Bay Crest Care Center

Inspectors wroteBased on interview and record review, the facility failed to notify the physician and Responsible Party (RP) for one of three sampled residents (Resident 2) when Resident 2 received medications that should have been held. This deficient practice resulted in Resident 2's physician and RP being unaware that Resident 2 received medications that should have been held. This deficient practice resulted in the inability of Resident 2's physician to give timely instructions for Resident 2's care and the inability for Resident 2's RP to participate and make decisions in Resident 2's immediate care needs. This deficient practice had the potential for the RP to remain uninformed about changes in Resident 2's health status.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident (Resident 2) who had a diagnosis of type 2 diabetes mellitus ([DM] a disorder characterized by difficulty in blood sugar control and poor wound healing) and received glipizide (a medication used to lower blood sugar levels) daily for his DM, was administered according to physician's orders for one of three sampled residents (Resident 2). These failures resulted in the resident receiving glipizide on eight separate occasions when Resident 2's capillary blood glucose ([CBG] blood sugar level) was less than 120. These failures placed the Resident 2 at risk for hypoglycemia (low blood sugar level).

Inspectors wroteBased on interview and record review, the facility failed to ensure resident was free from significant medication errors for one of six sampled residents (Resident 2) by failing to:1. Administer Quetiapine Fumarate (Seroquel), an antipsychotic medication prescribed to treat mental health conditions) , as ordered by the physician from 3/5/2026 through 3/12/2026.2. Notify the physician when the Seroquel order contained no dosage on 2/24/2026 and when the medication was not administered for eight consecutive days. These failures had the potential to result in increased agitation and behavioral disturbances due to the omission (failure to administer an ordered dose of medication) of a prescribed medication.

Inspectors wroteBased on observation and interview and record review, the facility failed to store food items safely for all residents by not ensuring that a carton of thickened water, chocolate pudding powder, frozen donut holes, and frozen pork chops were labeled with open dates. This failure had the potential to expose residents to food borne illnesses (any illness resulting from ingestion of food contaminated with bacteria, viruses, or parasites).

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain respect and dignity for one of two sampled residents (Resident 2) by standing over the resident while providing assistance during a meal. This failure had the potential to place Resident 2 at risk for choking and to negatively impact the resident's self esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one of four sampled residents (Resident 25) received a morning shower as requested and preferred by the resident. This failure resulted in Resident 25 waiting approximately six hours for a shower and had the potential to cause Resident 25 to experience feelings of uncleanliness.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure one of 18 sampled residents (Resident 2) was free from the use of a physical restraint (any object or device that an individual cannot remove easily which restricts freedom or movement). The facility failed to:1. Ensure an informed consent was obtained and documented before applying an abdominal binder (wide, elastic belt worn around the stomach reducing movement) as a restraint to prevent Resident 2 from pulling out her gastrostomy tube (GT- a feeding tube inserted directly into the stomach through the abdomen used for long term nutrition, and administration of medication) on 5/28/2025.2. Ensure an ongoing assessment, monitoring and evaluation to ensure the resident's safety and continued need for the use of the abdominal binder. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure a safe discharge and transfer for two of two sampled residents (Resident 7 and Resident 11) by falling to:1. Ensure the Long-Term Care (LTC) Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities) was notified when Resident 7 was transferred to the General Acute Care Hospital (GACH).2. Ensure Resident 7 and Resident 11 were offered a bed hold before being transferred to the GACH.These failures placed Resident 7 and Resident 11 at risk for an unsafe transfer and violated Resident 7 and Resident 11's rights to informed transfer to GACH.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an alternative means of communication in a language that the resident could understand for one of three sampled residents (Resident 2). This failure had the potential to cause Resident 2 to feel frustrated and isolated, and to limit her ability to communicate her needs to staff, which could lead to delays in receiving appropriate care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 7), who was dependent on staff for Activities of Daily Living (ADLs), received appropriate personal care. The facility failed to:1. Ensure Resident 7's long fingernails were trimmed and free of dirt and black grime underneath. This failure placed Resident 7 at risk for discomfort and increased the risk of infection from cross contamination (the transfer of bacteria, viruses, microorganisms, or other harmful substances from one surface to another through improper or unsanitary conditions) due to inadequate nail hygiene.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of one sampled resident (Resident 41) received ongoing activities in accordance with their comprehensive assessment, preferences, and interests, and supported their physical, mental, and psychosocial well-being. This failure had the potential to result in decreased physical activity and diminished sense of self-worth for Resident 41.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 67) received a recommended follow up appointment with an ear, nose, and throat (ENT- specialist for diminished hearing) per recommendation of ENT physician on 4/16/2025. This failure caused Resident 67 emotional distress due to frequently needing staff to repeat themselves and placed the resident at risk for miscommunicating her needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 25) was provided with additional food after informing Restorative Nursing Assistant (RNA) 1 she was still hungry. This failure had the potential to result in inadequate caloric intake and possible weight loss for Resident 25 who requested and were not offered additional food items of their choice and preference.

Inspectors wroteBased on interview and record review, the facility failed to ensure a coordinated hospice (compassionate care for people who are near the end of life provided at the person's home or within a health care facility) plan of care was integrated with the facility's plan of care and accessible to facility nursing staff for one of six residents reviewed for hospice services (Resident 5). The facility failed to:1. Incorporate Resident 5's active order for morphine (opioid pain medication) and fentanyl ( opioid pain medication) into the facility care plan,2. Document an effective communication process with the hospice provider to ensure 24 hour continuity of care, and maintained conflicting medication orders in Resident 5's health record without a coordinated plan between the hospice provider and the facility. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control practices for two of 18 sampled residents (Resident 2 and Resident 9). Specifically, the facility failed to:1. Provide hand hygiene (including handwashing with soap and water or use of alcohol based hand sanitizers) for Resident 2 before lunch service, as resident used her bare hands to eat.2. Performed COVID 19 (highly contagious respiratory disease caused by Coronavirus, which is transmitted thru coughing, talking, sneezing and touching contaminated surfaces) testing for staff who cared for Resident 9 after the resident tested positive for COVID 19. These failures had the potential to contribute to the transmission and spread of infection among residents, staff, and visitors in the facility.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure one of three sampled residents (Resident 1) with severe cognitive (ability to think, understand, learn, and remember) impairment and high fall risk was provided with fall prevention measures, including the use of bed rails (a barrier attached to the side of a bed) as ordered by Resident 1's physician on 2/23/2026. The facility failed to:1. Implement fall prevention interventions including use of bedrails immediately following Resident 1's falls on 2/20/2026 and 2/27/20262. Follow a physician's order written on 2/23/2026 to install bed rails and inform Resident 1's physician of the delay in installing the ordered bed rails.3. Revised Resident 1's care plan to include post fall interventions to prevent future falls.4. [...]

Inspectors wroteBased on observation, interviews and record review the facility failed to ensure one of three sampled residents (Resident 1) was assess for the risks of entrapment (event in which a resident is caught, trapped, or entangled in the space in or about the bed rail) and the possible risks and benefits of bed rails ( a barrier attached to the side of a bed) were reviewed prior to installation. The facility failed to:1. Obtain a bed rail assessment (a mandatory, documented evaluation conducted by healthcare staff before using bed rails) before bed rails may be used to ensure they are safe, necessary, and functioning as a physical restraint (devices, or materials used to restrict a person's movement, freedom, or access to their body). 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop an individualized care plan with measurable objectives, timeframes, and interventions to meet the resident's needs for one of three sampled residents (Resident 1). The facility did not develop an individualized care plan addressing Resident 1's refusal of care and treatment, including goals and interventions. This deficient practice had the potential to negatively affect the delivery of necessary care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the care plan for one of three sampled residents (Resident 1) was revised to address fall prevention needs. The facility failed to:1. Revised Resident 1's care plan to reflect the resident's current physical and cognitive (ability to think, understand, learn, and remember) status. This deficient practice had the potential to place Resident 1 at risk for preventable falls and inadequate supervision. Resident 1 subsequently experienced an unwitnessed fall on 2/20/2026, which resulted in multiple fractures (broken bone) to the left ribs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff followed infection prevention and control practices (procedures designed to prevent the spread of germs and infections) during an influenza (any infection or condition that affects the lungs and makes it difficult to breath) outbreak by failing to:1. Ensure that staff wore masks correctly while providing resident care. This deficient practice increased the risk for transmission of influenza among residents and staff and had the potential to result in additional infections, worsening of the outbreak, hospitalizations, and serious complications for vulnerable residents.

Inspectors wroteBased on interview and record review the facility failed to ensure proper management and documentation of a resident's personal funds for one of three sampled residents (Resident 1). The facility failed to: 1. Provide Resident 1 with the required monthly personal fund account statements and by failing to obtain the required authorization signatures. This deficient practice violated Resident 1's right to receive copies of monthly fund account statements. As a result, the facility did not ensure transparency, accountability, or protection of resident rights regarding the management of personal funds, placing the resident at risk for mismanagement or misuse of funds.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure call lights (a device used by residents to call for assistance from facility staff) for two of three sampled residents (Resident 3 and Resident 4 ) were within reach of the residents. This deficient practice resulted in Resident 3 and 4 not being able to use their call lights, which forced them to yell for help, causing a delay in care and services for Residents 3 and 4.

Inspectors wroteBased on interview and record review the facility failed to ensure Licensed Vocational Nurse (LVN) 1 provided direct supervision to Student Nurse (SN) 1 on 10/22/2025 when administering scheduled 9 am medications to one of three sampled residents Resident 1) along with not ensuring the five rights of medication administration were abided by. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure Licensed Vocational Nurse (LVN) 1 provided direct supervision to Student Nurse (SN) 1 on 10/22/2025 when administering 9 a.m., scheduled medications to one of three sampled residents (Resident 1). This deficient practice resulted in Resident 1 receiving Valsartan (a medication that lowers the blood pressure), multivitamin and minerals, Guaifenesin (a medication that helps loosen and thin mucus in the throat and chest) extended release ([ER] version of pill where medicine steadily throughout the day in the body), Eliquis (a medication used to prevent blood lots, thin blood), Carvedilol (used to lower the blood pressure and heart rate), Keppra (a medication used to treat seizures), Magnesium Oxide (a mineral supplement which could cause diarrhea, bloating and stomach cramps) in error. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure the responsible Party (RP) for one of three sampled residents (Resident 1) was notified when Resident 1 had a change of condition (COC) This deficient practice resulted in Resident 1's RP visiting Resident 1 at the facility and observing Resident 1 sleepier than usual, but she was unaware that Resident 1 had been given multiple medications that were not his. This deficient practice had the potential for Resident 1's RP to be unable to make decisions regarding Resident 1's care.

Inspectors wroteBased on observation interview and record review the facility failed to ensure one of three sampled residents (Resident 1), who required minimal assistance with ambulation (walking) using a front wheel walker (FWW- assistive walking device), did not exit through the unsupervised, non-alarmed front door without staff knowledge. The facility failed to: 1. Ensure there was a system in place to monitor the facility's front door after 6:30 pm during times when the receptionist was not present to prevent residents from leaving the facility without staff knowledge. 2. Ensure Resident 1 was accurately assessed for the risk of elopement (a situation in which a resident leaves the premises or a safe area without the facility's knowledge and supervision) and developed a plan of care with intervention to prevent elopement. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure admission orders were entered and implemented in a timely manner for one of three sampled residents (Resident 1) upon admission on [DATE] at approximately 9:00 p.m. The facility failed to:1. Initiate or carry out Resident 1's physician orders on the day of admission, despite the resident having multiple serious medical conditions. Licensed staff were unaware of Resident 1's presence in the facility for over two hours, and no admission packet or orders were available or processed during that time. This deficient practice placed Resident 1 at significant risk for harm, including potential neglect and unmet medical needs.

Inspectors wroteBased on interview and record review the facility failed to ensure one of three sampled residents (Resident 1) was accurately assessed for the risk of elopement (a situation in which a resident leaves the premises or a safe area without the facility's knowledge and supervision). This deficient practice resulted in an inaccurate assessment of Resident 1's risk for elopement and the facility's failure to develop and implement a care plan with appropriate interventions to prevent potential elopement.

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) received timely and appropriate medication administration upon admission. This deficient practice resulted in failure to accurately transcribe and process Resident 1's physician orders, resulting in a delay in administering eight prescribed medications for serious medical conditions.

Inspectors wroteBased on interview and record review, the facility failed to maintain and implement an ongoing Quality Assurance and Performance Improvement (QAPI) program as required. The facility was unable to provide documentation or evidence of any QAPI activities, committee meetings, or performance improvement projects since 7/17/2025. This failure had the potential to negatively impact the quality of resident care by allowing facility-identified issues to go unaddressed or reoccur, thereby compromising resident safety and regulatory compliance.

Inspectors wroteBased on interview and record review, the facility failed to ensure sufficient licensed nurses were available to pass medications to three out of three sampled residents sampled (Resident 1, 2 and 3). On 11/1/2025, from 3:00 p.m. to 11:00 p.m., Resident 2 did not receive four medications and Resident 3 did not receive three medications. On 11/2/2025, from 11:00 p.m. to 11/3/2025 at 7:00 a.m., Resident 1 did not receive two medications. The deficient practices resulted in scheduled medications not being administered to residents, and had the potential to result in medical complications from not receiving their scheduled medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure three out of three sampled residents (Resident 1,2, and 3) received scheduled medications as ordered.a) On 11/1/2025, during the 3:00 p.m. to 11:00 p.m. shift, Resident 2 did not receive his medications including Carbidopa-Levodopa (medication for Parkinson's [a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), Citalopram (medication for depression [a mood disorder that causes a persistent feeling of sadness and loss of interest], Depakote , (medication for mania [mental state of an extreme highs or depressive lows]) Visine eye drops (eye drops for minor eye irritation). [...]

Inspectors wroteBased on interview and record review the facility failed to ensure three of three residents' (Resident 1 to 3) Medication Administration Record (MAR) for 11/2/2025 were correctly documented. The deficient practice resulted in an inaccurate depiction of services and care rendered and had the potential to result in medication errors.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident, who had diagnoses of paraplegia (loss of voluntary movement and sensation in the lower half of the body) and generalized muscle weakness, did not sustain a second-degree burn (a burn injury that damages the outer layers of the skin [epidermis] and/or part of the underlying layer of the skin [dermis] but does not penetrate deeper into the subcutaneous tissue (the deepest layer of the skin beneath the epidermis and dermis) to his left thigh while using an egg cooker in his room for one of three sampled residents (Resident 1). The facility failed to: 1. Ensure Resident 1 did not have in his possession and use an unauthorized appliance (egg cooker) in his room. 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 2), who was provided a shower, was not left exposed with his uncovered buttocks visible while being transferred through the facility's hallway to his bedroom. This deficient practice resulted in Resident 2 feeling embarrassed and had the potential for mistrust with care and services provided by the facility staff.

Inspectors wroteBased on interview, and record review, the facility failed to separate, supervise and monitor one of three sampled residents (Resident 1), when on 10/7/2025 at approximately 9:30 p.m., Certified Nurse Assistant (CNA) 2 and Licensed Vocational Nurse (LVN) 1, were informed by Resident 1 that Resident 2, who had a history delusions (unrealistic false or unrealistic beliefs) and wandering into her (Resident 2) roommate's living spaces, yelled at her, threw water on her and hit her with a water bottle. This deficient practice resulted in Resident 1 feeling unsafe and fearful of being attacked by Resident 2 and placed Resident 1 at risk for continued verbal and physical abuse.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of abuse to the California Department of Public Health (CDPH) within two hours of the incident by one of three sampled residents (Resident 2). On 10/7/2025 at approximately 9:30 p.m., Certified Nurse Assistant (CNA) 2 and Licensed Vocational Nurse (LVN) 1, were informed by Resident 1 that Resident 2 came to her bedside, yelled at her, threw water on her and hit her with an object. This deficient practice resulted in CDPH being unaware of the abuse incident and injury to Resident 1 and had the potential for a delay in CDPH's investigation and other abuse allegations to go unreported.

Inspectors wroteBased on interview and record review, the facility failed to develop and a care plan with goals and interventions for one of four sampled residents (Resident 2), who had a history of delusions (unrealistic false or unrealistic beliefs), and wandering into her roommate's (Resident 1 and Resident 3) living space (a personal area belonging to each resident in a shared room) and was assessed with physical behaviors of hitting, and verbal behaviors of threatening and screaming. This deficient practice resulted in Resident 2 entering Resident 1's personal living area on 10/7/2025 without the consent of Resident 1 and unbeknownst to facility staff, Resident 1 feeling violated and threatened by Resident 2 invading her personal space, and an allegation of bodily harm inflicted by Resident 2 toward Resident 1.

Inspectors wroteBased on interview and record review the facility failed to provide a copy of medical records upon a written request for one of one residents (Resident 1). This deficient practice violated the rights of Resident 1 and its representative to obtain a copy of Resident 1's medical records.

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor and maintain the temperature of the resident refrigerator which contained personal food items, per the facility's policy and procedure (P&P) titled, Refrigerators and Freezers. This deficient practice had the potential to cause bacterial (germs) growth and food borne illnesses (food poisoning - symptoms which include nausea, vomiting, diarrhea, fever, and other flu-like symptoms) for residents consuming refrigerated personal food items.

Inspectors wroteBased on interview and record review, the facility failed to notify one of three sampled residents' (Resident 3) physician when Licensed Vocational Nurse (LVN 1) administered Resident 3's medications at 12:08 p.m., three hours later than the 9 a.m. administration time. This deficient practice had the potential to delay medical interventions for Resident 3, if needed.

Inspectors wroteBased on observation, interview and record review, the facility failed to administer medication per physician orders for one of three sampled residents (Resident 3) when Licensed Vocational Nurse 1 (LVN 1) administered medication at 12:08 p.m., three hours after the 9 a.m. administration time. This deficient practice had the potential for Resident 3 to experience delayed adverse drug events ([ADEs- reactions from a missed or delayed dose of medication) due to delayed medication administration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three facility doorbells were functioning. This failure resulted in Resident 1 having to wait several minutes for a staff member to hear Resident 1 knocking on the door after returning to the facility from an appointment.

Inspectors wroteBased on interview, and record review, the facility failed to ensure, when a resident was found unresponsive and pulseless (no detectable heart beat), the nursing staff immediately initiated basic life support ([BLS] care healthcare professionals provide to anyone who's heart stops beating suddenly) by performing cardiopulmonary resuscitation ([CPR] an emergency procedure to restart a person's heart and breathing after one or both suddenly stop) to one of five sampled residents (Resident 1). The facility failed to: 1. Ensure Certified Nursing Assistant (CNA) 1, who was CPR certified (successfully completed a training course and received a credential that qualifies a person to perform CPR), checked Resident 1's pulse when on [DATE] at approximately 4:50 a.m. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure care plans were developed with interventions for care for two of two sampled residents (Resident 1 and Resident 3) who had indwelling urinary catheters (a hollow tube inserted into the bladder to drain or collect urine) in place. These deficient practices resulted in the care needs related to the use of an indwelling urinary catheter being unknown/undocumented and had the potential for risk associated with the catheter's use such as displacement, urine retention and infection to go unmonitored and unrecognized.

Inspectors wroteBased on interview and record review, the facility failed to ensure turning an repositioning of a resident, along with the sequence of events related to the performance of cardiopulmonary resuscitation ([CPR] an emergency procedure to restart a person's heart and breathing after one or both suddenly stop) was accurately documented for one of five sampled residents (Resident 1), when Resident 1 was found unresponsive and pulseless (no detectable heart beat) on [DATE]. These deficient practices resulted in the inability to determine if Resident 1 was turned and/or repositioned on [DATE] to [DATE] during the 11 p.m. to 7 a.m. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was assisted to turn and reposition every two hours, as ordered by Resident 1's physician, and per Resident 1's care plan. This deficient practice resulted in Resident 1 not being turned or repositioned for approximately five hours on 8/4/2025 and had the potential for delay in healing, increase to Resident 1's sacral (tailbone) pressure sore ([bedsore] an open wound on the tailbone caused by constant pressure on the skin, cutting off blood flow and damaging the tissue) and/or the development of new pressure sores. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a QA/QAPI ([Quality Assurance/Quality Assurance and Performance Improvement] a data driven proactive approach to improvement used to ensure services are meeting quality standards) was implemented to verify the nursing staff's competency skills in performing cardiopulmonary resuscitation ([CPR] an emergency procedure to restart a person's heart and breathing after one or both suddenly stop) when residents' are found unresponsive and pulseless (no detectable heart beat). This deficient practice resulted in a delay in providing CPR to Resident 1 and calling 911 when Resident 1 was found unresponsive and not breathing on [DATE] at approximately 4:50 a.m., and subsequently pronounced dead on [DATE] at 5:05 a.m. [...]

Inspectors wroteBased on interview and record review the facility failed to accommodate one of one resident's (Resident 1) request to have female staff to deliver hygiene personal care. This deficient practice violated residents' rights and had the potential to result in negative psychological outcomes.

Inspectors wroteBased on interview and record review the facility failed to ensure one out of one resident (Resident 1) received assistance with toileting hygiene at least every shift and as needed. This deficient practice had the potential to increase the risk of skin breakdown.

Inspectors wroteBased on interview and record review the facility failed to ensure one out of three sampled residents (Resident 3) received Restorative Nursing Assistance (RNA) services (focus on helping residents regain or maintain physical mobility) as ordered by the physician. This deficient practice had the potential to result in a physical decline for Resident 3.

Inspectors wroteBased on interview and record review the facility failed to ensure one out of three sampled residents (Resident 2) with a foley catheter (flexible tube inserted into the bladder to drain urine), had documented evidence of cleaning and monitoring urine for signs and symptoms of infection. This deficient practice had the potential to result in urinary tract infections (UTI- an infection in the bladder/urinary tract), pain and urine retention.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure two out of three sampled residents (Resident 1 and 3) received meals at scheduled times and as needed to meet their dietary needs. These deficient practices resulted in Resident 1 and 3 not eating at their scheduled mealtime and had the potential to result in weight loss and hypoglycemia (low blood sugar).

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sample residents (Resident 1) who received enteral (a method of providing nutrition directly into the stomach, either through the mouth or via a feeding tube that goes directly into the stomach or small intestine) feeding via a Gastrostomy ([G-tube] a surgical opening fitted with a device to allow feedings to be administered directly to the stomach, common for people with swallowing problems) and had a history of pulling and dislodging (to forcefully remove) her G-Tube, Licensed Vocational Nurse (LVN) 1 assessed and checked placement of Resident 1 ' s G-tube site every four hours on 6/25/2025 per the facility ' s Policy and Procedure (P&P) titled, Enteral Feedings. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one out of three residents (Resident 2) was free from medication error when : Resident 2 received 2 doses of Temazepam (medication used to treat inability to sleep) 15 mg( milligrams- a unit of mass or weight). This deficient practice had the potential for Resident 2 to have difficulty in staying awake, slowed breathing , loss of consciousness , coma and potentially death.

Inspectors wroteBased on observation, interview, and record review the facility failed to accurately document the administration of temazepam (medication for sleep )15 milligrams (mg unit of measure) for one out of three resident ' s (Resident 2) when : Facility staff failed to document the accurate date temazepam 15 mg was administered on Controlled Drug Record (CDR) for Resident 2. This deficient practice had the potential to compromise Resident 2 ' s safety by administering medications at the wrong time, causing a missed dose, and or receiving duplicate administrations.

Inspectors wroteBased on interview and record review, the facility failed to ensure the care plan for one of three sampled residents (Resident 2), who had a history of wandering into other residents' rooms, care plan for a one to one (1:1) sitter (a healthcare worker who provides constant, continuous observation to a single resident to ensure their safety and prevention potential harm), was implemented. This deficient practice resulted in Resident 2 Resident 1's room without Resident 1's consent or the facility staff's knowledge and attempting to take Resident 1's cell phone.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 2), who had a history of wandering into other residents' rooms, and who had an order for a one to one (1:1) sitter (a healthcare worker who provides constant, continuous observation to a single resident to ensure their safety and prevention potential harm), was supervised to prevent him from entering the room of another resident (Resident 1) . This deficient practice resulted in Resident 2 entering Resident 1's room on 2/25/2025 without Resident 1's consent or facility staff's knowledge and attempting to take Resident 1 ' s cell phone.

Inspectors wroteBased on observations, interviews and record reviews the facility failed to ensure Residents 16, 51 and 65 needs were provided for when: 1. Resident 16's call light was not functioning properly 2. Resident 16's, overhead light was missing the cord to turn it on and off 3. Resident 51's overhead light cord was not long enough for Resident 51 to reach it. 4. Resident 16 and 65's TV remotes did not have any batteries. 5. Resident 65's overbed table was not functioning properly. These failures resulted in Resident 16, 51, and 65 needs not provided to make comfortable and homelike environment.

Inspectors wroteBased on interview and record review, the facility failed to ensure a preadmission screening and annual review of a 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) was accurately documented for five of eight residents (Resident 5, 12, 17, 34, 46). This deficient practice had the potential to result in an inappropriate placement and delay of needed services for Resident's 5, 12, 17, 34, and 46.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure five of five sampled residents (Resident 6, 69, 13, 34 and 68) fingernails were trimmed and free from accumulation of unknown substances underneath their fingernails. This failure has resulted to Resident 6, 69 , 13, 34 and 68 fingernails to have irregular edges, accumulation of dark brown substance under the fingernails and had the potential to cause infection and impaired skin integrity.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the residents, who were assessed as high risk for falls, were free from fall accidents for one of four sampled residents (Resident 69). The facility failed to: 1. Conduct fall risk re-assessment after each Resident 69's fall. 2. Evaluate and revise Resident 69's care plan after each fall to evaluate the current preventative measures effectiveness and to develop new measures. 3. Conduct evaluation of Resident 69's condition after the falls and to follow Interdisciplinary Team ([IDT] team members from different departments working together with a common purpose to set goals and make decisions that ensure residents receive the best care) recommendations to provide a sitter for Resident 69. 4. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of four sampled residents (Resident 19) was provided the prescribed liquid to drink during medication pass. This deficient practice resulted for Resident 19 unable to swallow his medications effectively and can potentially cause aspiration (accidentally inhaling food or liquid or medication through the vocal cords into the airway) to Resident 19.

Inspectors wroteBased on interview and record review, the facility's Quality Assessment and Assurance Committee (QAA) failed to ensure effective oversight of the facility and implementation of the facility's plan of correction (POC) of the deficient practices identified during the previous recertification survey. This deficient practice resulted the facility to have repeat deficiencies in resident's rights, comprehensive resident centered care plans, pharmacy services, Quality assurance and performance improvements and infection control.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain resident dignity by failing to: 1. Ensure Resident 34 was provided with a privacy curtain. 2. Ensure Resident 45's urine collection bag was covered with a dignity or privacy bag. This failure had the potential to violate Resident 34 and Resident 45's rights to dignity and privacy.

Inspectors wroteBased on observation, interview and record review, the nursing staff failed to protect the resident's rights for one out of seven sampled residents (Resident 14) by not closing the privacy curtain to ensure Resident 14 would not be visually exposed to the roommates and others while the staff was doing personal care. This deficient practice violated Resident 14's right for privacy.

Inspectors wroteBased on interview and record review, the facility failed to protect one of three sampled residents (Resident 45) right to be free from verbal abuse by Certified Nurse Assistant (CNA) 6 when he became verbally aggressive with Resident 45. This deficient practice resulted in Resident 45 being verbally abused by CNA 6 and had the potential for Resident 45 to feel unsafe and unprotected.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 61) was free from unnecessary physical restraints (any object or device that an individual cannot remove easily which restricts freedom of movement) as evidenced by: 1. Resident 61's bed was against the wall on the right side with an upper side rail on the left side of the bed. This deficient practice had the potential to place Resident 61 at risk at risk for injury and potential for entrapment (event when an individual is trapped or entangled in the spaces of the bed rail).

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person center care plan for two of four sampled residents (Resident 34 and Resident 61) by failing to: 1. Develop a comprehensive person-center care plan to address Resident 34 refusal of nail care and Resident 61's restraints. These failures had the potential to negatively affect the delivery of care and services to Residents 34 and 61.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of four sampled residents (Resident 69) care plan interventions for risk of fall was revised and updated after Resident 69 had a fall. Resident 69 had fallen five times (12/19/2024, 1/2/2025, 1/7/2025, 1/9/2025 and 1/26/2025) in the facility. On 1/7/2025, the Interdisciplinary Team (IDT) indicated a recommendation from a licensed nurse for Resident 69 to have a sitter to provide assistance, supervision and close monitoring, with the IDT recommendation to revise the care plan and update to prevent recurrence. This deficient practice has resulted to a fourth and fifth fall of Resident 69 on 1/9/2025 and 1/26/2025.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of four sampled residents (Resident 69) was assisted to get out of bed to perform his activities of daily living and enjoy his preferred activities. This failure had the potential for Resident 69 to decline in his mobility and negatively affect his psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to ensure one of 7 sampled residents (Resident 33) received two liters of oxygen continuously according to physician's order. This deficient practice had the potential to cause complications associated with oxygen therapy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a medication error rate less than 5% (percent) during medication pass for one of four sampled residents (Resident 61) by failing to crush allopurinol ({medication used to treat gout} (type of inflammatory arthritis), Vitamin D ) a nutrient that your body needs for building and maintaining healthy bones), and ferrous sulfate (an iron supplement used to treat iron deficiency) individually prior to administering. This failure resulted in a medication administration error rate of 12% exceeding the five (5) percent threshold.

Inspectors wroteBased on observation, interview, and record review, the facility failed to remove an expired medication from medication cart in station 1 (Cart 1). This failure had the potential to result in the use of ineffective medication for the residents.

Inspectors wroteBased an observation, interview and record review, the facility failed to ensure the dietary aide washed his hands upon entering the kitchen to deliver the food trays. This deficient practice had the potential to cause food-borne illnesses (an illness caused by eating or drinking contaminated food or water) to the residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure employee files were maintained and kept up to date for five out of five employees. 1. Ensure that upon hire and annually, employees had a Tuberculosis (TB- a lung disease) test, (a skin test to check if you have been infected with Tuberculosis). 2. Ensure health examinations were completed prior to hire and annually. These failures had the potential to negatively affect the patient's quality of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed maintain and observe infection control practices for three of three sampled residents (Resident 17, 45, and 61). This failure had the potential to result in cross contamination (physical movement or transfer of harmful bacteria from one person, object, or place to another) and place residents at risk for the spread of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 22 out of 36 resident rooms met the 80 square feet (sq. ft.- unit of area equal to a square foot long on each side) per resident in multiple resident rooms. Rooms one through 11 and rooms 14, 16 and rooms 18-26 house two residents per room. This deficient practice had the potential to result in an inadequate provision of safe nursing care, and privacy for the residents.

Inspectors wroteBased on interview and record review the facility failed to maintain a training program based off the facility assessment when five employee education files were reviewed and four out of the five employee education files were missing training on abuse, dementia, infection control, lesbian, gay, bisexual, transgender, queer (LGBTQ), behavioral health, resident rights, and communication. This failure has the potential to put the resident's safety at risk.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), whom had a history of left leg skin graft (surgical procedure that involves removing a patch of healthy skin from one part of the body and attaching it to another area that is missing or damaged skin), was provided Aquaphor ointment (medication is used as a moisturizer and protectant to treat or prevent dry, rough, scaly, itchy skin) as ordered by the physician. This deficient practice violated Resident 1's rights in receiving treatment as ordered and had the potential to cause skin breakdown, infection, and pain to her left leg.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of one sampled residents (Resident 1) was assessed for competency prior to participating in administration of changing her own colostomy (a surgical procedure that brings one end of the large intestine out through the abdominal wall to allow waste to leave the body) care (including emptying the colostomy pouch [waterproof [NAME] that collects waste from the body], cleaning the skin, and changing the colostomy pouching system). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staffing information was posted and placed in a visible and prominent place on a daily basis. As a result, the total number of staff and the actual hours worked by the staff was not readily accessible to residents and visitors.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of nine sampled residents (Resident 1) was monitored and reassessed during a change in condition (COC), when Resident 1 complained of a persistent headache, dizziness, and anxiety (feeling of fear dread, and uneasiness). This deficient practice resulted in Resident 1's progressive health status missing from her medical record, Resident 1's physician not being made aware of Resident 1's continuing headache and dizziness and Resident 1 calling 911 herself for transfer to a General Acute Care Hospital (GACH) where she was diagnosed with a complete heart block and treated with a pacemaker (a small electronic device placed in the chest to monitor heart rate and rhythm and to give the heart electrical stimulation when it does not beat normally) implantation. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure call lights were answered in a timely manner for three of three sampled residents (Residents 1, 2, and 3). This deficient practice resulted in the residents feeling forgotten, tossed aside, looked over, and not heard.

Inspectors wroteBased on interview and record review, the facility failed to ensure Protein Liquid ( supplement used to enhance wound healing ) was administered for one of three sampled residents (Resident 2) as prescribed by the physician. This failure resulted in the omission (not given) of Protein Liquids doses and had the potential to delay wound healing for Resident 2.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure food served was palatable, at the proper temperature and served in a timely manner for four of four sampled Residents (Resident 1, Resident 2, Resident 3, and Resident 4 ' s). This failure resulted in Resident 1 asking for replacement meals and for food to be re-heated or re-cooked. Resident 2 had most meals brought into the facility from family. This failure had the potential for Resident 1, Resident 2, Resident 3, and Resident 4 poor meal intake that can lead to weight loss.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one of four sampled residents (Resident 1) had a clean environment. Facility failed to: 1. Ensure Resident 1 ' s room was clean and free of trash on the floor, and trash container was emptied and not pilling up. 2. Ensure meal trays were not left at the bedside after each meal. These failures resulted in Resident 1 having flies in the room and the potential for the spread of infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of five sampled residents' (Resident 1 and 2) needs and preferences were accommodated when the facility failed to: A. Ensure Resident 2 was accommodated with gurney (wheeled stretcher) transportation to the dialysis (procedure to remove waste and excess fluids from the body) center on [DATE] and [DATE]. B. Ensure Resident 1 was provided a bed bath and or showered daily consistent with Resident 1's preference. The failure to provide Resident 2 with gurney transportation resulted in a missed dialysis appointment on [DATE] and [DATE] potentially causing fluid overload (too much fluid in the body) to Resident 2 and caused frustration and worry for Resident 2's responsible party (RP). [...]

Inspectors wroteBased on interview, and record review the facility failed to provide restorative nursing services (nursing interventions that promotes the resident's ability to adapt and adjust to living independently and safely as possible) to two of three sampled residents (Resident 3 and 4) as indicated in the residents' physician orders and care plans when the facility failed to: a. Ensure Resident 3 received Active Assistive Range of Motion([AAROM] resident uses muscles to complete stretching exercises with the help of restorative nurse aide [RNA]) bilateral (both sides) on upper extremities (UE) and lower extremities (LE) three times a week as tolerated every dayshift; b. Ensure the RNA provided Resident 4 ambulation assistance with platform walker ([PFW] -device that assists resident in ambulation) every day, three times a week as tolerated; and c. [...]

Inspectors wroteBased on interview, and record review the facility failed to provide sufficient staffing to provide restorative nursing services (nursing interventions that promotes the resident's ability to adapt and adjust to living independently and safely as possible) to two of three sampled residents (Resident 3 and 4) as indicated in the physician orders and care plan. The facility had one full time Restorative Nursing Assistant ([RNA]functions to perform restorative nursing procedures that maximize the resident's existing ability) to provide Restorative Nursing services (RNA) services to 40 residents. This deficient practice resulted in Residents 3 and 4 not receiving ordered therapy potentially causing a decline in mobility such as contractures (loss of motion of a joint), and a decline in physical functioning such as the ability to eat, dress, and walk.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) received treatment and care in accordance with professional standards of practice when: a. The Director of Staff Development (DSD- licensed vocational nurse who is responsible for training and education to the facility staff), and Certified nurse assistant (CNA)1 failed to notify the Registered Nurse Supervisor after Resident 1 sustained a witnessed fall. b. The facility failed to ensure the physician was notified of Resident 1's fall immediately after the incident. This deficient practice resulted in a delay in care and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled residents (Resident 2), received routine hemodialysis (HD, a treatment to filter wastes, water, and balance essential minerals in the blood) on 5/2/2024 and 5/3/2024. This deficient practice had the potential to result in fluid overload (too much fluid in the body) to Resident 2 and caused frustration and worry for Resident 2's responsible party (RP).

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident, who had severe generalized body pain, and had pain medication (Oxycodone Hydrochloride [a narcotic (a drug that works in the brain to dull the sense of pain) to relieve moderate to severe pain] 10 milligrams ([mg] a unit of measurement) available for administration to control their pain, was provided pain medication, for one of six sampled residents (Resident 1). The facility failed to: 1. Ensure licensed nurses ordered a refill of Oxycodone Hydrochloride 10 mg for Resident 1's moderate to severe pain before the medication's quantity was depleted. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a physician, who was also the facility's Medical Director, acted upon the pharmacy's request timely, to authorize an order to refill Oxycodone Hydrochloride ([HCL] a medication used to relieve moderate to severe pain)10 milligrams ([mg] a unit of weight measurement) for a resident who was experiencing severe generalized body pain for one of six sampled residents (Resident 1). This deficient practice resulted in Resident 1 experiencing unrelieved severe pain and increased anxiety (persistent and excessive worry which interferes with daily activities) when it took seven days to refill Resident 1's Oxycodone order.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure they had safe guards in place to account for their controlled drugs (a drug or other substance that is tightly controlled by the government because it may be abused or cause addiction) through accurate reconciliation (the process of comparing patient's medication orders to all of the medications that the patient has been taking/prescribed) of the controlled substances to prevent loss of and/or diversion (the illegal distribution or abuse of prescription drugs or their use for purposes not intended by the prescriber) of controlled substances in their facility, for four of six sampled residents (Residents 1, 2, 3 and 4). By failing to: 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement pain management for one of three sampled residents (Resident 1) when the facility failed to assess the pain levels before and after administering Norco (medication used to relieve moderate to severe pain), monitor for side effects after Norco was administered, and ensure the Medication Administration Record (MAR) record indicated whenever Resident 1 received Norco for pain from 1/21/2024 to 1/29/2024. These deficient practices had the potential to negatively affect Resident 1's pain management goals and interventions and left Resident 1 unmonitored for side effects and adverse reactions to the medication.

Inspectors wroteBased on interview and record review, the facility failed to account for the disposition of nineteen doses of Norco (strong potent medication used to manage moderate to severe pain) from 1/21/2024 to 1/29/2024 for one of three sampled residents (Resident 1). This deficient practice had the potential to result in medication errors such as omissions, duplications, dosing errors, or drug interactions.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled resident's (Resident 1) Medication Administration Record (MAR), indicated whenever Resident 1 received Norco (strong potent medication used to manage moderate to severe pain). From 1/21/2024 to 1/29/2024 there were nineteen missed opportunities where Norco was administered to Resident 1 but not documented in the MAR. This deficient practice resulted in an inaccurate depiction of Resident 1's pain interventions, had the potential to negatively affect Resident 1's pain management goals and interventions.

Inspectors wroteBased on observation, interview and record review, the facility failed to notify one of three sampled resident's (Resident 1) physician that Resident 1's Norco (strong potent medication to manage moderate to severe pain) needed authorization for refill. This failure caused Resident 1 to feel frustrated and had the potential to delay and inadvertently affect Resident 1's pain management.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent the resident from having an unplanned severe (severe weight loss is the weight loss greater than 5 % in one month and greater than 7.5 % in three months) weight loss of 22 pounds ([lbs.] 5.9 percent [%] in one month and 19.6 % in three months) for one of 18 sampled residents (Resident 57). The facility failed to: 1. Ensure the Registered Dietitian (RD) followed the facility's P&P titled Weight Management to assess Resident 57's nutritional needs while the resident was on isolation due to Covid-19, document the assessment, and make recommendations in the resident's medical record. 2. [...]

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. Kitchen wash cloths/towel were stained and discolored. Staff using discolored and stained wash cloths to clean food contact surfaces. 2. Cans opener was not maintained in a sanitary manner. 3. Dishwasher staff working in the dish machine area did not wash hands after changing gloves and when removing the clean and sanitized dishes from the dish machine. These deficient practices had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness in 73 out of 73 residents who received food from the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain proper infection control (prevents or stops the spread of infections in healthcare settings) practices for and follow its facility policy related to safe and sanitary (readily kept in cleanliness) environment for two of 18 sampled residents (Residents 15 and 31) by: 1. Failing to ensure Resident 15 water pitcher was covered. 2. Failing to properly store the nasal cannula (a device that delivers extra oxygen through a tube and into your nose) tubing for Resident 31. 3. Failing to ensure Laundry Aide changed gloves and performed hand hygiene (a way of cleaning one's hands that substantially reduces potential pathogens) after touching dirty linen carts stored outside and then folding clean resident laundered (to wash something, such as clothing in water) towels and sheets. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure six of 18 sampled residents (Residents 18, 40,26 and 4) were treated with respect and maintained the right to a dignified existence by: 1. Failing to ensure call light's request for assistance were answered timely and taking over 30 minutes up to five hours to answer the call lights for Residents 18, 40 and 4. 2. Failing to change Resident 4 wet diaper and leaving Resident 4 soaked in urine for over eight hours. These deficient practices resulted in Resident 4 being left soaked in urine and with feelings of anger, pain, and frustration from the burning urine on the skin. Residents 18,40, and 4 being left without assistance from facility staff for long periods of time despite calling for help.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 18 sampled residents (Resident 221), including: 1. Failing to implement and/or develop a Care Plan([CP] a form where summarize a person's health conditions and specific care needs) with goals and interventions for indwelling urinary catheter (a flexible tube that drains urine from bladder into a bag outside the body) for Resident 221. This deficient practice had the potential for inappropriate use of indwelling urinary catheter for Resident 26, had the potential to result in a lack of or delay in delivery of necessary care and services for Resident 26, and 221.

Inspectors wroteBased on observation, interview and record review, the licensed nurses failed to follow the facility policy and procedure (P&P) for initiation and maintenance of intravenous therapy ([IV] a way to give fluids, medicine, nutrition, or blood directly into the blood stream through a vein) for two of two residents (Residents 173 and 221) by failing to label and date a peripheral intravenous catheter ([PIV] a short catheter inserted through a peripheral vein for the administration of solution or medication) site for two of 18 sampled residents (Residents 173 and 221). This deficient practice had the potential to result in harm and lead to development of infection, infiltration (accidental leakage of non-vesicant solutions out of the vein into the surrounding tissue) and phlebitis (inflammation of a vein) for Residents 173 and 221.

Inspectors wroteBased on observation, interview, and records review the facility failed to provide sufficient staffing to accommodate resident needs for five of 18 sampled residents (Resident 40 and 34,) by: 1. Failing to ensure Resident 40, and 34 call lights were answered timely. This deficient practice resulted in Residents 40 and 34 delay of care and services needed to achieve maximum quality of life.

Inspectors wroteBased an observation, interview, and record review the facility failed to ensure meals are served timely and at a safe and appetizing temperature for four out of ----sampled residents (Resident 221,47,34, and 1). This deficient practice resulted in Resident 221,47, 34, and 1 not to receive meal trays on time and received cold food and had the potential for undernutrition (insufficient intake of food to meet individual needs to maintain good health) and further compromise of residents' nutritional standards.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medication was not left at the bedside for one of one sampled resident (Resident 273). This failure had the potential for staff, other resident, and visitor to access medication and can possibly result in an overdose of medication for Resident 273.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide reasonable accommodations for resident needs and preferences for three of 18 residents (Residents 5, 34 and 271) by: a) Failing to ensure Resident 34 privacy curtain (create a private space for resident) was clean at bedside and three clear plastic bags with trash was removed from Resident 34 bedside. This failure had the potential to violate Resident 34 rights to have a clean, comfortable, and homelike environment. b) Failing to ensure Resident 34 call light was answered timely. c)Failing to ensure Resident 5 and Resident 271 call light was within reach at the bedside. d) Failing to ensure Resident 271 was made aware by facility staff how to call for help while using the bathroom. [...]

Inspectors wroteBased on interview and record review the facility failed to accurately code the Minimum Data Set (MDS-comprehensive assessment and care screening tool) for one of 18 sampled residents (Resident 54). This deficient practice had the potential to result in Resident 54's delay in necessary care and treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to remove expired medications from medication carts (Carts 2 and 3). This failure had the potential for harm to residents due to the potential loss of strength of the medications, and the potential for the residents to receive ineffective medication dosages.

Inspectors wroteBased on interview and record review, the facility's Quality Assessment and Assurance (QAA committees established for the purpose of improving the safety and quality of health services) and Quality Assurance Performance Improvement (QAPI- approach to maintaining and improving safety and quality in nursing homes ) committee failed to ensure effective oversight and implementation of indicators for facility wide issues including weight loss, call lights and food temperatures identified in previous complaints and previous recertification surveys and resident grievances. These failures resulted in significant weight loss for Resident 57 and had the potential to jeopardized other residents' safety residing in the facility to not be assisted and receive medically related necessary care and treatment.

Inspectors wroteBased on interview and record review, the facility failed to assess and document wound measurements and description of the wound upon admission on [DATE] and weekly thereafter for one of four residents (Resident 1) until Resident 1's first documented wound measurement and descriptive assessment on 12/20/2023. This deficient practice had the potential for wound declines to go unnoticed by facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure an uninterrupted supply of pain medication during between 12/04/2023 to 12/07/2023 for 1 of three sampled Residents Resident 1. 2. Get a physican ' s order that it was okay to administer Resident 1 ' s own pain medication brought to the facility by Resident 1. These deficient practices had the potential for Resident 1 to not have received pain medication according to his physician ' s orders resulting in diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to notify one of four sample resident's (Resident 1) primary care doctor (MD 1) that Resident 1's urine culture (lab test to check for germs in urine) was positive for Extended Spectrum Beta-Lactamase ([ESBL]resistant to many antibiotics [medication that destroys germs] Escherichia coli (bacteria [germ]), immediately after the results were obtained on 10/7/2023. The facility notified MD 1 of the Resident 1's urine culture two days after the lab results were received on 10/9/2023. This deficient practice resulted in a two-day delay in treatment that could have resulted in Resident 1 becoming septic (life-threatening blood infection).

Inspectors wroteBased on observation, interview and record review, the facility failed to provide dignity and respect for two of seven sampled residents (Resident 2 and 4) when Resident 2 and 4's call light was not answered in a timely manner to assist with the residents' toileting needs. These deficient practices resulted in Resident 2 and 4 to feel frustrated and undignified.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of seven sampled residents (Resident 2) were provided incontinence (loss of control of bladder and bowel control) care to prevent skin breakdown. This failure placed Resident 2 at high risk for moisture associated skin dermatitis (skin damage that occurs when the skin is repeatedly exposed to various bodily wastes and fluids, also known as MASD).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of seven sampled resident's (Resident 3) bathroom light was replaced after it was reported broken for approximately four days. This deficient practice resulted in an inadequately lit bathroom placing Resident 3 at high risk for injury or fall.

Inspectors wroteBased on observation, interview and record review, the facility failed to create and implement care plans for the prevention and management of pressure ulcers (injury to skin and underlying tissue resulting from prolonged pressure on the skin) for one of two residents (Resident 1) as evidenced by: a. the facility failing to develop a care plan for the newly identified pressure ulcers in the sacrum (bones on the lower back), coccyx (tailbone), and the bilateral ischium (lower back region of the hip bone); b. the facility failing to turn and reposition one of one resident (Resident 1) every two hours; and c. the facility failing to provide pressure relieving devices as indicated in the care plan. These deficient practices placed Resident 1 at higher risk for developing the resident's current pressure injuries: a. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow up on Registered Dietician's (RD) recommendation, for an appetite stimulant (medication that will stimulate appetite), for one of one resident (Resident 1). This deficient practice had the potential to negatively affect Resident 1's meal intake percentage and Resident 1's overall nutritional status. Findings During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and re-admitted on [DATE] with the diagnoses including hemiplegia (paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (a slight paralysis or weakness on one side of the body) following a cerebrovascular accident (a stroke [impaired blood flow to the brain]). [...]

Inspectors wroteBased on interview and record review, the facility failed to accurately document the meal intake percentage and urinary output for one of one resident (Resident 1). This deficient practice had the potential to provide an inaccurate status of Resident 1's nutrition and hydration (replacement of body fluids lost through sweating, exhaling, and eliminating waste) and could delay appropriate care and interventions to Resident 1. Findings During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and re-admitted on [DATE] with the diagnoses including hemiplegia (paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (a slight paralysis or weakness on one side of the body) following a cerebrovascular accident (a stroke [impaired blood flow to the brain]). [...]