Avalon Villa Care Center

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure, interventions to monitor, one (1) of three (3) residents (Resident 1), aggressive behavior, impulsiveness and impulsivity were implemented as indicated in the resident's care plan titled, Positive toxicology screen (drug test ) for amphetamine (a potent central nervous system stimulant that speeds up messages between the brain and the body) use with potential risk for altered behavior, impaired judgement, cardiovascular complications and safety concerns. This deficient practice placed Resident 1 at risk for injury.

Inspectors wroteBased on interview and record review, the facility failed to implement safety measures for three of five sampled residents (Residents 1, 3 and 4) by failing to: 1. Follow its policy and procedure titled, Pass Procedures - Sending Resident Out on Pass (OOP- temporary permission for a resident to leave the facility for a specified period), which indicated staff will obtain a physician's order allowing the resident to leave the facility, including the reason (medical or social), and complete the Release of Responsibility for Leave of Absence form.2). Develop an OOP care plan for Residents 1, 3 and 4. These failures had the potential to negatively affect Resident 1, 3 and 4's safety and well-being when going OOP.

Inspectors wroteBased on interview and record review, the facility failed to follow its Policy and Procedure (P&P) titled, Grievances/Complaints Filing which indicated the Administrator and staff will make prompt efforts to resolve grievances, for one of five sampled residents (Resident 2) when Resident 2 informed the facility that a Certified Nursing Assistant (CNA) 1 was disrespectful when CNA 1 provided Activities of Daily Living (ADL) care to Resident 2 on 4/27/2026. This deficient practice violated Resident 1's rights and could negatively impact the residents' feelings and sense of self-worth.

Inspectors wroteBased on interview and record review, the facility failed to provide care and services that meet professional standards of practice for one of three sampled residents (Resident 1) by failing to provide interventions for Resident 1 and notify the physician when the resident:Had an altered level of consciousness, was unresponsive to commands and unable to accept medication. Experienced labored breathing after a previous Change in Condition (COC) for Oxygen (O2) desaturation (drop in O2 saturation [O2 sat- a measurement of how much oxygen the blood is carrying as a percentage]). This deficient practice had the potential to result in Resident 1 not receiving selective lifesaving or comfort measures and could lead to death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 1) received showers and grooming when requested. This deficient practice resulted in Resident 1 not receiving scheduled showers and had the potential to result in compromised personal hygiene, skin integrity, decreased dignity and psychosocial distress.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services to improve or maintain range of motion ([ROM] full movement potential of a joint) and mobility (ability to move) for five of six sampled residents (Resident 37, 35, 5, 110, 114) with positioning, mobility, and restorative nursing ([RNA] nursing aide program that helps residents to maintain their function and joint mobility) concerns.a. For Resident 37, the facility failed to:1. Measure Resident 37's ROM in the joints of both arms during the Occupational Therapy ([OT] profession aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]) Evaluation, dated 9/17/2025. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure coordination of the resident's PASRR Level II (PASRR II-a federally mandated screen for individuals for Serious Mental Illness [SMI], Intellectual Disabilities [ID], or Developmental Disabilities [DD] to ensure they get the right care in the least restrictive setting, preventing inappropriate nursing home placement and identifying needs for specialized services) determination with ongoing assessment, interdisciplinary review, care planning revisions, reconsideration of appropriate placement following significant changes in the residents behavioral condition for one of three sampled residents (Resident 27). This deficient practice had the potential to result in inaccurate care for Resident 27 while residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure care plans were in initiated addressing a resident's diagnosis of stroke (loss of blood flow to a part of the brain) and cranial surgical incision, and the use of Apixaban (a type of blood thinner used to prevent and treat blood clot) for two of two sampled residents (Resident 65 and Resident 4). These deficient practices had the potential to place Resident 65 at risk for neurological deterioration, infection, and other life-threatening complications, and had the potential for Resident 4 to exhibit complications related to bleeding due to the lack of individualized monitoring, interventions and staff guidance related to anticoagulant (blood thinner) therapy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary care and services to ensure a resident received appropriate post-stroke (loss of blood flow to a part of the brain) care and post-surgical wound monitoring for one of three sampled residents (Resident 65), when nursing staff failed to assess and monitor Resident 65's post-surgical cranial incision and staples since his admission on [DATE] and failed to advocate for a specialty follow-up appointment with a neurologist (a medical doctor specializing in the diagnosis and treatment of disorders affecting the brain). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident received mental health and psychosocial treatment necessary to attain and maintain the highest practicable mental and psychosocial (focuses on emotions, thoughts, coping mechanisms, sense of self, and mental health) well-being for one of three sampled residents (Resident 27). This deficient practice led to Resident 27 continuing to exhibit repeated episodes of verbal and physical aggression without effective therapeutic mental health intervention.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure licensed staff practiced safe and effective medication administration practices for three out of 14 sampled residents (Residents 63, 138, and 137) by failing to: 1. Ensure Resident 63's vitamin D3 (a crucial fat-soluble vitamin that helps your body absorb calcium for strong bones, supports immune function, and aids muscle/nerve health) was available and administered timely, as ordered by the physician during a medication pass. 2. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to follow recipes when:a. The cook (Cook 1) altered the ingredients in beef patties by adding unindicated ingredients.b. Ingredients for preparing texture-modified versions of the beef patty recipe were omitted.c. [NAME] 2 used a garnish for three of 26 soft-and-bite-sized texture diets when not indicated. These deficient practices had the potential to alter nutrition, provide the inappropriate therapeutic texture, and introduce allergens to resident meal trays.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate texture-modified diets when:a. The cook (Cook 2) used a garnish for three of 26 soft-and-bite-sized textures when not indicated. b. [NAME] 2 used a food-processor to mince pork instead of chopping to indicated size for 26 of 114 diets. These deficient practices had the potential to cause residents with swallowing disorders to choke, and prevent the progression of residents' meals by voluntarily downgrading textures.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation practices when:a. The stand mixer observed with heavy debris was not cleaned and sanitized.b. The countertop was covered with crumbs. c. The steam table had eggs remnants. These deficient practices had the potential to result in harmful bacterial growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) in 114 of 117 medically compromised residents who received food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain complete and accurate medical records for five of 16 sampled residents (Resident 63, 12, 138, 37, and 110) by: 1. Not ensuring licensed nursing staff maintained an accurate recording of the lidocaine patch (a medication in the form of a patch used to treat inflammation and pain) in Resident 63's medication administration record (MAR). 2. Not ensuring Resident 12's nursing progress notes, change of condition (COC) and transfer/discharge notes were completed and signed as required following the resident's transfer to the general acute care hospital (GACH) on 1/2/2026. 3. Not documenting Resident 138's missed doses of meropenem and the resident's dislodgement of his intravenous ([IV] administering fluids, medicine, blood, or nutrients directly into the bloodstream via a needle or catheter) line. 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to perform hand hygiene (act of cleaning hands with soap and water or an alcohol-based sanitizer to remove or destroy germs, preventing the spread of infections) before and after direct contact with three of 28 sampled residents (Resident 37, 114, 48). This deficient practice had the potential to continue the spread of infection, including influenza ([flu] a contagious respiratory infection caused by viruses).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dignity, privacy, and respect were maintained for one of eight sampled residents (Resident 3), when the indwelling urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) drainage bag was not covered with a dignity bag (a privacy cover placed over a urinary catheter drainage bag to help maintain a resident's dignity and privacy by preventing exposure of the bag and its contents). This deficient practice had the potential to compromise Resident 3's dignity, privacy, and respect due to the indwelling urinary catheter drainage bag being left uncovered.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dignity, privacy, and treatment were provided in a respectful manner for one of eight sampled residents (Resident 105) during a toileting request. This deficient practice resulted in Resident 105 becoming visibly frustrated and had the potential to cause psychosocial harm, including emotional distress and loss of dignity.

Inspectors wroteBased on observation and interview, the facility failed to ensure one of eight sampled residents (Resident 118) had access to a call light system to summon assistance. This deficient practice had the potential to prevent Resident 118, who was unable to communicate verbally, from requesting assistance or communicating needs in a timely manner.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the physician was notified of a significant change in condition when a resident exhibited inappropriate sexual behavior for one of eight sampled residents (Resident 27). This deficient practice resulted in a delay in physician evaluation and the development of an appropriate plan of care for Resident 27's behavioral needs. Cross reference F644 and F742.

Inspectors wroteBased on interview and record review, the facility failed to accurately assess and code a resident's recent surgery on the Minimum Data Set (MDS], a resident assessment tool) for one of eight sampled residents (Resident 65). This deficient practice led to a delay in proper care area assessment identification, which affected the facility's ability to address Resident 65's post-surgical and neurological needs. Cross reference F656 and F684.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a communication board for three of three residents with language barriers (Residents 6, 57 and 118). This deficient practice interfered with Residents 6, 57 and 118's ability to communicate effectively with staff and had the potential to impact their care, safety and ability to exercise their rights.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of eight sampled residents (Resident 13) received bathing assistance as needed and failed to ensure refusals of showers were reported, documented, and communicated to the interdisciplinary team (IDT - a group of healthcare professionals from different healthcare roles who work together to plan and provide resident care). This deficient practice had the potential to result in compromised skin integrity, infection, and psychosocial distress and prevented the IDT from evaluating and intervening to address Resident 13's ongoing refusal of bathing services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the low air loss mattress ([LALM], a mattress that provides airflow to help keep skin dry, as well as to relieve pressure, treat pressure sores and prevents pressure sores) settings were set to accurately reflect the resident's weight for two of eight sampled residents (Resident 24 and Resident 100), who were at risk for developing pressure injuries (localized area of tissue damage that develops when prolonged pressure or shear forces are applied to the skin and underlying tissues). This deficient practice placed Residents 24 and 100 at risk for pressure injury development.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe environment for two out of eight sampled residents (Resident 40 and Resident 65), when Resident 40's lighter was left on his bedside table in close proximity to Resident 65's oxygen concentrator (a medical device that gives you extra oxygen). This deficient practice placed Residents 65 and 40 at risk for harm related to an oxygen-accelerated fire.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure oxygen delivery equipment functioned properly to provide oxygen therapy for one out of one sampled residents (Resident 65), when the oxygen concentrator (a medical device that gives you extra oxygen) regulator lacked a visible metal ball (flow indicator) to confirm oxygen was flowing at the prescribed rate ). This deficient practice led to the inability for licensed nursing staff to verify effective oxygen delivery and placed Resident 65 at risk for hypoxia (when the lungs cannot adequately oxygenate the blood) and respiratory compromise.

Inspectors wroteBased on interview and record review, the facility failed to ensure Licensed Vocational Nurse (LVN) 8 maintained current certification in cardiopulmonary resuscitation (CPR- an emergency procedure used when a person's breathing or heartbeat stops). The facility also failed to clarify a physician order prior to administering pain medication, and failed to clarify an insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) sliding scale (amount of insulin to be administered changes or slides up or down based on the person's blood sugar) order for two of two sampled residents (Resident 22 and Resident 54). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a clean, sanitary and safe environment for medication storage in the bottom drawer of one of two inspected medication carts (West Station Medication Cart), and failed to ensure the facility's licensed nurse did not leave medications unattended for one of 28 sampled residents (Resident 37) for self-medication administration. These deficient practices resulted in an unsafe and unsecured environment for medication storage, which had the potential to increase the risk of cross contamination of prescription and non-prescription medications in the medication cart, and Resident 37's unsupervised storage and ingestion of medications, which had the potential to result in choking and medication administration errors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide one of six residents (Resident 110) with range of motion ([ROM] full movement potential of a joint) and positioning concerns with Physical Therapy ([PT] profession aimed in the restoration, maintenance, and promotion of optimal physical function) in accordance with the established treatment plan of three times per week and Occupational Therapy ([OT] profession aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]) services in accordance with the established treatment plan frequency of five times per week. This deficient practice had the potential for Resident 110 to experience a decline in mobility and ability to perform activities of daily living ([ADLs] basic tasks that individuals perform to maintain their daily lives and independence). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Infection Preventionist Nurse (IPN) completed 10 hours of continuing education ([CE], post-secondary learning for adults to update or enhance professional skills, meet licensure requirements, or for personal growth) in the field of infection prevention and control on an annual basis. This deficient practice had the potential to result in the IPN not having the knowledge to educate facility staff on updated information regarding infection prevention control and the knowledge of infection prevention in residents.

Inspectors wroteBased on interview and record review, the facility failed to obtain informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) from Responsible Party (RP) 1 prior to administering Depakote (an anticonvulsant medication used to treat seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness] and other behavioral conditions) for one of four sampled residents (Resident 2). This deficient practice resulted in the removal of RP 1's right to make decisions about the care and treatments Resident 2 received in the facility.

Inspectors wroteBased on interview and record review, the facility failed to conduct monitoring for one of four sampled residents' (Resident 2) who had behaviors of angry outbursts. This deficient practice had the potential to result in the inaccurate assessment of the effectiveness of Resident 2's medication regimen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide two of four sampled residents (Residents 1 and 4) with enough space to maneuver their wheelchairs around their room. This deficient practice resulted in Residents 1 and 4 becoming frustrated with one another when their wheelchairs continuously bumped into one another.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received timely incontinence care (providing support, management, and treatment for people who can't control their bladder or bowel) for three of four sampled residents (Residents 1, 2, and 4). This deficient practice had the potential to negatively affect Resident 1, 2, and 4's comfort, dignity, and safety, and had the potential to lead to pressure-related skin injuries (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence).

Inspectors wroteBased on observation, interview, and record review the facility failed to develop a comprehensive care plan in a timely manner for one of three residents (Resident 2) who was at risk for skin breakdown. This deficient practice had the potential for the resident to not receive appropriate care and treatment and to develop or have worsening skin issues.

Inspectors wroteBased on interview and record review, the facility failed to update care plan for one of three sampled residents (Resident 3) to include the resident's noncompliance with non-weight bearing on right foot due to diabetic ulcer (an open wound due to nerve damage and poor circulation) of the right heel. This deficient practice had the potential to place the resident at risk for complications including delayed wound healing and infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure an order for non-weight bearing for the right foot was transcribed from a doctor's order for one of three sampled residents (Resident 3) into Resident 3's electronic health record . This deficient practice placed Resident 3 at risk of non-weight bearing order not being followed and delayed wound healing.

Inspectors wroteBased on interview and record review, the facility failed to ensure a licensed nurse notified the physician and received clarification of orders of a scheduled medication for one of four sampled residents (Resident 1). This deficient practice led to an unapproved alteration of Resident 1's ordered medication regimen and had the potential to result in untreated pain caused by muscle spasms. Cross reference F842.

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate and reliable medication administration documentation when the following occurred for one of four sampled residents (Resident 1):1. Licensed nurses failed to accurately document the medication administration of Resident 1's ordered doses of midodrine (a medication used to treat low blood pressure) in December 2025.2. Licensed Vocational Nurse (LVN) 3 failed to ensure Resident 1's blood pressure was documented accurately on 12/10/2025.3. LVN 3 failed to document the reason why Resident 1's methocarbamol (a muscle relaxant medication) was held on 12/11/2025. These deficiencies resulted in inaccurate medication administration documentation, which had the potential to place Resident 1 at risk for inappropriate medication administration, untreated conditions, and adverse medication effects.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a Hemodialysis Emergency Kit (HD [E-kit], a kit containing essential supplies necessary to manage the dialysis line in case of emergency, like bleeding) was at the bedside of 1 of 4 sampled residents, Resident 1, who had a permacath (a special catheter used for short-term dialysis treatment) for HD treatment. This failure had the potential to cause delay in providing intervention should complication like excessive bleeding from hemodialysis access site occur which could be life-threatening and can result in hospitalization or death.

Inspectors wroteBased on observation, interview, and record review, the licensed nursing staff failed to remove a pressure dressing (a type of bandage applied to a hemodialysis access site after hemodialysis treatment [a medical procedure that removes waste products and excess fluid from the blood when the kidneys are unable to do so] to stop bleeding) for one of three sampled residents (Resident 1) and failed to document the condition of the hemodialysis access site dressing and any part of report from the hemodialysis nurse post-hemodialysis, every shift, for three of three sampled residents (Residents 1, 2, and 3). These deficient practices placed Resident 1 at risk for impaired circulation (disruption of the movement of blood through the body, preventing delivery of oxygen and nutrients to tissues) and infection to the hemodialysis access site. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 4) received a soft and bite-sized texture diet as ordered. This deficient practice placed Resident 4 at risk of choking, aspiration (accidental inhalation of foreign substances, such as food, liquids, or mucus, into the lungs), and possible infection within the lungs and/or death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure kitchen staff wore appropriate hair covering in the food service or preparation areas of the kitchen. This deficient practice had the potential to result in improper food safety practice and could lead to food contamination, and possible foodborne illness in residents who received food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program to ensure the environment was free of cockroaches. This deficient practice had the potential to place all residents in the facility at risk for exposure to cockroach-borne contaminants (unsafe, harmful substances) and unsanitary conditions

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 4), was not laying in soiled diaper for over five hours. This deficient practice resulted in Resident 4 feeling pissed off with the potential to affect the resident's dignity.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that one of four sampled residents (Resident 4) had call lights answered in a timely manner. This failure had the potential to result in Resident 4 having a risk for skin injury or skin breakdown.

Inspectors wroteBased on interview and record review, the facility failed to ensure routine drugs and biologicals were provided to residents by allowing an unlicensed nurse (Staff 1) to administer medications to four of six sampled residents (Residents 1, 2, 3, and 4) for over one and a half years. This deficient practice caused an increased risk in unsafe and inappropriate care of the residents, medication errors, and adverse outcomes to the residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure services were administered effectively and efficiently, as the facility Administrator did not confirm the credentialing process was completed prior to hiring one of five sampled staff (Staff 1), who worked in the facility as a Licensed Vocational Nurse (LVN) for over a year and a half without a nursing license. This deficient practice resulted in the hiring of unlicensed Staff 1 who was permitted to function as a LVN and placed all residents at risk for unsafe and inappropriate care.

Inspectors wroteBased on interview and record review, the facility failed to ensure Staff 1 met the qualifications of a Licensed Vocational Nurse (LVN, an entry level healthcare provider who must complete a state approved educational program and pass a licensing exam to practice) to provide administration of narcotic medications (controlled substance used to relieve severe pain, by prescription only with a high potential for addiction, abuse and misuse) to the residents. Staff 1 was working in the facility as a LVN, since the hire date of 1/8/2024, without a professional LVN license. This deficient practice caused an increased risk for medication errors, unsafe care, adverse outcomes, and potential death to the residents.

Inspectors wroteBased on interview and record review, the facility did not conduct behavior monitoring for one of two sampled residents (Resident 1), who was receiving the psychotropic medication (drug that affects how the brain works) escitalopram (an antidepressant, a medication used to treat depression [a serious medical illness that negatively affects how you feel, think, and act]). This deficient practice placed Resident 1 at risk of receiving escitalopram without an indication.

Inspectors wroteBased on interview and record review, the facility failed to ensure an allegation of staff-to-resident and resident-to-resident abuse was reported timely for one of three sampled residents (Resident 1). This deficient practice placed Resident 1 and other facility residents at risk of sustaining abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure a care plan was developed for one of two sampled residents' (Resident 1) diagnosis of major depressive disorder (MDD, a serious mood disorder characterized by persistent feelings of sadness, loss of interest, and other symptoms that interfere with daily life). This deficient practice placed Resident 1 at risk of not receiving non-pharmacologic (non-medication) care and interventions to address her depression and her verbalizations of sadness.

Inspectors wroteBased on interview and record review, the facility failed to ensure Registered Nurse (RN) 1 and Licensed Vocational Nurse (LVN) 1 demonstrated competency related to the facility's abuse reporting policies when RN 1 and LVN 1 did not know the facility's abuse reporting requirements and who the facility's abuse coordinator was. This deficient practice placed all facility residents at risk of abuse allegations being unreported or delayed to the State Agency (SA) and other relevant agencies.

Inspectors wroteBased on interview and record review, facility failed to ensure the code (a numeric or alphanumeric sequence used as a security feature of authorized facility staff to enter the facility) used by facility staff to open the facility's gate and entrance door was changed, after an employee, Certified Nurse Assistant (CNA 1) was beaten by three (3) unidentified males (perpetrators) known by a facility employee (CNA 2) gained knowledge and access of the facility's code on 7/19/2025. This deficient practice had the potential for the perpetrators to return to the facility and placed all the residents and staff at risk for severe injuries due to the violent behavior, hospitalization and death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection prevention and control measures while changing the colostomy ([stoma] a surgical opening on the surface of the abdomen created to divert the flow of feces) bag (where the feces drain), for 1 of 1 sampled (Resident 1) who was on Enhanced Standard Precautions ([EBP] set of infection control measures designed to reduce the spread of certain multidrug-resistant organisms (MDROs) in healthcare settings including the use of gowns and gloves during high-contact resident care activities, including dressing, bathing, transferring, wound care, and device care, particularly nursing homes), by failing to: 1. Wash hands prior to donning (putting on) gloves.2. Change the gloves that were visibly soiled of feces, after cleaning the stoma.3. Clean the bedside table prior to putting on clean colostomy supplies. [...]

Inspectors wroteBased on interview, and record review, the facility failed to implement an individualized person-centered plan of care with measurable objectives, timeframe, and interventions for one of three sample residents (Resident 1) after Resident 1 went into Resident's 2 room and took Resident 2's personal belongings. This failure had the potential to negatively affect the delivery of necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sample residents' (Resident 2) clinical record was maintained by not documenting reporting a change of condition to the attending physician and psychiatrist. This deficient practice had the potential to result in delay of communication between the staff and provision of care/intervention to the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of four sampled residents (Resident 1 and Resident 3) were treated with dignity and respect when the facility failed to provide the daily dietary menu to Residents 1 and 3, who were unable to get out of bed without staff assistance. This deficient practice violated Resident 1 and Resident 3 rights and resulted in the resident's not being able to choose their food preferences.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Zinc oxide (cream used for skin health, soothing irritated skin, and promoting wound healing) was not left unattended at the bedside for one of four sampled Residents (Resident 4). This failure had the potential to cause an accidental use or misuse of the medication by any residents at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored in a sanitary manner to prevent growth of microorganisms that could cause food borne illnesses (food poisoning- any illness resulting from food spoilage, contamination) by not: 1. Labeling thawing food items with a date and time of when it started to thaw in the refrigerator. 2. Ensuring opened items in the refrigerator had an opened and discard date. 3. Ensuring opened items in the refrigerator was properly sealed. These deficient practices had the potential to place residents at risk for food borne illnesses.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1), had a completed Release of Responsibility for Leave of Absence Form before going out of the facility on pass (permission from the facility to allow a resident to leave the premises). This deficient practice resulted in the facility not knowing the approximate return time and where the resident went to when he went out on pass after he did not return to the facility after being out of the facility on pass.

Inspectors wroteBased on interview and record review, the facility failed to ensure licensed nurses had competencies and skill sets to care for residents by failing to ensure: 1. The facility checked and verified the license for Registered Nurse (RN 1), who was had probationary status (RN allowed to practice under certain restrictions). 2. RN 1 completed mandatory competencies and assessments. This failure had the potential for 113 residents in the facility to not receive proper and safe care.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sampled resident's (Resident 1) clinical records was maintained in accordance with professional standards of practice by failing to ensure the documented times accurately reflected when Resident 1's Vital Signs (measurements that reflect the body's functional status including blood pressure, heart rate, temperature, respirations) were obtained and when Resident 1's Change of Condition occurred on 4/11/2025. This deficient practice had the potential to result in a lack of or a delay in communication between staff and adversely affect the provision of care/interventions for Resident 1.

Inspectors wroteBased on observation, and interview, the facility failed to address a resident's request to move to a different room for one out of six residents (Resident 1.) This resulted in Resident 1 having feelings of anger and hurt feelings for three days.

Inspectors wroteBased on interview and record review, the facility failed to develop an individualized plan of care for one of 6 residents (Residents 5) who had both hands skin itchiness and swelling. This deficient practice resulted in the unresolved skin itchiness and swelling and led to Resident 5 ' s worsening skin condition and multiple hospitalizations.

Inspectors wroteBased on observation, interview and record review the facility failed to: 1. Document in the progress notes, Change of Condition Evaluation (COC) assessment for one of five residents (Resident 5), who was sent out to a General Acute Care Hospital (GACH) on 1/9/2025 due to shortness of breath. 2. Carry out the physician ' s order dated 2/11/2024 for a Dermatology (skin specialist) consult for Resident 5. 3. Create a non-pressure skin assessment form as indicated in the facility ' s policy and procedure (P&P) titled, Skin Tears - Abrasions and Minor Breaks, Care of for Resident 5. These failures resulted in the provision of poor-quality care, worsening condition of Resident 5 ' s skin condition on both hands and multiple hospitalizations. These failures had the potential to affect in maintaining the highest practicable physical, mental and psychosocial well-being of Resident 5.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sampled residents (Resident 4), was administered scheduled medications (Losartan, hypertension [high blood pressure] medicine) and Aspirin (medicine to prevent blood clots and for cerebrovascular accident [CVA] prophylaxis), on 2/21/2025. This deficient practice had the potential to cause complications of hypertensive crisis and CVA that could lead to resident ' s hospitalization and death.

Inspectors wroteBased on observation, and interview, the facility failed to provide safe and comfortable environment for two of six sampled residents (Resident 4 and Resident 5) by failing to ensure the resident restrooms (A & B) were in good repair. This deficient practice caused Resident 4 to feel uncomfortable and avoid using the restroom because of her fear of getting an infection. This deficient practice also placed Resident 4 and Resident 5 at risk for accidents or falls.

Inspectors wrote2. During a review of Resident 117's admission Record, the admission Record indicated Resident 117 was admitted on [DATE]. Resident 117's diagnoses included a broken right thigh bone and displacement of internal fixation device of the right thigh bone (when a surgical implant, like a plate, screw, or rod used to stabilize a broken bone, has moved out of its original position). During a review of Resident 117's History and Physical (H&P), dated 5/7/2024, the H&P indicated Resident 117 had the capacity to understand and make decisions. During a review of Resident 117's admission Minimum Data Set (MDS, a resident assessment tool), dated 5/16/2024, the MDS indicated Resident 117 did not have cognitive impairments (problems with a person's ability to think, learn, remember, use judgement, and make decisions). [...]

Inspectors wroteBased on interview and record review, the facility failed to safely discharge three of six sampled residents (Residents 117, 320, and 321) when: 1. The facility discharged Resident 117 from the facility, without his knowledge, request, or consent, on 11/9/2024. 2. The facility discharged Resident 320 from the facility, without his knowledge, request, or consent, on 10/13/2024. 3. The facility discharged Resident 321 from the facility, without his knowledge, request, or consent, on 10/7/2024. These deficient practices placed all three residents at risk for avoidable physical and psychosocial harm due to their discharge without confirmation of their whereabouts and/or safety, and no notification provided to the residents, local law enforcement agencies, the State Agency, or the Ombudsman (a neutral third party who investigates and resolves complaints) for further follow-up. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide advance notice of discharge to three of six sampled residents (Residents 117, 320, and 321) and the Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities). This deficient practice placed all three residents at risk for avoidable physical and psychosocial harm due to their discharge from the facility, without sufficient time for housing, transportation, and/or care arrangements to be made. The deficient practice also prevented the Ombudsman (a neutral third party who investigates and resolves complaints) from being aware of the need for follow-up related to the unsafe discharges.

Inspectors wroteBased on interview and record review, the facility failed to conduct competency skills evaluation for five of five sampled employees Certified Nursing Assistant (CNA 1), CNA 4, CNA 2, Registered Nurse (RN 2), and Licensed Vocational Nurse (LVN 1), by failing to: 1. Ensure competency skills evaluation was conducted upon hire date and annually for CNA 1 and CNA 4. 2. Ensure competency skills evaluation was conducted annually for CNA 2. 3. Ensure competency skills evaluation was conducted upon hire date for RN 2 and LVN 1. This deficient practice had the potential to result in licensed employees being unaware of any areas in their competency skills required and/or improvement to provide care and services for the residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment by failing to: 1. Ensure five water pitchers were not stored on top of the ice machine located in the ice machine room outside of the kitchen. 2. Ensure dirty resident water pitchers from the previous evening (identified by a blue color) were not stored on the same rack as the clean water pitchers (identified by a pink color) located in the ice machine room. 3. Ensure Resident 115 intravenous ([IV] a method of administering fluids or drugs directly into a vein using a needle or tube) dressing was changed and monitored. [...]

Inspectors wrotef. During a review of Resident 75's Face Sheet, the Face Sheet indicated Resident 75 was admitted to the facility on [DATE] with diagnoses included dysphagia (difficulty swallowing), muscle weakness (loss of muscle strength), and hypertension ([HTN]- high blood pressure. During a review of Resident 75's MDS, dated [DATE], the MDS indicated Resident 75's cognitive skills for daily decision making was intact. The MDS indicated Resident 75 was independent with eating, toileting hygiene, and upper body dressing. The MDS indicated Resident 75 required moderate (helper does less than half the effort) assistance from staff for showering/bathing. During a concurrent observation and interview on 1/27/2025 at 9:23 a.m., with Resident 75, in Resident 75's room, Resident 75 was observed lying in the bed. Resident 75's bed had quarter side rails on the left and right side of the bed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the standardized recipes for the lunch menu was followed on 1/27/2025 and 1/28/2025 when: 1. Food items listed on the menu were not available and were replaced with other items without the registered dietician (RD) approval. 2. Residents receiving a mechanical soft diet (a modified diet that consists of soft, easily chewed foods that can be safely swallowed by individuals with difficulty chewing or swallowing) received shredded instead of ground pork pot roast per the menu. Residents receiving a pureed diet (foods that have been blended or mashed into a smooth, uniform consistency) received bread slurry (bread soaked in milk and melted margarine-the mixture was thin and lumpy and not cohesive) instead of pureed bread that was smooth with no lumps. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that food was prepared by methods that conserved flavor and served at appetizing temperatures for 115 out of 120 residents who received food from kitchen and for Resident 70, who complained the food did not match the menu and was cold. These deficient practices had the potential to result in meal dissatisfaction, decreased food intake and placed residents at risk for unplanned weight loss.

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 supplements labeled store frozen with manufacturers instruction to use within 14 days of thawing, were not monitored for the date they were thawed to ensure expired shakes were discarded after this time frame. Two boxes of unpasteurized shell eggs were stored in the facility walk-in refrigerator. Residents received fried eggs with unpasteurized shell eggs. One bag of breakfast pork sausage open 1/22/25 stored in the walk-in refrigerator exceeding storage period for pork sausage. One large pot containing cooked turkey soup stored in the walk-in refrigerator with no date. One open bag of pasta with use by date of 1/10/25 expired and stored in the dry storage room. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of eight sampled residents (Resident 75 and 42) were accommodated with their requests for a blanket and clean bed linens, and a walker and/or wheelchair. These deficient practices had the potential to violate Residents 75 and 42's rights.

Inspectors wroteBased on interview and record review, the facility failed to obtain informed consent (a process during which residents or caregivers are educated regarding the potential risks and benefits of medication therapy) from the resident or their responsible party (a person delegated to make medical decisions for the resident in the event they are unable to do so) prior to treatment of Cymbalta (a medication used to treat mental illness) for one of five residents sampled for unnecessary medications (Resident 1). The deficient practice of failing to obtain informed consent prior to initiating treatment with psychotropic (medications that affect brain activities associated with mental processed and behavior) medications could have prevented Resident 1 from exercising his right to decline treatment with Cymbalta. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light (a device that residents use to request assistance from staff) was within reach for one of eight sampled residents (Resident 42). This deficient practice had the potential to negatively impact Resident 42's psychosocial well-being and/or result in delayed provision of care and services.

Inspectors wroteBased on interview and record review, the facility failed to notify the California Department of Public Health (CDPH), law enforcement, and the ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities) when the facility failed to provide necessary services to prevent potential physical harm, pain, mental anguish, or emotional distress for one of one sampled resident (Resident 118) that resulted in: 1. Resident 118 eloping (the act of leaving a facility unsupervised and without prior authorization) from the facility on 10/13/2024. 2. Resident 118 eloping from the facility, a second time, on 11/24/2024. [...]

Inspectors wroteBased on interview and record review, the facility failed to accurately complete the minimum data set (MDS - a resident assessment tool) assessment Section I (active diagnoses) by failing to include a diagnosis of depression per information in the medical record for one of five residents sampled for unnecessary medications (Resident 36). The deficient practice of failing to accurately assess active diagnoses and complete MDS Section I increased the risk that Resident 36 may not have received care planning and treatment according to her needs possibly leading to a decline in her overall health and well-being.

Inspectors wroteBased on interview and record review, the facility failed to accurately complete the Preadmission Screening and Resident Review (PASARR - a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) level I screening by omitting a diagnosis of schizophrenia (a mental illness characterized by hearing or seeing things that are not there) for two of five residents sampled for unnecessary medications (Residents 1 and 36). The deficient practice of failing to accurately complete the PASARR Level I screening increased the risk that Residents 1 and 36 could have failed to receive special psychiatric services related to their diagnosis of schizophrenia possibly leading to a decline in their overall health and well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure Certified Nursing Assistant (CNA) 7 and CNA 8 accurately documented the percentage of meals eaten for one of five sampled residents (Resident 1). This deficient practice created the potential for licensed nursing staff, the dietician, and the dietary supervisor to be unaware of Resident 1's actual meal intakes, and result in Resident 1 sustaining undetected malnutrition and weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the settings on the low-air-loss mattress (LALM, an air mattress designed to help prevent and treat pressure ulcers [localized damage to the skin and/or underlying tissue usually over a bony prominence]) were correct for one of one sampled resident (Resident 99). This deficient practice placed Resident 99 at risk for a worsened condition of his existing pressure ulcer and/or the development of new pressure ulcers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a meal substitute provided to one of five sampled residents (Resident 99) was of equal nutritive value to the meal originally provided. This deficient practice had the potential to result in Resident 99 not receiving the required number of calories, and amount of protein and nutrients needed, and could lead to weight loss, malnutrition, and delayed wound healing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) tubing was dated, not touching the floor, and an oxygen in use sign was posted outside the room for three out of eight sampled residents (Resident 100, 103, and 269) receiving oxygen therapy. These deficient practices had the potential to cause a negative respiratory outcome, increased the risk for Resident 100, 103 and 269 to acquire a respiratory infection and placed resident 100 at risk of injury due to fire hazard.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policy and procedure (P&P) titled Proper Use of Side Rails, which indicated consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) for side rail use would be obtained from the resident, after presenting potential benefits and risks for four of eight sampled residents (Resident 75, Resident 42, Resident 71, and Resident 6). This deficient practice had the potential to result in inappropriate use of side rails for Residents 75, 42, 71, and 6, and could lead to injury.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were seen by a physician at least once every 30 days, for the first 90 days after admission, for one of three sampled residents (Resident 60). This deficient practice resulted in Resident 60 receiving an initial comprehensive visit on 10/20/2024, and subsequent monthly visits on 11/30/2024 and 12/29/2024, from a non-physician provider (NPP), Nurse Practitioner (NP, a registered nurse who has advanced training to diagnose and treat patients) 1, whose scope of practice was different and more limited than that of a physician.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately account for one dose of lorazepam (a controlled medication used to treat mental illness) 0.5 milligrams (mg - a unit of measure for mass) affecting Resident 47 in one of two inspected medication carts (East Cart), and ensure licensed nurses administered intravenous (IV, a method of administering fluids or drugs directly into a vein using a needle or tube) medication as ordered and the IV access site was monitored per the doctor's orders for one of eight sampled residents (Resident 115). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure three of 16 sampled residents (Residents 4, 24, and 71), who were receiving Apixaban, Xarelto, and Eliquis (anticoagulants [medication, used to prevent blood clots from forming in the blood vessels and the heart]) were monitored for side effects and signs and symptoms of bleeding. These deficient practices had the potential to result in Residents 4, 24 and 71 suffering from an undetected hemorrhage (release of blood from a broken blood vessel, either inside or outside of the body), which could result in death.

Inspectors wroteBased on interview and record review, the facility failed to provide monitoring for one of five sampled residents (Resident 9) who was receiving Zyprexa (an antipsychotic medication, a medication that affects the mind, emotions, and behavior), temazepam (a hypnotic medication, a medication used to treat insomnia [difficulty falling asleep, staying asleep, or waking up too early, despite having adequate opportunity for sleep]), haloperidol (an antipsychotic medication), and divalproex sodium (an anticonvulsant medication, a medication used to prevent or treat seizures and can be used to treat behavioral disorders) by failing to: 1. Monitor Resident 9 for side effects for his antipsychotic, anticonvulsant, and hypnotic medications. 2. Monitor Resident 9 for tardive dyskinesia (a neurological condition characterized by involuntary, repetitive, and uncontrollable movements of the body). 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two unopened insulin (a medication used to treat high blood sugar) pens were stored in the refrigerator according to the manufacturer's requirements affecting residents 112 and 114 in one of two inspected medication carts (East Cart). The deficient practices of failing to store medications per the manufacturers' requirements increased the risk that Residents 112 and 114 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 mechanically altered diets (a diet consisting of foods and liquids that have been prepared to be easier to chew and/or swallow) were prepared, provided, and served as ordered for four of eight sampled residents (Resident 11, Resident 99, Resident 5 and Resident 82). This deficient practice had the potential to result in aspiration (when food, liquid, or other material enters a person's airway and eventually the lungs by accident) and complications of aspiration, such as pneumonia (an infection/inflammation in the lungs) and/or inability to breathe.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a preference for a Magic Cup (a frozen dessert used for providing additional calories and protein to those experiencing involuntary weight loss) was provided with meals, for one of five sampled residents (Resident 11). This deficient practice had the potential to result in decreased meal intake and could lead to weight loss and malnutrition.

Inspectors wroteDuring an observation, interview, and record review, the facility failed to provide an assisted device during mealtime for one resident out of eight sampled residents (Resident 5) by: 1. Not ensuring Resident 5 received a plate guard during his mealtime. 2. Not ensuring dietary staff and nursing staff checked Resident 5's food tray for a plate guard. These deficient practices made it difficult for Resident 5 to feed himself and made Resident 5 feel upset about his food spilling over his plate.

Inspectors wroteBased on interview and record review, the facility failed to ensure the registered nurses (RN) accurately documented the medication administration and monitoring of Meropenem (used to treat a wide variety of bacterial infections) for one out of eight sampled residents (Resident 155) by failing to: These deficient practices resulted in Resident 115's missed administration and incomplete assessments of the resident's intravenous (through the vein) administration site that would potentially cause a delay in care and placed Resident 115 at risk of developing an antibiotic-resistant infection.

Inspectors wroteBased on interview and record review, the facility failed to employ a social worker that met the basic qualifications of having a bachelor's degree (an undergraduate degree) in social work (profession that helps people improve their lives and overcome challenges) or in the human services field (field that provides support and assistance to individuals, families, and communities in need). This deficient practice had the potential to affect 115 residents residing in the facility by potentially not receiving the assistance and guidance they needed to attain their highest practicable well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow its infection prevention and control policies and procedures (P&P) by failing to ensure staff properly wore personal protective equipment (PPE, specialized clothing or equipment such as an N95 respirator [filtered mask that fit over the nose and mouth], face shield or eye protection worn to minimize exposure to serious illness) during a coronavirus disease ([Covid-19], a highly contagious illness caused by a virus that could easily spread from person to person) outbreak in the facility. This deficient practice had the potential to cause the spread of Covid-19 and cause other residents, staff and visitors to become ill.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement the care plan after a resident's refusal of Levetiracetam (medication used to treat seizures [burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements, behaviors, sensations, or states of awareness]) and implement interventions to monitor for seizure activity for one of six sampled residents (Resident 2) as per the resident's care plan. As a result, Resident 2 had an unwitnessed fall in the bathroom during a seizure activity and sustained a right ankle fracture (broken bone) which required hospitalization in a general acute care hospital (GACH) for evaluation and treatment. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the physician when one of six sampled residents (Resident 2) continued to refuse to take her prescribed seizure (burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements [stiffness, twitching or limpness], behaviors, sensations or states of awareness) medication. This deficient practice had the potential to result in seizure activity and potentially leading to falls and/or injury.

Inspectors wroteBased on interview and record review, the facility staff failed to immediately report not later than two hours an allegation of abuse regarding one of six sampled residents (Resident 1) to the facility Administrator (ADM), and to other officials including to the State Survey Agency (SSA) and adult protective services where state law provides for jurisdiction in long-term care facilities. These deficient practices had the potential to place the resident at risk of further abuse, and neglect.

Inspectors wroteBased on interview and record review, the facility's Quality Assurance Performance Improvement committee ([QAPI] takes a systemic, interdisciplinary, comprehensive, and data driven approach to maintaining and improving safety and quality in nursing homes while involving residents and families, and all nursing home caregivers in practical and creative problem solving) failed to identify facility and resident care issues, and develop and implement appropriate plans of action which included to evaluate measures to maintain resident supervision practices. This deficient practice had the potential to increase the risk of an unsafe environment for all residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure care was provided in a dignified and respectful manner for eight out of eight sampled residents (Residents 8, 40, 41, 70, 77, 89, 91 and 115) by failing to: a. Answer resident call lights in a timely manner. b. Ensure Certified Nursing Assistants (CNAs) did not provide care while wearing headphones. c. Ensure nurses or staff were not sleeping at the nurses' station during the night shift (11 p.m. to 7 a.m.). These failures had the potential for the residents to exhibit feelings of hopelessness, sadness, and a less dignified existence.

Inspectors wroteBased on interview and record review, the facility failed to: a. Provide information and education regarding Advance Directives (a written instruction, such as a living will or durable power of attorney for health care, recognized under State law, relating to the provision of health care when the individual is incapacitated) to three of three sampled residents (Residents 6, 46, and 101). b. Ensure one of three sampled residents (Resident 101) had their desired code status (a description of the type of resuscitation procedures (if any) that someone would like the health care team to conduct if their heart stopped beating and/or they stopped breathing) readily available in the paper (physical) medical record. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide treatments and services to five of six sampled residents (Residents 2, 6, 79, 101, and 107) to prevent and/or limit a decline in joint (where two bones meet) range of motion (ROM, full movement potential of a joint) and mobility (ability to move). a. For Resident 2, the facility failed to provide Restorative Nursing Aide (RNA, nursing aide program that helps residents maintain their function and joint mobility) ROM exercises to the left arm (shoulder, elbow, wrist, hand) and both legs (hip, knee, ankle, feet) three times a week as ordered. b. For Resident 6, the facility failed to provide RNA ROM exercises to both arms and both legs and apply right elbow splint (rigid material or apparatus used to support and immobilize a broken bone or impaired joint) three times a week as ordered. c. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate supervision was provided to prevent elopement (to leave unnoticed) and failed to ensure safety and equipment was maintained appropriately to prevent accidents and/or hazards for six of nine residents (Resident 21, Resident 67, Resident 107, Resident 100, Resident 46, and Resident 2) when: 1. Residents 21, Resident 67, and Resident 107 were left unsupervised in the employee parking lot (near the facility's unlocked employee entrance and exit door). 2. Resident 100 left the facility premises in his wheelchair for ten minutes and was later found by staff. 3. The interdisciplinary team (IDT, a team of professionals with different roles, that participate in joint problem solving for the benefit of the patient) failed to conduct a meeting following Resident 46's sixth fall in the facility on 11/17/2023. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide adequate and sufficient nursing staff to provide care for residents needing hygienic care, residents requiring Restorative Nursing Aide (RNA, nursing aide program that helps residents maintain their function and joint mobility) services, and the answering of resident call lights in a timely manner for four out of eight sampled residents (Resident 8, 77, 89, and 115). These deficient practices resulted in residents' dissatisfaction with the care provided by the Certified Nursing Assistants (CNAs) and had the potential for 60 residents with physician's orders for RNA services to experience a decline in range of motion (ROM, full movement potential of a joint) and mobility (ability to move) and resulted in residents not receiving needed services in a timely and efficient manner. Cross Reference F550 and F688.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the standardized recipes and portions for the lunch menu was followed on 12/26/2023 and 12/27/2023 when: 1. [NAME] 1 used small scoop sizes to serve food for residents and did not measure the slices of meatloaf when serving. 59 residents receiving a regular texture diet received the wrong amount of food, 39 residents receiving a mechanical soft diet (consists of any foods that can be blended, mashed, pureed, or chopped designed for people who have trouble chewing and swallowing), and 12 residents receiving a pureed (includes soft, smooth foods for people with trouble chewing, swallowing, or digesting) diet received less food. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare food by methods that conserved flavor, texture, and appearance. The texture of the zucchini was mushy (soft), soft with pale yellow color and would not hold when picked up with fork. The carrots were mushy and when pierced with fork it collapsed. This deficient practice had the potential to result in meal dissatisfaction, decreased meal intake and placed residents at risk for unplanned weight loss.

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. [NAME] 1 did not wear a properly fitted hair net while in the food preparation area. 2. Resident cups, trays and dishes were not thoroughly clean after being removed from the dishwashing machine and stored to air dry. 3. One Dietary Aide/Dishwasher working in the dishwashing area did not change their gloves and wash their hands when removing the clean and sanitized dishes from the dishwasher machine. 4. The floor and shelving in the dry food storage area were dirty. The Coffeemaker machine's glass gauge pipes were stained with dark-brown colored residue and bulk food items were stored in bins lined with non-food grade (made from material that can typically contain toxins or dangerous substances) plastic liners. 5. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an unvaccinated Certified Nursing Assistant (CNA 1) wore a respiratory mask (device worn over the mouth and nose) in the hallway and in patient care areas, and failed to implement and maintain infection control procedures when Restorative Nursing Aide 1 (RNA 1) did not properly clean and disinfect a cloth gait belt (thick fabric or vinyl belt placed at the patient's waist near his or her center of mass used by staff to assist that patient's balance during mobility) according to manufactures instructions after resident use for one of six sampled residents (Resident 82). These failures placed the residents, staff, and visitors at risk for infections that could potentially cause a decline in resident health and quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the call light device was within reach for one of six sampled residents (Resident 2). This deficient practice had the potential to prevent Resident 2 from receiving necessary care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a person-centered care plan (document helps nurses and other team care members organize aspect of resident care) for three of 22 sampled residents (Resident 104, 108, and 115) by failing to: 1. Develop a care plan when Resident 104 had episodes of vomiting and diarrhea. 2. Develop a care plan for Resident 115's bowel and bladder incontinence (problem controlling urine and stool) and painful urination. 3. Develop a care plan for Resident 108's persistent cough. These failures had the potential to result for the residents' care needs not to be addressed and the lack of ability to identify the resident's ongoing needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policy and procedure titled Hearing aid, care of, dated 8/2008 by failing to document when a resident's hearing aids were received, ensure the hearing aids were functioning, and document the resident's refusal to wear the hearing aids and interventions addressing the resident's refusal for one out of 32 sampled residents (Resident 64). These deficient practices caused Resident 64 to be unable to fully hear and had the potential to negatively impact Resident 64's needs and psychosocial wellbeing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide treatment and care in accordance with professional standards of practice for the assessment and application of splints (rigid material or apparatus used to support and immobilize a broken bone or impaired joint) for one of six sampled residents (Resident 101) by failing to ensure: a. Physical Therapist (PT) 1 performed an assessment to ensure the two splints issued and applied to Resident 101's left knee and left elbow were the correct fit. b. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two out of 32 sampled residents (Resident 107 and Resident 64) received proper treatment and/or devices to maintain proper vision and hearing abilities by: a. Not ensuring Resident 64 was provided with hearing aids. b. Not following the optometrist (specialized field of medicine that examines, diagnoses, and treats patient's eyes) recommendations for an ophthalmology (specialized field of medicine that focuses on the health of the eye, and its anatomy, physiology and diseases that may affect the eye) referral for Resident 107. These deficient practices caused Resident 64 to be without being able to fully hear and caused Resident 107 to live with decreased vision to the left eye, and negatively impacted Resident 64 and Resident 107's needs and their psychosocial wellbeing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the low air loss mattress (LALM, a mattress designed to distribute body weight over a broad surface area to help prevent skin breakdown) settings were accurate while in use for one of one sampled resident (Resident 46). This failure had the potential to cause the avoidable development of a new pressure ulcer (PU, an injury that breaks down the skin and underlying tissue, caused when an area of skin is placed under prolonged pressure), or the reopening of Resident 46's healed PUs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a licensed vocational nurse (LVN 4) thoroughly assessed a resident's indwelling urinary catheter (plastic tubing used to drain urine from the bladder) for sediment (causes encrustation and blockage of the catheter lumen [the inside space of the tube]) for one sampled resident (Resident 64) and failed to promote bowel and bladder continence (ability to control urine and stool) for Resident 115. These deficient practices placed Resident 64 at risk for developing a urinary tract infection (UTI, bladder infection), and placed Resident 115 at risk for a compromised health status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure oxygen therapy was administered and documented as ordered for one of one sampled resident (Resident 57). This failure had the potential to cause Resident 57 avoidable harm and respiratory distress.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain proper refrigeration storage of two medications, Lorazepam (antianxiety [feeling of unease or excessive worry] medication) and Latanoprost (eye drops) for two out of two sampled residents (Resident 124 and Resident 25). These failures had the potential to lead to the ineffectiveness and decreased potency (strength) of the two medications for Resident 124 and Resident 25.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one sampled resident (Resident 41) food preferences were honored when a tomato was placed on Resident 41's lunch plate, despite tomatoes being listed as an allergy and dislike on the resident's meal tray ticket. This deficient practice had the potential to result in decreased meal satisfaction and an allergic reaction.

Inspectors wroteBased on interview and record review, the facility failed to offer the pneumococcal vaccine (medication that trains the body's immune system so that it can fight pneumonia [an infection that inflames the air sacs in one or both lungs]) to one of five sample residents (Resident 115), who was eligible for the vaccination. This failure had the potential to result in the development and spread of pneumonia.

Inspectors wroteBased on interview and record review, the facility failed to revise the comprehensive care plan to address two out of three sampled residents (Resident 2 and Resident 3) episodes of verbal and physical aggression towards others. This deficient practice had the potential to negatively impact the delivery of nursing care and medical interventions for Resident 2 and Resident 3.

Inspectors wroteBased on interview and record review, the facility failed to prevent resident-to-resident abuse involving three of four sampled residents (Residents 1, 2, and 3) when Resident 1 did not have a care plan developed following an episode of verbal aggression towards other residents on 11/26/2023 at 2:41 PM. This failure led to staff being unaware of the need to monitor and supervise Resident 1 for further episodes of aggressive behavior, resulting in a physical altercation involving Resident 1, Resident 2, and Resident 3 on 11/26/2023 at 7:05 PM, and created the potential for avoidable physical and psychosocial harm to all three residents involved.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy and procedure regarding Abuse Investigation and Reporting , by failing to report the two separate resident allegations of physical abuse (regarding a remote control that hit the resident's face and the staff's use of a scalding hot water to clean the resident) to the Department of Public Health, Licensing and Certification unit and the local police, for one of four sampled residents, Resident 1. This failure resulted in the delay of investigation by the Department of Public Health, and had the potential for the abuse to continue, and cause resident's further physical and psychosocial harm.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) was free from abuse. This deficient practice resulted in Resident 1 being verbally and physically abused by CNA 1.

Inspectors wroteBased on observation, interview and record review, the facility failed revise (update) the comprehensive care plan (a written plan that outlines how nursing home staff will help the resident) to monitor one of one resident (Resident 1) for continued aggressive behavior and after Resident 1 pushed Resident 2 to the floor on 10/7/23. This failure resulted in Resident 1 not being monitored for aggressive verbal and physical behavior toward residents and staff which had the potential to cause further abuse and possible injury to residents and staff in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility's staff failed to perform hand hygiene before administering a wound treatment for 1 of 3 sampled residents (Resident 2). This deficient practice had the potential to lead to infections and impede healing.