Bakersfield Post Acute

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure call lights were answered in a timely manner for four of 53 sampled residents (Resident 107, Resident 76, Resident 14, and Resident 85). This failure had the potential for residents not being assisted with their activities of daily living and have a delay in care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to notify physician and responsible party of abuse allegation and change of condition for three of five sampled residents (Resident 81, Resident 83, Resident 4). This failure had the potential for Resident's not to receive care and services and for physician and responsible party not to be made aware of the alleged abuse and change of condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure:1) Floor mats were implemented bilaterally for one of six sampled residents (Resident 51).2) Falling star was implemented for one of six sampled residents (Resident 70).3) Certified Nursing Assistants (CNAs) were knowledgeable on falling star program.4) One of three sampled residents (Resident 51) was safely transferred when utilizing a Hoyer lift (a mechanical assistive device designed to safely transfer residents with limited mobility between a bed, wheelchair, or bathroom). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure resident Hemodialysis Communication Observation/Assessment (HCOA) forms were accurately completed for three of three sampled dialysis (medical procedure that filters waste products and excess fluids from the blood when the kidneys no longer function adequately) residents (Resident 5, Resident 7, and Resident 83). This failure had the potential for Resident 5, Resident 7, and Resident 83 not to receive necessary care during and after dialysis, and for any adverse event to be addressed.

Inspectors wroteBased on interview and record review, the facility failed to follow their Facility Assessment (a document that indicates the facility's resources to meet resident needs), when Certified Nursing Assistant (CNAs) had more residents than it was planned. This failure had the potential for all residents not receiving sufficient nursing care.

Inspectors wroteBased on interview and record review, the facility failed to provide documentation of competency and skills performance for three of five sampled Certified Nursing Assistants (CNA 8, CNA 10, and CNA 11). This failure had the potential to result in lack of competent and skilled staff and residents needs not being met.

Inspectors wroteBased on interview and record review, the facility failed to complete annual performance evaluations for five of five sampled Certified Nursing Assistants (CNA 7, CNA 8, CNA 9, CNA 10, and CNA 11). This failure had the potential for CNAs not being aware of their need for improvement in a certain area which could affect all the residents' care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control practices when:The residents' clean personal laundry was not stored in a designated space to reduce the risk of contamination. The portable air conditioner (AC) in the laundry room had thick grey colored debris in the front and side vent grills. Two of two Certified Nursing Assistants (CNA 12 and CNA 13), did not follow their policy and procedure (P&P) on Enhanced Based Precaution (EBP - an infection control intervention designed to reduce the spread of multidrug-resistant organisms [MDROs - These are germs-primarily bacteria-that have evolved to resist multiple classes of antimicrobial drugs, making the infections they cause highly difficult, and sometimes impossible, to treat with standard medications in nursing homes and long-term care facilities]). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure:1. One of 53 sampled resident's (Resident 51) call light was within reach. This failure had the potential for Resident 51's care needs, health and safety concern not to be addressed timely.2. One of 53 sampled residents (Resident 49) had access to a working call light. This failure prevented Resident 49 from calling staff to bring him water. 3. Three of four resident shower rooms (shower rooms in halls 200, 400 and 500) had call lights inaccessible to residents. This failure had the potential to prevent residents from calling for assistance.

Inspectors wroteBased on observation and interview, the facility failed to maintain a safe environment when cardboard boxes containing detergents, bleach and soap, were being stored behind the washing machine. This failure had the potential for increasing the fire hazard affecting all residents, staff, and visitors in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure three of 53 sampled residents (Resident 79, Resident 23, and Resident 81) were treated with respect and dignity when facility staff converse in a language other than the resident's primary language while providing care. This failure had the potential to negatively affect Resident 79, Resident 23, and Resident 81's psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, when allegations of abuse were not investigated timely for one of 53 sampled residents (Resident 81). This failure resulted in Resident 81's abuse allegation not being investigated timely.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure allegations of abuse were reported timely for one of three sampled residents (Resident 81). This failure resulted in Resident 81's abuse allegation not being reported timely and delaying the investigation.

Inspectors wroteBased on interview, and record review, the facility failed to accurately complete the Pre-admission Screening and Resident Review (PASRR - federal requirement to help ensure that individuals are not incorrectly placed in nursing homes or long-term care instead of a psychiatric setting), for one of two sampled residents (Resident 4). This failure had the potential for Resident 4 to be placed in an inappropriate setting and not receive required services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement care plans for two of 53 sampled residents (Resident 51 and Resident 70). This failure had the potential for Resident 51 and Resident 70's safety to be at risk.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer medication according to the physician order for one of six sampled residents (Resident 23) when Resident 23 had an order for the administration of one inhalation (drawing the medication into the lungs) of Trelegy Ellita inhalation Aerosol Powder (a medication to treat inflammation of the lungs) 100-62.5-25 MCG (micrograms-unit of measurement)/ACT (actuation - refers to a single spray, puff, or activation of an inhaler) and Resident 23 did not receive the medication. This failure had the potential for Resident 23 to experience negative health outcomes due to breathing problems.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 53 sampled residents (Resident 51) was turned and repositioned every two hours. This failure had the potential for delayed wound healing and worsening of pressure injuries (localized injury to the skin and/or underlying tissue usually over a bony prominence, from pressure, or pressure in combination with shear and/or friction) for Resident 51.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nutritional assessment was accurate for one of two sampled residents (Resident 11). This failure had the potential for Resident 11 to not meeting her nutritional needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure physician progress notes (PPN) were completed for the months of February, March, and April 2026 for one of three sampled residents (Resident 90). This failure had the potential for a change in condition to go unnoticed and a delay in care.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure (P&P) titled, MedBank [automated medication dispensing system] Policies & Procedures when narcotic medications (controlled drugs - those drugs highly regulated by the government that carry a high potential for abuse, addiction or physical and psychological dependence) were not counted and documented consistently. This failure had the potential for the facility not to have prompt identification of loss or diversion of narcotic medication.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of six sampled residents' (Resident 51 and Resident 6) clinical documentation was complete and accurate. This failure resulted in Resident 51 and Resident 6's clinical records to be incomplete and inaccurate.

Inspectors wroteBased on interview and record review, the facility failed to ensure flu vaccines (an immunization to protect from the flu) were offered to two of five sampled residents (Resident 11, Resident 60). This failure had the potential for the flu spreading to all the residents in the facility due to not receiving immunizations.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two Hoyer lift (equipment used to safely lift a person with limited mobility) battery chargers were working correctly affecting two of five sampled residents (Resident 1 and Resident 2) safety using the Hoyer lift when:1. One of two Hoyer lift battery chargers was not charging the Hoyer lift batteries2. Maintenance logs and records were not being kept for the maintenance of the Hoyer lifts and Hoyer lift batteries These failures had the potential to result in the Hoyer lift batteries not working and placing residents at risk for injuries and accidents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of three sampled residents (Resident 1, Resident 2, and Resident 3) call lights were answered timely. This failure resulted in a negative psychosocial effect for Resident 1, Resident 2, and Resident 3.

Inspectors wroteBased on interview and record review, the facility failed to ensure medications were:1) Administered timely for one of three sampled residents (Resident 1).2) Medications were administered per physicians' orders for one of three sampled residents (Resident 2). These failures had the potential for Resident 1 and Resident 2 to suffer adverse outcomes.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) was able to make and receive phone calls privately. This failure had the potential to violate Resident 1's rights.

Inspectors wroteBased on interview and record review, the facility failed to develop a plan of care for one of two sampled residents (Resident 1) when Resident 1 was at risk for contracting head lice after her roommate (Resident 2) contracted head lice. This failure had the potential for Resident 1 to contract head lice and spread infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure call lights were answered timely for two of five sampled residents (Resident 4 and Resident 5). This failure had the potential to result in unmet care needs, and to negatively impact the physical, mental, and psychosocial well-being for Resident 4 and Resident 5.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled licensed staff (Certified Nursing Assistant [CNA] 2) had the skills and abilities necessary to provide adequate nursing care to the facility's residents. This failure had the potential for CNA 2 to be unable to appropriately care for residents, not meeting residents' needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure the responsible party (RP) and hospice provider for one of three sampled residents (Resident 1) were notified when a psychotherapeutic medication (a class of drugs that alter brain chemistry to treat cognitive, emotional, and behavioral conditions) was discontinued. This failure resulted in Resident 1's RP and hospice provider not to be part of the decision-making process.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy and procedure for Access to Personal and Medical Records, for one of three sampled residents (Resident 1). This failure resulted in violation of Resident 1's rights.

Inspectors wroteBased on interview and record review, the facility failed to provide sufficient staffing for one of three sampled residents (Resident 2), when call lights were not answered timely. This failure resulted in delay in meeting Resident 2's basic needs and potential for emotional distress.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 2) medical records were accurate. This failure had the potential to affect the continuity of care for Resident 2.

Inspectors wroteBased on interview and record review, the facility failed to ensure medications were administered according to the physician's orders (PO) for one of three sampled residents (Resident 1) when: 1. Resident 1's Docusate Sodium (medication for constipation [problem with passing stool]) was not held for episodes of loose stools. 2. Resident 1 was not administered Imodium or Loperamide (medications to treat diarrhea [loose stools]) for episodes of loose stools. These failures had the potential for Resident 1 to develop skin breakdown due to episodes of loose stools.

Inspectors wroteBased on interview and record review, the facility failed to ensure medications were administered according to the physician's orders (PO) for one of three sampled residents (Resident 1) when Resident 1 did not receive two medications on time. This failure had the potential to result in Resident 1 developing adverse health outcomes due to delay in receiving his medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure the allegation of sexual abuse for one of three sampled residents (Resident 1) was reported timely to California Department of Public Health (CDPH-local stated agency) and local ombudsman (representatives assist residents in long-term care facilities with issues related to day-to-day care, health, safety, and personal preferences). This failure had the potential for Resident 1 not to be protected from further abuse and resulted in emotional distress.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of seven sampled residents (Resident 1) was protected from physical and verbal abuse. This failure had the potential to result in physical and psychosocial harm for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, when the facility failed to: 1. Submit the SOC 341(Report of Suspected Dependent Adult/Elder Abuse) timely to California Department of Public Health (CDPH-local stated agency) and local ombudsman for two of four sampled residents (Resident 1 and Resident 2). This failure resulted in the allegation of abuse not being reported to CDPH and the local ombudsman timely. 2. Thoroughly investigate resident to resident physical abuse for two of four sampled residents (Resident 1 and Resident 2). This failure had the potential to result in an incomplete investigation.

Inspectors wroteBased on interview and record review, the facility failed to consistently implement Interdisciplinary Team (IDT- a group of health care professionals with various areas of expertise who work together to improve patient safety and outcomes) recommendation for two of four sampled residents (Resident 1 and Resident 2). This failure had the potential for Resident 1 and Resident 2's physical and psychosocial needs to be unmet.

Inspectors wroteBased on interview and record review the facility failed to follow their policy and procedure (P&P) titled, Change in Condition or Status when facility did not complete assessments for three of four sampled residents (Resident 2, Resident 3, and Resident 4) after a verbal altercation incident. This failure had the potential for residents not being assessed and monitored for psychosocial distress.

Inspectors wroteBased on interview and record review, the facility failed to provide sufficient staffing for three of five sampled residents (Resident 1, Resident 2, and Resident 3), when call lights were not answered timely. This failure resulted in residents' increased wait times for basic needs to be met and had the potential for emergent needs not attended.

Inspectors wroteBased on interview and record review, the facility failed to ensure professional standards were followed when medications and treatments were not administered according to physicians' orders for two of four sampled residents (Resident 4 and Resident 5). These failures had the potential for worsening skin breakdown and infection to Resident 4 and Resident 5.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy and procedures (P&P) titled, Prevention of Pressure Injuries (localized damage to the skin and underlying soft tissue usually over a bony prominence), for one of three sampled residents (Resident 79) when staff did not evaluate, report and document potential changes in the skin. This failure resulted in Resident 79 developing a facility acquired right heel injury which progressed to a pressure ulcer (open sore caused by poor blood flow or pressure) causing pain to Resident 79.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when: 1. The treatment nurse had long artificial nails. 2. One of one linen cart cover was a mesh (uniform small openings) material, and the mesh cover was frayed in the center. 3. Two of two housekeeping carts trash bins did not have lids. 4. Three of four sample resident rooms (Resident 36, Resident 14 and Resident 133) who were on Enhanced Barrier Precaution (EBP-infection control strategy that uses PPE to reduce the spread infections) had no Personal Protective Equipment supplies (PPE-equipment worn to minimize exposure to a variety of hazards). These failures had the potential to spread infections to residents, staff, and visitors.

Inspectors wroteBased on interview and record review, the facility failed to follow their Advanced Directive (AD - legal document which indicates a person's wishes for medical treatment) policy and procedure (P&P) for three of three sampled Residents (Resident 32, Resident 40, and Resident 28) to provide AD information and obtain a signed or declined AD. This failure had the potential for the facility to be unaware of Resident 32's, Resident 40's, and Resident 28's wishes for treatment.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 19) had informed consent (resident recieves enough information regarding treatment risk and benefits to accept or reject treatment) forms for physician ordered psychotropic (drug that affects behavior, mood, thoughts or perception) medications. This failure had the potential for Resident 19 to be unable to make an informed decision regarding medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 3), was treated with dignity while assisting with meals. This failure had the potential to negatively impact emotions, behavior and social needs for Resident 3.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure call light were within reach for two of 48 sampled residents (Resident 186 and Resident 13). This failure had the potential for not meeting the psychosocial and physical needs of Resident 186 and Resident 13 .

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure (P&P) titled, Personal Property, for one of six sampled residents (Resident 50) when Resident 50's belongings were not inventoried and documented on admission. This failure had the potential to result in lack of reimbursement for lost belongings.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 66) change of condition assessment was completed and the physician was notified of Resident 66's significant weight loss. This failure resulted in Resident 66's physician was not notified of the change in condition and continued weight loss.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of three sampled residents (Resident 10 and Resident 12) had a care plan for preferred activities and interests. These failures had the potential for unmet pyschosocial needs when Resident 10 and Resident 12 were not be provided activities of their choice.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure (P&P) titled, Sensory Impairments- Clinical Protocol, for one of three sampled residents (Resident 50) when staff did not assist resident to obtain hearing aids. This failure resulted in unmet communication needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure policy and procedure (P & P) titled, Podiatry [treatment of the feet] Services were provided timely for one of three sampled residents (Resident 79) when Resident's 79's thicken toe nails were overgrown. This failure had the potential for Resident 79 to experience podiatric complications.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 19) was provided social services (SS) assistance with changing her Power of Attorney (POA - legal document that allows someone else to act on your behalf). This failure resulted in Resident 19 experiencing frustration and emotional distress related to lack of assistance from facility to change her POA.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy and procedure (P & P) titled, Controlled Medications to ensure controlled medications (drugs that are regulated by federal laws and have a high risk for dependence) for one of eight sampled residents (Resident 385) were accounted when one tablet of Hydrocodone (opioid pain medication) was missing. This failure had the potential for drug diversion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement their policy and procedure (P&P) titled, Medication Storage for one of three sampled residents (Resident 284) when two 50 ml (milliliters) of expired (less effective) IV (intravenous - in the vein) were not removed from medication storage. This failure had the potential for expired medication to be administered to Resident 284 resulting in a negative health outcome.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 66), was provided dental services in a timely manner when significant weight loss was identified. This failure had the potential for Resident 66 to have difficulty eating and continued weight loss due to ill fitting dentures.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy and procedure (P&P) titled Administering Medications, for one of three sampled residents (Resident 51) when topical medication was administered without a physician's order by unlicensed staff. This failure resulted in physician and licensed staff being unaware of Resident 51's skin condition which had the potential for an adverse health outcome.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy and procedure (P&P) titled, Administering Medication, to ensure one of 48 sampled residents (Resident 133) medication administration was documented. This failure resulted in Resident 133's medication administration record (MAR) being inaccurate and incomplete.

Inspectors wroteBased on interview and record review, the facility failed to follow the physician's order for one of four sample residents (Resident 1) to provide treatment for Resident 1's right lower extremities (RLE) cellulitis [infected/swollen inflamed area of skin]. This failure had the potential to result in Resident 1's worsening of skin condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an effective implementation of pest control when there were cockroaches found in the facility ' s staff break room. This failure had the potential for placing residents at risk for infectious disease and foodborne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of four sampled residents ' (Resident 2 and Resident 4) call lights were answered timely. This failure had the potential for residents not being assisted with their activities of daily living (ADL).

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy and procedure (P&P) on Abuse, Neglect, Exploitation and Misappropriation Prevention Program for one of four sampled residents (Resident 1) when an alleged abuse incident was not investigated within five working days. This failure had the potential for Resident 1 to suffer further physical and psychosocial harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure four of four sampled residents' (Resident 1, Resident 2, Resident 3, and Resident 4) call lights were answered timely. This failure had the potential for residents not being assisted with their activities of daily living (ADL) affecting their quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure three of nine sampled residents (Resident 3, Resident 7, and Resident 8) received the necessary care and assistances needed for showers/baths. This failure resulted in Resident 3, Resident 7, and Resident 8, not receiving appropriated care and services to maintain cleanliness and prevent infection.

Inspectors wroteBased on interview and record review, the facility failed to provide sufficient staffing for eight of nine sampled residents (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 7, Resident 8, and Resident 9) when call lights were not answered timely. This failure had the potential to result in the residents' needs not being met in a timely manner, and to result in physical and/or psychosocial harm.

Inspectors wroteBased on interview and record review, the facility failed to ensure a bed hold (holding or reserving a resident's bed while the resident is absent from the facility for therapeutic leave or hospitalization) was offered to one of nine sampled residents (Resident 8). This failure had the potential for Resident 8 and Resident 8's Representative not to be informed of the rights and benefits of bed hold and return policy of the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure three of three sampled Licensed Vocational Nurses (LVN 1, LVN 2, and LVN 3) were competent in the application and operation of a Bi-Level Positive Airway Pressure (BIPAP- a machine that helps you breathe). This failure resulted in incorrect application of the BIPAP machine on Resident 8.

Inspectors wroteBased on interview and record review, the facility failed to ensure four of five sampled employees' (Certified Nursing Assistant [CNA 2], CNA 3, Licensed Vocational Nurse [LVN 1], and LVN 2) had the required screening prior to their date of hire. This failure had the potential to expose the facilities resident to abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control practices when: 1. Registered Nurse (RN 1) was not wearing the appropriate PPE (personal protective equipment) while providing direct care for one of 11 sampled residents (Resident 1) on contact precautions. 2. Phlebotomist 1 and Phlebotomist 2 did not perform hand hygiene prior to donning (put on) and doffing (removing) gloves and did not perform hand hygiene in between rooms for one of 11 sampled residents (Resident 8). 3. Certified Nursing Assistant (CNA 1) did not perform hand hygiene before donning gloves for two of 11 sampled residents (Resident 2 and resident 3). These failures had the potential for the spread of infectious diseases to all residents, staff, and visitors.

Inspectors wroteBased on interview and record review, the facility failed to ensure three of five sampled residents (Resident 5, Resident 6, and Resident 7) were offered and educated on the COVID- 19 (coronavirus disease- is an illness caused by a virus that spreads most commonly through the air in tiny droplets of fluid between people in close contact, can cause mild to severe acute respiratory infection) vaccination. These failures had the potential for Resident 5, Resident 6, and Resident 7, acquiring, transmitting, or experiencing complications from COVID- 19.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy and procedure to complete skin assessments and shower sheets for three of four sampled residents (Resident 2, Resident 3, and Resident 4). These failures had the potential for Resident 2, Resident 3, and Resident 4, to develop skin injuries and delay treatment.

Inspectors wroteBased on interview and record review, the facility failed to ensure showers or baths were provided to three of four sampled residents (Resident 1, Resident 3, and Resident 4). Theses failures had the potential for Resident 1, Resident 3, and Resident 4, to have delayed identification of skin issues and negative health outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop an individualized care plan for refusal of care for one of four sampled residents (Resident 4). This failure had the potential for Resident 4 to have adverse health outcomes.

Inspectors wroteBased on interview and record review, the facility failed to administer a blood pressure medication on time for one of three sampled residents (Resident 2). This failure had the potential to negatively affect Resident 2's medical condition.

Inspectors wroteBased on interview and record review, the facility failed to implement the safe use of a Hoyer lift (a mechanical lift device designed to assist caregivers in safely transferring patients or individuals with limited mobility) for one of three sampled residents (Resident 1). This failure had the potential for physical harm.

Inspectors wroteBased on interview and record review, the facility failed to provide sufficient staffing for three of three sampled residents (Resident 1, Resident 2 and Resident 3) who required two persons physical assists with transfers. This failure had the potential to place Resident 1, Resident 2, and Resident 3 at risk for accidents and injuries.

Inspectors wroteBased on interview and record review, the facility failed to honor the preferences for two of three sampled resident (Resident 1 and Resident 2) when a bariatric (person classified as obesity- disorder involving excessive body fat) shower bed (specialized bed designed to support more than 300 pounds of evenly distributed weight to allow easy patient transfer to and from the shower room) with adjustable headrest was not repaired or replaced. This failure resulted in Resident 1 unable to maintain his independence and Resident 2 not receiving a shower for approximately 70-days.

Inspectors wroteBased on interview and record review, the facility failed to resolve a grievance for one of three sampled residents (Resident 1). This failure resulted in Resident 1 care needs to go unresolved for 2 months.

Inspectors wroteBased on interview and record review, the facility failed to implement a care plan for one of three sampled residents (Resident 2) when needed equipment was not provided. This failure resulted in Resident 2 refusing showers for approximately 70-day, the refusals were not documented, and Resident 2's doctor was not notified.

Inspectors wroteBased on interview and record review, the facility failed to ensure medications were administered according to physician's order for one of three sampled resident (Resident 1). This failure resulted in medications not administered as ordered and had the potential for adverse outcome due to Resident 1 not receiving medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure shower documentation was complete and accurate for two of three sampled resident (Resident 1 and Resident 2). This failure resulted in Resident 1 and Resident 2 medical records to be inaccurate.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement comprehensive plan of care (helps nurses and other care team members organize aspects of resident care according to a timeline) to address risk for falls for one of two sampled residents (Resident 1). This failure resulted in Resident 1 sustaining a fall with fracture (break in the bone) to the anterior (near the front of the body or nearer to the head) column of the left acetabulum (the socket portion of the ball-and-socket hip joint) with extension of the fracture into the left superior (higher in position) and left inferior (lower in position) pubic rami (pubic rami are a group of bones that make up part of the pelvis (basin-shaped complex of bones that connects the trunk [central part of the body] and the legs), unnecessary hospitalization, and pain.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide scheduled showers for four of four sampled residents (Resident 1, Resident 2, Resident 3, and Resident 4) when there were no documented showers for these residents (Resident 1, Resident 2, Resident 3, and Resident 4). This failure had the potential for Resident 1, Resident 2, Resident 3, and Resident 4 to have skin break down, skin infections, and affect their quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide RNA (Restorative Nursing Assistant -nursing care designed to improve or maintain the functional ability of residents, so they can achieve their highest level of well-being possible) program for one of four sampled residents (Resident 4) according to the physician's order. This failure had the potential for Resident 4 to have a decline in mobility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its policy and procedure on hand hygiene (cleaning one's hands that substantially reduces potential pathogens [harmful microorganisms] on the hands. Hand hygiene is considered a primary measure for reducing the risk of transmitting infection among residents and health care personnel) for three of three sampled residents (Resident 1, Resident 2, Resident 3). This failure had the potential to spread infection amongst the residents and staff and result in negative consequences up to and including death.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure to ensure the Dietary Manager was certified and had a competency skills checklist completed. This failure had the potential to affect all residents nutrition status when served the wrong food consistency, or unpalatable (unpleasant to taste) food.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy and procedure (P&P) to provide annual training on Abuse Prohibition & Prevention to all facility staff. This failure had the potential for exposing all residents to abuse and neglect while residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure call lights were answered timely for six of 58 sampled residents (Resident 66, Resident E, Resident J, Resident D, Resident B, and Resident G). This failure had the potential for delayed provision of care affecting residents' health and safety.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Follow their Advanced Directive (legal document which indicates a person's wishes for medical treatment) policy and procedure (P&P) for two of six sampled Residents (Resident 37 and Resident 48) to provide AD information and obtain a signed or declined AD. This failure had the potential for the facility to be unaware of residents' wishes for treatment. 2. Ensure one of five sampled residents (Resident 42), with mental capacity to make medical decisions, was able to make his own healthcare decisions. This failure had the potential for competent residents not being allowed to make their own healthcare decisions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide assistance with activities of daily living (ADL) when: 1. Facility did not provide showers to two of five sampled residents (Resident 46 and Resident 27). 2. Facility did not assist four of five sampled residents (Resident 7, Resident 27, Resident 30, and Resident 85) to trim their fingernails and toenails. 3. Facility did not provide grooming assistance to one of five sampled residents (Resident 7). These failures resulted in residents not receiving assistance with their personal hygiene which negatively affected their quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Complete an assessment for one of five sampled residents (Resident 46's) foot drop (difficulty lifting the front part of the foot). This failure had the potential for Resident 46 to experience worsening of foot contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints). 2. Ensure one of 58 sampled residents (Resident 37) had a proper fitting wheelchair. This failure had the potential to result in Resident 37 falling or slipping out of her wheelchair.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide Restorative Nursing Assistant (RNA - person-centered nursing care designed to improve or maintain the functional ability of residents, so they can achieve their highest level of well-being possible) services for three of five sampled residents (Resident 46, Resident 29, and Resident 28). This failure had the potential for residents' worsening of contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints), decline in mobility, and range of motion.

Inspectors wroteBased on interview and record review, the facility failed to follow its Dialysis policy (procedure to remove waste products and excess fluids) for three of three sampled residents (Resident 5, Resident 70 and Resident 83). This failure had the potential for the residents to suffer complications from dialysis which may lead to hospitalization and death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure sufficient nursing staff to meet the needs of 87 out of 87 residents. 2. Ensure the Federally mandated Direct Care Service Hours Per Patient Day (DHPPD - actual hours of work performed per patient day by a direct caregiver. The total number of hours worked per patient day divided by the average daily census) were met. These failures had the potential for all residents in the facility to not receive timely and necessary nursing care and related services, to assure the residents' safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of six sampled staff had the skills (specific abilities to perform their job) and competency (knowledge, skills, abilities, and behaviors) to provide care and services to the residents. This failure had the potential for all residents to be exposed to negligent care and compromised safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a medication error rate of less than five percent (%) when there were three errors out of 33 opportunities (9.09 %). This failure had the potential for residents not receiving the full therapeutic effects of the medication and potential for adverse health outcomes.

Inspectors wroteBased on observation and interview, the facility failed to: 1. Ensure discontinued medications were removed from the medication cart. This had the potential for medications administered to the wrong resident. 2. Ensure medications were stored in appropriate compartments. This failure had the potential for contamination and medication errors. 3. Ensure expired medications were discarded. This failure had the potential for toxic, expired medications to be administered to residents and had the potential for adverse health outcomes. 4. Ensure medications were labeled with open and discard date according to pharmacy recommendation. This failure had the potential for medications to lose their potency and had the potential for residents to not receive the full therapeutic effect.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food served was palatable (pleasant to taste) for 13 of 13 sampled residents (Resident 14, Resident 29, Resident 44, Resident A, Resident B, Resident C, Resident D, Resident E, Resident F, Resident G, Resident H, Resident I, and Resident J). This failure had the potential for residents to not eat and not meet their nutrional needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide three of three sampled residents (Resident 20, Resident 28, and Resident 52) with a properly prepared pureed (food that is smooth and lump free, not firm or sticky, requires no chewing) diet. This failure had the potential for three residents diagnosed with Dysphagia (difficulty with swallowing that can lead to inhaling food and liquid into the lungs) to suffer from choking or inhaling the food.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policy and procedure on Water Pitchers to provide clean water pitchers and fresh water daily to four of 26 sampled residents (Resident E, Resident A, Resident B, and Resident 14). This failure had the potential for resident hydration needs to not be met.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement infection control standards when: 1. Certified Nursing Assistant (CNA) 1, passed meal trays to multiple residents in multiple rooms without performing hand hygiene. 2. Licensed Vocational Nurse (LVN) 4 did not perform hand hygiene and was wearing long artifical nails while providing direct patient care. These failures had the potential for spread of infectious diseases to all residents, staff, and visitors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a clean and orderly physical environment when two of 55 rooms (room [ROOM NUMBER] and room [ROOM NUMBER]) had a cracked-opened ceiling and a paint-patched fire sprinkler. This failure had the potential for the risk of the health and safety of two residents in room [ROOM NUMBER] and two residents in room [ROOM NUMBER].

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 58 sampled residents (Resident 54) had access to his facility managed funds after 5 PM, weekends, or holidays. This failure had the potential for residents to not have access to their funds when needed.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled residents (Resident 42), his family, or the ombudsman (person in a government agency whom people can go to for assistance with navigating the programs or policies of a long-term care agency) was notified, in writing, of Resident 42 transfer to the hospital. This failure resulted in Resident 42, his family, and the ombudsman to be not fully informed of Resident 42's physical location.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 42) was: 1. Assessed for abdominal distention (abnormally swollen outward). 2. Assessed for unexpected weight loss. These failures resulted in Resident 42's physical condition and weight loss not being reported to the physician and for physician orders for laboratory and diagnostic testing to be delayed.

Inspectors wroteBased on interview and record review, the facility failed to ensure Interdisciplinary Team (IDT-members from various disciplines who review and discuss information and make plans to meet residents' needs) care conferences were completed at least quarterly for two of five sampled residents (Resident 42 and Resident 54). This failure had the potential for comprehensive care needs to go unmet.