to contribute to the spread of infection for residents who shared the room with Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to report to the California Department of Public Health (CDPH), an allegation of misappropriation of resident property when Resident 1's Bank Debit card (ATM card) was missing. This had the potential for resident financial abuse to go unrecognized and unresolved in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure narcotic (controlled drugs, also called opioid pain relievers with potential for abuse) medications for pain control were accurately used and documented in the medical records for one out (Resident 1) of eight sampled residents. This deficient practice had the potential for medication errors and risk of drug diversion.

Inspectors wroteBased on interview, and record review, the facility failed to ensure three of 10 sampled residents (Resident 6, 8 and Resident 9) were treated with dignity and respect when Licensed Nurse (LN) D spoke to the residents with a demeaning tone, was rushing with medication administration, and was not gentle with medication administration. This failure had the potential to result in emotional stress, embarrassment, feelings of neglect, increased anxiety, fear, and isolation.

Inspectors wroteBased on interview, record review, and the facility's policy, the facility failed to update a change of condition for one of three sampled residents (Resident 1) when: 1. The Licensed Nurse (LN) did not update the physician when Resident 1 needed oxygen for a new onset of shortness of breath. 2. The LN did not notify Resident 1's family or responsible party when there was a major decline in health status. This failure resulted in a poor negative clinical outcome for Resident 1.

Inspectors wroteBased on interview, record review, and the facility's policy, the facility failed to ensure timely, accurate, and complete documentation for one of three residents (Resident 1) when there was a change in condition. This failure resulted in an incomplete, and an inaccurate clinical medical record, for Resident 1.

Inspectors wroteBased on observation, interview and record review the facility failed to assure that there was sufficient, qualified nursing staff available at all times to provide nursing and related services to meet the residents' needs safely and in a manner that promotes each resident's rights, physical, mental and psychosocial well-being for 11 of 32 residents sampled for sufficient staffing (Residents 307, 407, 132, 408, 147, 20, 117, 52, and three confidential residents) when call lights were observed and reported to be left on for extended periods of time, and/ or resident(s) could not locate their call bell, resulting in bowel and bladder incontinence, residents being left in bowel movement and urine, or waiting for assistance in bed for a variety of reasons, including attempting to go to the toilet. [...]

Inspectors wroteBased on observation and interview, the facility failed to provide a safe, clean, comfortable homelike environment for all residents when areas throughout the facility were unclean and/or in disrepair. 1. A trash can in the Station One shower room contained trash with no liner and was dirty 2. Resident 28's bed, restroom, bedside table, and walls were in disrepair 3. A wall mounted piece of electronics outside room three was missing from the wall. 4. The built-in wooden cabinet finishes in rooms [ROOM NUMBERS] appeared to be chipped, scratched, gouged and missing areas of finish and appear porous and uncleanable and unhomelike. 5. Resident 92's bathroom ceiling fan had an accumulation of greyish debris on the blades and did not work when it was turned on. This failure had the potential to negatively impact the residents' emotional and physical well-being.

Inspectors wroteBased on interview and record review, the facility failed to prevent abuse for two of three sampled residents (Residents 16 and 63) when Resident 16 complained to nursing staff about verbal abuse from their roommate, Resident 63, and the residents were not separated. This failure resulted in a physical altercation between the two residents, which had the potential to threaten their health and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: 1. Parsley was stored under sanitary conditions when it was not labeled, dated or stored safely in the walk-in refrigerator. 2. The walk-in freezer was free from frost build up. These failures had the potential to result in foodborne illnesses. 1. During a concurrent observation and interview on the initial tour, in the walk-in freezer with Dietary Manager (DM), on 2/3/25 at 9:40 am, frost was noted to multiple areas on the ceiling of the walk-in freezer. DM confirmed frost was on multiple areas of the ceiling and confirmed frost should not be on the ceiling. During a concurrent observation and interview in the walk-in freezer, on 2/6/25 at 8:15 am with Maintenance Supervisor (MS), frost was noted on the ceiling. MS confirmed there was frost on the ceiling. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to keep complete and accurate records for one of five sampled residents (Resident 16) when documentation about skin assessments and treatments was inconsistent. This failure had the potential to negatively impact Resident 16's skin care and treatment, and to make it difficult to track the history and progress of any skin issues.

Inspectors wroteBased on interview, observation and record review, the facility failed to meet this requirement when a nurse did not sanitize a blood pressure cuff in between using it on two of 32 sampled residents, (Residents 74 and 42). This practice was not supported by the facility's policy and resulted in the potential to spread infection and illness.

Inspectors wroteBased on interview, and record review, the facility failed to protect 1 out 3 residents (Resident 1) from abuse when, Licensed Vocational Nurse 1 (LVN 1) on duty told Resident 1 to mind his own f***ing business. Resident 1 stated he backed off and that the response from LVN 1 surprised him because they had got along prior to this. Resident 1 stated he asked LVN 1 how his Resident 2 was doing after her fall. He had his phone in his hand and asked if she wanted him to call 911. LVN 1 said, If you ' re calling 911, I will f***ing kill you. This had the potential to result in psychosocial harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the nursing staff respond in a timely manner to the resident's requests for assistance for three out of three sampled residents (Resident 3, Resident 4, and Resident 5), when: 1. Resident 3 was soiled, and the nursing staff was not available to assist Family 1 to change Resident 3. 2. Resident 4's call-light was on and was yelling for help for 12 minutes when she was leaning on the bedrail, three staff walked past Resident 4's room, and did not respond to Resident 4's calling for help. 3. Resident 5's call-light was not answer in a timely manner for multiple times. These failures resulted in Resident 3 and Resident 5 soiling their incontinence briefs which had a negative effect on the residents' self-esteem and self-worth and placing Resident 4 at risk of falling from her bed.

Inspectors wroteBased on observation, interview and record review, the facility failed to protect the resident's right to be free from physical abuse when Certified Nursing Assistant (CNA) D insisted on changing Resident 2's brief when Resident 2 refused and asked CNA D to leave. This failure caused a 4.5-centimeter (cm) x 5-centimeter (cm) bruise between Resident 2's thumb and the 1st finger, Resident 2 was angry and humiliated.

Inspectors wroteBased on interview and record review, the facility failed to provide appropriate staffing necessary to care for 4 out of 5 Residents sampled for nursing services (Residents 1, 2, 3, 4). Residents 1, 2, 3, and 4 had call lights wait times of 40-50 minutes, making them feel like the facility does not care, embarrassed, and concerned for their skin. Licensed Vocational Nurses 1, 2, 3, and Registered Nurse 1 feel overwhelmed, shifts are too hard, and feel they cannot care for their residents appropriately.

Inspectors wroteBased on interview and record review, the facility failed to protect one of five sampled residents (Resident 1) from being injured by staff. This resulted in a skin tear to the resident and had the potential to cause psychosocial (mental/socializing) harm. Findings Resident 1 was admitted to the facility with difficulty in walking, falls and a fractured leg, colon cancer, and vascular dementia, a type of memory loss from insufficient blood flow to the brain. Resident 1 was unable to complete a mental assessment conducted on 8/6/24 and was assessed with moderate impairment of her cognitive ability (mental health). A review of the facility ' s policy titled Abuse Prevention and Management, dated 1/1/12, indicated that the facility does not condone any form of resident abuse, neglect, misappropriation of resident property, exploitation, or mistreatment. [...]

Inspectors wroteBased on interview and record review the facility failed to follow physician orders to consistently cover and protect Resident 2 ' s nephrostomy stoma (a hole in a resident ' s back with a tube to drain urine from the kidney into a bag) during showers, and failed to remove the dressings for Resident 2, Resident 3, and Resident 4 following their dialysis treatments as required. This had the potential to contribute to infection, illness, and may have contributed to an interruption to Resident 2, 3 and 4 ' s care. Findings Resident 2 was admitted to the facility for conditions including end stage renal disease (kidney disease worsening), diabetes, history of stroke, dementia, and was dependent on dialysis (using a machine to do the work of the kidney to clean the blood of waste). [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure that 2 of 3 residents sampled (Resident 1 and Resident 2), for assistance with activities of daily living (ADLs) received scheduled showers or baths, when twice weekly bathing was not completed scheduled. These failures had the potential to result in residents feeling depressed with poor self-esteem, and had the potential to contribute to skin breakdown, infection, and negatively impact their ability to attain or maintain their highest practicable level of well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to comply with applicable Federal, State, and local laws, regulations, and with accepted professional standards and principles for one of three sampled residents (Resident 1) when: 1. The administrator (ADMIN) requested Registered Nurse (RN) D to reword her progress note. 2. The administrator directed Licensed Nurse (LN) B to change LN A ' s progress note. 3. The administrator directed LN A to redraft his progress note, because the time on the note was showing the delay of the care. These failures had the potential to inaccurately document the care provided to all the residents, and the inappropriate care services go undetected and unreported to the authorities. Refer to F 678.

Inspectors wroteBased on interview, and record review, the facility failed to immediately initiate Basic Life Support (BLS) including Cardiopulmonary Resuscitation (CPR- an emergency lifesaving procedure performed when the heart stops beating) when one of three sampled full code (as full support which includes cardiopulmonary resuscitation, if the patient has no heartbeat and is not breathing) residents (Resident 1) was found unresponsive and without a pulse in his bed, and staff took 10 minutes to start CPR on Resident 1. These deficient practices had the potential to delay provisions of emergency care for current residents who wish to have full treatments in a life-threatening situation.

Inspectors wroteBased on observation, interview and record review, the facility failed to promptly notify the Medical Director (MD), who was the attending physician, for one of three residents sampled for change of condition (Resident 1), when Resident 1 was experiencing signs and symptoms of stroke (a life-threatening medical emergency, when the blood supply to part of the brain is blocked or reduced) on 4/14/2024, he was transferred to the Acute hospital on 4/16/2024. This failure resulted in a three-day delay in transferring Resident 1 to the hospital for treatment, and increased Resident 1's pain and discomfort. Resident 1 suffered significant declines on his functional abilities: slurred speech, left-sided weakness, inability to swallow. Resident 1 died on 5/11/2024, within a month of his initial admission [DATE]).

Inspectors wroteBased on observation, interview and record review, the facility failed to provide sufficient nursing staff in the facility to meet the need of the residents' acuity (the level of severity of residents' illnesses, physical, mental, and cognitive limitations and conditions) when: 1. Facility failed to sufficiently staff multiple nursing Stations during the week of 3/30/2024 through 4/5/2024. 2. Residents 14, 2, 3, 4, 5, 6, and 8 did not receive showers as scheduled. This failure resulted in long wait times for call lights to be answered (average 30 minutes) and residents not receiving Activities of Daily Living (ADLs) including hydration and shower assistance. This had the resulted in residents to feel neglected and affected their dignity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide nursing staff with necessary competencies and skill sets to meet the care and services for residents' need for one of three sampled residents (Resident 1) when a change of condition was not promptly identified and reported to the physician. Resident 1 was experiencing signs and symptoms of stroke (a life-threatening medical emergency, when the blood supply to part of the brain is blocked or reduced) on 4/14/2024, he was transferred to the Acute hospital on 4/16/2024. This failure resulted in a three-day delay in transferring Resident 1 to the hospital for proper treatment, and increased Resident 1's pain and discomfort. Resident 1 suffered significant declines on his functional abilities: slurred speech, left-sided weakness, inability to swallow. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that a direct care staff interacted and communicated in a manner that promoted the mental and psychosocial well-being for one of three sampled residents (Resident 9) when the Certified Nursing Assistant (CNA) G said to Resident 9 Don't be a smartass . This failure resulted in upsetting Resident 9 and Resident was crying.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement safe and successful discharge plan for one of 15 residents (Resident 15) when the Interdisciplinary Team (IDT, a team composed of nursing, social work, and therapy who develop resident plan of care) did not ensure she and her family were prepared for returning home. This resulted in Resident 15 to return to the skilled nursing facility with 24 hours of discharging after falling at home.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure equipment in the facility was maintained when: 1. The Central Air Conditioning (AC) system and Packaged Terminal Air Conditioners (PTAC, a standalone AC/heater, self-contained, meaning they do not rely on ducts to operate) on Station 3 and 4 were not working. This resulted in an uncomfortable temperature during the warmer months and resident discomfort. 2. A resident rooms lights did not work. This put two residents at risk for falls.

Inspectors wroteBased on interview and record review the facility failed to implement it ' s abuse policy for one of 3 sampled residents (Resident 1) when it did not identify, investigate, and protect a resident after the facility was informed of an abuse allegation involving Resident 1 and Responsible Party (RP, person legally responsible medical decisions). These failures resulted in Resident 1 to be physically held down by RP when he pushed her head down into her pillow and forced her mouth open during medication administration and put her at risk for further abuse and injuries.

Inspectors wroteBased on interview and record review, the facility failed to protect resident ' s rights to be free from physical, mental, and verbal abuse for one of three sampled residents (Resident 1) was free from physical abuse by the Responsible Party (RP, person legally responsible for medical decisions). This resulted in Resident 1 to be physically held down by RP when he pushed her head down into her pillow and forced her mouth open during medication administration.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three residents (Resident 2) reviewed for admission and transfer processes was readmitted to the facility after a hospitalization. This failure had the potential to cause Resident 2 further psychosocial decline by not letting her return to the facility she called home.

Inspectors wroteBased on interview and record review, the facility failed to protect one of seven sampled residents ' right to be free from verbal abuse by staff when a staff member used profanity directed to a resident. This resulted in the resident's rights being violated. Findings Resident 1 was admitted to the facility with a shoulder fracture, difficulty walking, and the need for assistance with his personal care. A review of the facility ' s policy titled, Abuse Reporting and Investigations, dated 2022, indicated that the facility will report all allegations of resident abuse . [...]

Inspectors wroteBased on interviews, record reviews, and document review, the facility failed to transmit Minimum Data Set (MDS) assessments within 14 days of the completion date for 5 (Residents #34, #48, #57, #68, and #100) of 5 sampled residents reviewed for resident assessments.

Inspectors wroteBased on observations, interviews, record reviews, and facility policy review, the facility failed to ensure the medication error rate was less than 5 percent (%). There were six errors out of 32 opportunities, which resulted in a medication error rate of 18.75 % for 2 (Resident #103 and Resident #88) of 3 residents observed for medication administration.

Inspectors wroteBased on record review and interviews, the facility failed to ensure a Minimum Data Set (MDS) was accurate for 1 (Resident #2) of 2 sampled residents reviewed for hospice services.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to develop and implement a comprehensive care plan to include food allergies for 1 (Resident #97) of 3 sample residents reviewed for food allergies.

Inspectors wroteBased on observations, record review, interviews, and facility policy review, the facility failed to ensure physician's orders were followed for 1 (Resident #11) of 26 sampled residents.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to implement measures to ensure 1 (Resident #97) of 3 sampled residents reviewed for food allergies did not receive a food they were allergic to.

Inspectors wroteBased on interview and record review, the facility failed to ensure that a direct care staff interacted and communicated in a manner that promoted the mental and psychosocial well-being for one of three sampled residents (Resident 3) when the Nursing Assistant (NA) 3 said to Resident 3 You got a big booty. This failure resulted in upsetting Resident 3.

Inspectors wroteBased on observation, interview and record review, the facility failed to protect the resident ' s right to be free from physical abuse when Resident 2 smacked one of three sampled residents (Resident 1) on the hand. This had the potential to negatively impact Resident 1 emotionally and psychologically.

Inspectors wroteBased on interview and record review this requirement was not meant when two of four sampled residents heard staff arguing in the hall outside their rooms. This resulted in creating and environment that disturbed the residents ' sense of well-being and had the potential to cause depression or symptoms to worsen in two residents who had a history of psychiatric problems. Findings 1. Resident 1 was admitted to the facility for Parkinson ' s Disease (a disease of the nervous system that causes tremors and weakness), depression, psychotic disorder (mental problem) with delusions. In an interview on 1/15/24 at 1:15 PM, Resident 1 stated that he recently overheard staff arguing in the hallway outside his room. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to review and revise a comprehensive care plan for two of eight sampled residents, (Resident 2 and Resident 6) when: 1-Resident 2 did not have specific interventions listed for staff to provide nectar thickened (a specific type of consistency of liquids needed for problems swallowing, a common problem after a stroke), liquids for safety while drinking fluids per physician ' s orders. 2-Resident 6 did not have specific interventions for staff to provide Foley catheter (a sterile tube placed into the bladder to drian urine), care (cleansing of the tube site with soap and water to prevent infections), and to empty catheter drainage bag. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide activities of daily living, (adls, are activities related to personal care. Adls include bathing, dressing, getting in and out of bed or a chair, walking, toileting, and feeding) assistance. 1-No water was provided for Resident 6 on 11/20/23 and 11/28/23 on the bedside table. 2-Incontinent care was not provided for Resident 2 and Resident 8 on 11/20/23. 3-Foley Catheter (F/C) drainage bag was not emptied for Resident 6, and F/C care was not provided on 11/18/23. 4-Resident 4 did not receive a dinner meal with assistance needed to eat when the meal trays were delivered on 11/21/23. This failure resulted in the potential for physical decline, including the potential for a bladder infection, altered skin integrity, potential for dehydration, and the potential for a decline in psychosocial wellbeing.

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of eight sampled residents (Resident 5) was treated with dignity and respect when Resident 5 was rushed while being fed by the Certified Nursing Assistant (CNA) N, and Resident 5 was spoken to with a demeaning tone and attitude. This failure had the potential to result in emotional stress, embarrassment, feelings of neglect, and the potential for negative clinical outcomes, such as weight loss.

Inspectors wroteBased on interview and record review, the facility filed to protect the resident ' s right to be free from verbal abuse by the Certified Nursing Assistant (CNA) 1 who used profanity while providing care for one of three sampled residents (Resident 2). This resulted in Resident 2 tearing up and withdrawing from social interaction.

Inspectors wroteBased on interview and record review, the facility failed to: 1. update the care plan for one of three sampled residents (Resident 2); 2. hold an Interdisciplinary Team (IDT-a group of professionals from different disciplines who met to discuss the residents' care) meeting to address a new problem added to the Care Plan of another one of three sampled residents (Resident 1). These failures had the potential to negatively impact the residents' quality of life by failing to identify and address unmet needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure the plan of care for a safe transfer was implemented for one of 4 sampled residents (Resident 1) when Certified Nursing Assistant (CNA) l and Nursing Assistant (NA) 2 did not use a Hoyer lift (a mechanical device for lifting and transferring immobile patients) and assisted Resident 1 to a standing position. Resident 1 was unable to stand and was lowered to the floor. This failure resulted in an avoidable fall for Resident 1 and caused fractures to her right knee, pain, and delay in physical therapy treatments.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide competent nursing care to 1 of 4 sampled residents (Resident 1) when Certified Nursing Assistant (CNA)1 and Nursing Assistant (NA) 2 did not implement the care plan to safely transfer Resident 1 from her wheelchair to her shower chair. This failure resulted in an avoidable fall for Resident 1 and caused fractures to her right knee, pain, and delay in physical therapy treatments. (Reference F689)

Inspectors wroteBased on interview and record review, the facility's Governing Body (GB), legally responsible for establishing and implementing facility policies, failed to effectively manage the facility when: 1. The facility failed to ensure the Air Conditioning (AC) system on Station 1 and 2 were in operating condition to keep temperatures at a comfortable level for residents. 2. Facility did not ensure building was maintained in safe, secure, clean and homelike manner. This had the potential for accident and hazards when the portable AC units were not used according to manufacturer's instructions. 3. The facility failed to ensure sufficient and competent nursing staff to meet the needs of all residents. This resulted in activity of daily living resident needs not to be met. Refer to F 584, F689, F725 and F 908.

Inspectors wroteBased on observation, interviews and record review the facility failed to ensure a clean and comfortable home-like environment when: 1. Facility temperatures made residents on Station 1 and 2 uncomfortable during the summer. 2. Residents 8, 16, 15, 14, 13 and 34 did not have a clean and homelike environment. These failed practices resulted in disturbed sleep patterns, discomfort, skin rashes, and emotional distress.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the safety of all residents when: 1. The main entrance to the facility was observed to be unsecured outside of normal working hours. This failure had the potential to allow 4 of 4 residents at risk for elopement (leaving the facility unsafely or unescorted) to leave the facility and for unrestricted and unsafe access to the facility by unwelcome and unwanted persons after hours. 2. Multiple tripping, falling, and electrical hazards caused by cooling equipment observed in resident rooms. This failure had the potential for all residents, staff and visitors to be a risk for injuries related to falling and electrical fires.

Inspectors wroteBased on observation, interviews and record review the facility failed to provide nursing staff to meet the needs of the residents when: 1. There was insufficient nursing staff to assure resident safety, comfort and to attain and maintain the highest practicable physical, mental and psychosocial well-being of each resident. 2. Nursing assistants did not receive orientation and mentoring post graduation from CNA program. These failures resulted in residents having to wait for extended times for assistance, not being provided scheduled baths/showers, and had the potential for unwitnessed falls, skin breakdown, and frustration when resident needs were not met.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure all equipment in the facility was maintained when: 1. Central air conditioning (AC) system was not maintained. This resulted in an uncomfortable temperature range and caused resident discomfort. 2. Portable AC units were not used according to manufacturer's instructions. 3. Shower room and leaking AC pipes in a resident room ceiling exposed corroded, conduit and electrical wiring. This had the potential to put all residents at risk for building hazards and fires.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure one out of 3 residents (Resident 1) had an intervention in the care plan directing nursing staff how to safely transfer Resident 1. This failure had the potential for Resident 1 to be transferred incorrectly and cause an injury.

Inspectors wroteBased on interview and record review the facility failed to provide three out of three sampled residents (Resident 1, 2, and 3) with appropriate services to maintain or prevent a decline in range of motion (ROM, the normal movements that a joint should be able to perform, for example bending the head down or raising an arm up) when: 1a. Restorative Nursing Program orders were not followed for Resident 1. 1b. Restorative Nursing Program orders were not followed for Resident 2. 1c. Restorative Nursing Program orders were not followed for Resident 3. This failure had the potential to cause a decline in ROM and mobility which could negatively impact resident health status out-comes and well-being.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide needed care and services for one out three sampled residents (Resident 1) when wound care orders and recommendations were not followed, and documentation was not present that reflected Resident 1's choices regarding care being provided. This failure had the potential to result in wound worsening, a decline in health status, and negatively affect Resident 1's overall well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure medical records were complete when: 1. There was no documentation present in the medical record for one out three sampled residents (Resident 1), that indicated the physician had been notified when Resident 1 had a decrease in meal consumption (eating less). 2. Certified Nurse Assistants (CNA) did not consistently document meal percentages (amount of meal eaten), when nourishment (snacks) had been provided, or if meal substitutions (a different meal) had been offered for three out of three sampled residents (Resident 1, 2, and 3). These failures had the potential to negatively impact resident care which could lead to negative clinical outcomes and cause a delay in care for residents with weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to address and monitor the safe storage and handling of medications and biologicals in accordance with manufacturers' specifications and standards of practice. This failure resulted in medication refrigerators in Med room [ROOM NUMBER] and #2 having temperatures out of range for 20 days without documented interventions or follow-up, and 11 days with no temperatures recorded. This failure had the potential to result in decreased potency or new side effects of the medications administered to residents. Refer to F658.

Inspectors wrote2.a. During an observation in Resident (Resident 11) in room [ROOM NUMBER] C, on 08/09/21 at 7:54 AM, the following was noted a 5 inch by 7 inch hole in a wall behind Resident 11's bed with sheet rock exposed and peeling wallpaper above baseboard with dried light brown, liquid stains. b. During a concurrent observation and interview with Plant Maintenance (PM A) in room [ROOM NUMBER] C, on 08/12/2021 at 8:55 AM, PM A stated he did not know about this damage to the wall and that he was going to patch it up immediately. Using a facility measuring tape, PM A measured the hole in the wall as approximately 5 inches x 7 inches. c. During a concurrent observation and interview with Resident 4 in room [ROOM NUMBER] C, on 08/10/2021 at 7:30 AM, it was noted that dried bright pink nail polish was on floor beside resident bed and on the bottom of the bedside table stand. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide sufficient nursing services when 1. 7 of 21 sampled residents (Residents 5, 18, 20, 42, 56, 67, 74) 2. four of 8 confidentially interviewed residents reported that their call lights were not answered in a timely manner. As a result, one resident was mad and one felt humiliated. This failure had the potential to affect residents' dignity, quality of care and for the residents not to receive nursing services in a timely matter.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were administered per manufacturers instructions and physician orders when: 1. Respiratory rate was not assessed prior to administration of a medication as directed. 2. Medication doses were not being delivered as instructed in physician orders or per manufacturer specifications and professional standards. This failure resulted in an error rate of 18.25 percent and had the potential to cause decreased therapeutic effects of medications, and respiratory depression.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain kitchen equipment in safe working order when there were ice deposits on the ceiling by the freezer fan, and water leaking from a drainage pipe from the ice machine. These failures had the potential to cause contamination of the food by germs and dirt which could have made residents ill.

Inspectors wroteBased on observation, interview, and record review, licensed nursing staff failed to follow manufacturers' specifications and standards of practice for the safe storage and handling of medications and biologicals. This failure resulted in medications and vaccines being stored in temperatures not in accordance with professional standards of quality, and had the potential to result in decreased potency or new side effects of the medications administered to residents.

Inspectors wroteBased on observation and interview, the facilty failed to make sure that two residents (Residents 10 and 46) were kept free of accident hazards when: 1. both residents were left unattended in beds in the high position; 2. Resident 46 was left up in a wheelchair in their room without supervision or access to their call light. Leaving beds in the high position posed a safety hazard to the residents and not having a call light within reach to call for help put the resident at risk for falls and injuries.