Bayshire Yorba Linda Post-Acute

Inspectors wroteBased on interview and facility P&P review, the facility failed to provide reasonable accommodations to meet the needs for one of three sampled residents (Resident 1). * The facility failed to ensure Resident 1's call light was within the resident's reach. This failure had the potential to delay care and interventions and could negatively impact on the health outcome and safety of the resident.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent the development and/or worsening of pressure ulcers for one of three sampled residents (Resident 2). * The facility failed to complete the skin assessment, change of condition, notification of the physician, provide wound treatment, and initiate care plan for pressure ulcers on the bilateral buttocks of Resident 2. These failures had the potential for the residents to develop pressure ulcers and/or worsening of the existing pressure ulcers.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the pharmaceutical services to ensure accurate administration and documentation of the ordered medication for one of three sampled residents (Resident 1). * The facility failed to ensure the acetaminophen medication (analgesics/pain relievers and antipyretics) was administered to Resident 1 as ordered by the physician. In addition, the facility failed to document in the MAR when Resident 1 was administered with acetaminophen for pain. These failures posed the risk for the resident to receive medications not ordered by the physician and negatively affect the resident's well-being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the medical records were accurate and complete for one of three sampled residents (Resident 2). * The facility failed to ensure the information in Resident 2's shower skin check form were accurate. This failure had the potential for the residents' health care needs not be met as the medical record was inaccurate.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen. * The facility failed to ensure the sanitary condition of the hood over the stove was maintained. * The facility failed to ensure the kitchen utensils had a smooth cleanable surface and in good condition. * The facility failed to ensure the kitchenware and kitchen utensils were clean and free of food particles or residue. * The facility failed to ensure the cutting boards were kept in a sanitary condition and with cleanable surface. * The facility failed to ensure the heavy-duty blenders used for puree preparation, the clear rectangular plastic bucket containers used for marinating meats and food storage were air dried prior to storing and stacking and to ensure the blender was free of food residue prior to storing. [...]

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility's Consultant Pharmacist failed to identify and make recommendation for drug irregularities for three of 15 residents (final sampled Resident 19 and nonsampled Residents 17 and 30) reviewed for the medication administration. * Resident 17's drug regimen review failed to identify drug irregularities with the administration of levothyroxine sodium and lansoprazole (PPI medication used to treat GERD) together. * Resident 19's drug regimen review failed to identify drug irregularities with the administration of levothyroxine and pantoprazole sodium delayed release together. [...]

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the food items were served in the appetizing temperatures. * The food temperature was above the recommended temperature for cold beverages and below the recommended temperature for hot food. * Test tray temperatures were below the recommended temperature for hot meat and vegetables. These failures had the potential for the residents not to eat the food served and could affect the residents nutritional status for 41 of 41 residents who received food from the kitchen .

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the medical records for five of 12 final sampled residents (Residents 2, 4, 10, 15, and 26) were accurate and complete. * The facility failed to ensure the POLST and social services notes contained the same information regarding the advance directive for Residents 2, 4, and 26. * The facility failed to ensure the social services assessment was completed upon admission for Resident 10. * The facility failed to ensure the behavior monitoring documentation was accurate for Resident 15. These failures had the potential for the residents' care needs not being met as their medical information were inaccurate and/or incomplete.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to maintain the infection prevention and control practices to help prevent the development and transmission of communicable diseases and infections. * LVN 5 failed to perform hand hygiene during the medication administration for 12 residents and blood glucose checks for seven residents. * LVN 5 failed to clean the glucometer between use for seven residents. * LVN 5 utilized an alcohol swab from the floor of an isolation room to wipe blood from the finger of Resident 35. These failures posed the risk for transmission of disease-causing microorganisms and infections to the resident, staff, and visitors.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to inform and provide the written information regarding the rights to formulate the advance directive to one of 12 final sampled residents (Resident 26). * The facility failed to ensure the information and formulation of an advance directive was offered to Resident 26. This failure had the potential to violate the resident's rights to decline or formulate an advanced directive and for the resident's healthcare preferences not honored.

Inspectors wroteBased on interview, record review, and facility P&P review, the facility failed to ensure the prescriber documented an appropriate clinical rationale for the continued use of the psychotropic medication for one of five final sampled residents (Resident 15) reviewed for unnecessary medications. * The facility failed to ensure an appropriate clinical rationale for Resident 15's continued use of the PRN zolpidem (a psychotropic sedative used to treat insomnia) was documented. This failure had the potential for the Resident 15 to receive unnecessary psychotropic medication and could negatively impact the resident's health outcomes and well-being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the person-centered care plan for the use of the psychotropic medications were complete for one of 12 final sampled residents (Resident 15). * The facility failed to ensure the care plan included the specific targeted behavior monitoring for Resident 15's use of zolpidem tartrate (a psychotropic sedative used to treat insomnia) and buspirone HCl (antianxiety) medications. This failure posed the risk of not providing appropriate, consistent, and individualized care to the resident.

Inspectors wroteBased on observation, interviews, medical record review, and facility P&P review, the facility failed to ensure the proper IV care was provided for one of one final sampled residents (Resident 19) receiving IV infusions. * The facility failed to ensure Resident 19's PICC line dressing was changed every seven days and Resident 19's IV infusion tubing was labeled. These failures posed the risk for Resident 19 developing complications related to IV infusions.

Inspectors wroteBased on observation, interview, medical record review and facility P&P review, the facility failed to provide the necessary respiratory care and services for two nonsampled residents (Residents 17 and 52) reviewed for respiratory care. * The facility failed to ensure Residents 17 and 52 were provided the humidifier attached to the concentrator for the use of continuous oxygen therapy. This failure posed the risk for the residents to have nasal dryness and throat irritation.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care of the dialysis access site was provided for one of 12 final sampled residents (Resident 4). * The facility failed to ensure Resident 4's dialysis access site was consistently and accurately assessed pre and post hemodialysis treatments. This failure had the potential for delay in identifying complications related to the resident's dialysis access site.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to provide the pharmaceutical services to ensure for accurate reconciliation and administration of the medications for one of 12 final sampled residents (Resident 55). * The facility failed to ensure the Lasix (a diuretic medication) order for Resident 55 listed the appropriate indication for use. This failure had the potential for the resident's needs not being met as the indication of the medication use was incorrect.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 20%. Two of four licensed nurses (LVNs 1 and 5) who were observed during medication administration were found to have errors. * LVN 5 failed to ensure medications levothyroxine (medication to treat underactive thyroid) and pantoprazole/lansoprazole (medication to relieve stomach acids) were administered a minimum of four hours apart for Residents 17 and 19 * LVN 5 crushed a delayed release medication (pantoprazole) for Residents 2 and 46 * LVN 1 failed to ensure Resident 30's levothyroxine sodium and pantoprazole sodium medications were not administered together. These failures created the risk for the residents to have potential side effects or complications related to the medications.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medications were store in a safe manner for one of 12 final sampled residents (Resident 55), one nonsampled resident (Resident 56) and in one of two medication carts (Medication Cart B). * LVN 5 failed to ensure Residents 55 and 56's medications were safely stored during the medication administration. This failure posed the risk for unauthorized individuals to have access to the medication. * An open foil packet of Sorbalgon Ag (Ca Alginate Ag) wound dressing was stored in Medication Cart B. This failure had the potential for residents to receive medications that was contaminated and/or losing stability and effectiveness.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the menu was followed for three of 41 residents that consumed the foods prepared in the kitchen. * The facility failed to provide bread or roll with margarine to Resident 30 as per her meal ticket. * The facility failed to provide bread or roll with margarine to Resident 36 as per his meal ticket. * The facility failed to provide mashed potatoes to Resident 33 as per her meal ticket. These failures had the potential for the residents to not receive adequate nutrition and appropriate servings to meet their individual needs.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the facility's garbage and refuse was properly disposed of in three of seven garbage dumpsters. * Three garbage dumpsters were observed with the lids partially propped open by the cardboard boxes and black trash bags, preventing the lids from closing. This failure had the potential to harbor pests and rodents and cause unsafe sanitary conditions.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the necessary care and services were provided to one of four sampled residents (Resident 4). * The facility failed to ensure Resident 4's orthostatic blood pressure was obtained per the physician's order. This failure had the potential to negatively impact the resident's health and safety.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen as evidenced by: * The facility failed to ensure the proper labeling and dating of the food items and expired food items were discarded in the satellite kitchen. * The facility failed to ensure the proper labeling and dating of the foods in the refrigerator was in place for the residents' food brought in by the visitors. * The facility failed to ensure the bins, scoops, spoons, peeler, can opener, and microwave were clean. * The facility failed to air dry the scoops before storing in the storage bin. * The facility failed to ensure the cutting boards were kept in a sanitary condition. These failures had the potential to cause foodborne illnesses in a medically vulnerable resident population who consumed food prepared from the kitchen.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to develop the plan of care to reflect the individual care needs for one of 13 final sampled residents (Resident 25). * The facility failed to develop a care plan problem to address Resident 25's spinal precautions and use of LSO brace while out of bed. This failure posed the risk of not providing appropriate, consistent, or individualized care to the resident.

Inspectors wroteBased on interview and medical record review, the facility failed to revise the residents' comprehensive care plans to address the use of side rails for three of four final sampled residents (Residents 16, 17, and 339) reviewed for the side rail use. * The facility failed to ensure the plan of care for Residents 16, 17, and 339 addressing the use of the side rails were revised to show the accurate least restrictive interventions prior to the use of side rails. The residents' plan of care showed the grab rails and quarter-sized rails were used as the least restrictive interventions prior to the use of the side rails. These failures posed the risk of not providing an individualized care for Residents 16, 17, and 339 related to the use of the side rails.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary respiratory care and services were provided to three of 13 final sampled residents (Residents 1, 2, and 19) reviewed for the respiratory care. * The facility failed to ensure Resident 19 received the oxygen as per the physician's order. * The facility failed to ensure Residents 1 and 2 were provided with the No Smoking/Oxygen in Use sign indicating the oxygen use continuously. These failures had the potential to negatively affect the residents' well-being and posed the risk for safety due to the residents' use of the oxygen continuously.

Inspectors wroteBased on interview, facility record review, and facility P&P review, the facility failed to ensure the necessary pharmacy services were provided to one of 13 final sampled residents (Resident 25) and the proper accounting and safeguarding was performed to prevent loss, or diversion of the controlled medications. * The facility failed to provide the insulin medication (medication used to lower the blood sugar) to Resident 25 as ordered by the physician. * The facility failed to ensure the Narcotic Shift Count sheets were completely signed by the incoming and outgoing licensed nurses assigned to Medication Cart 1. These failures posed the risk to negatively affect the resident's well-being and loss or diversion of the controlled medications.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure two of five final sampled residents (Residents 4 and 26) reviewed for the unnecessary medications were free from the unnecessary psychotropic medications. * The facility failed to ensure Resident 26's quetiapine (antipsychotic medication) order had the necessary diagnoses to treat a specific condition. * The facility failed to ensure Resident 4 was monitored for the adverse effects related to the use of the risperidone medication (antipsychotic medication). These failures had the potential for Residents 4 and 26 to receive the unnecessary psychotropic medications and negatively affect the residents health.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 22.58%. Two of two licensed nurses (LVNs 1 and 2) were observed to have made the errors during the medication administration. * LVN 2 failed to ensure the correct medications were administered to Resident 591 as per the physician's orders. * LVN 1 failed to ensure the education provided for not chewing the extended release medications for Residents 19 and 29. Additionally, LVN 1 failed to assess or ask Residents 19 and 29 if they had any signs or symptoms of bleeding or bruise. These failures had the potential to negatively affect the residents' health conditions.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the medications were stored in a safe and secure manner. * The facility failed to the medications were properly stored in the location where they could not be accessible by the non-licensed staff. * The facility failed to ensure Medication Cart 1 was locked when not in use. These failures had the potential for unauthorized persons to have access to locked medications.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the residents' medical records were complete and accurate for six of 13 final sampled residents (Residents 16, 17, 25, 28, 29, and 339) and two nonsampled residents (Residents 640 and 641). * The facility failed to ensure the signatures on the informed consent for the buspirone (antianxiety medication) medication for Resident 16 matched the printed names on the consent form. Additionally, Resident 16's MAR entries failed to show the job designation of the staff signing. * The facility failed to ensure the MAR entries showed the job designation of the staff signing the MAR for Residents 17, and 339. * The facility failed to ensure Resident 28's medication administrations, treatments, and monitorings were documented in the MAR after it was administered or provided. [...]

Inspectors wroteBased on interview, facility document review, and facility P&P review, the facility failed to ensure the infection control practices were maintained. * The facility failed to accurately classify which residents met the McGeer's Criteria in the infection control surveillance. This failure posed the risk of inaccurately identifying if the residents met the criteria for true infections and appropriate antibiotic use. * The facility failed to implement the neutropenic precautions for Resident 17. Fresh flowers were observed at bedside, the door was not kept closed, and the IP was observed entering the room without a mask. * The facility failed to ensure the enhanced barrier precautions for Resident 591 were observed. * The sink in Medication Room A was not clean. These failures posed the risk of potential transmission of communicable diseases to other residents in the facility.

Inspectors wroteBased on observation, interview and facility P&P review, the facility failed to ensure the equipment was maintained in a safe and operable manner. * The sink faucet in Medication Room A was leaking. * The facility failed to ensure the ice machine in the main kitchen was cleaned and sanitized as per the manufacturer's specifications. * The facility failed to ensure there was no ice build-up in the walk-in freezer in the main kitchen, the freezer in the satellite kitchen, and the freezer of the refrigerator used for residents' food brought from outside source. * The facility failed to ensure the thermometer used in the satellite kitchen was calibrated properly. These failures had the potential for the equipment to not function in the way it was intended.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the residents' beds were inspected and the entrapment assessments were conducted when identifying areas of possible entrapment with the use of bed rails for two of four final sampled residents (Residents 26 and 339) investigated related to the use of side rails. These failures had the potential to negatively impact the residents resulting in possible entrapment, serious injury, and death.

Inspectors wroteBased on observations, interview, and facility document review, the facility failed to ensure the most recent Recertification Survey's plan of correction was readily accessible to the residents and public. This failure posed the risk for the residents, their families, and visitors to not be aware of the facility's plan of correction for the last Recertification Survey as the documents were not available to review.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to implement the P&P to ensure proper storage of food brought in by family members. * An unlabeled and undated bag of cereal was observed on Resident 29's bedside table. This failure had the potential to result in foodborne illnesses in a highly susceptible resident population.

Inspectors wroteBased on interview, medical record review and facility P&P review, the facility failed to develop a plan of care to reflect the individual care needs for one of two sampled residents (Resident 1). * The facility failed to develop the care plan problem and interventions to address Resident 1's behavior of getting up from the wheelchair. This posed the risk of not providing appropriate, consistent, and individualized care to the resident.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen as evidenced by: * The facility failed to ensure proper hand hygiene were practiced by the dietary staff in the satellite kitchen. * The facility failed to ensure hair and beard restraint were worn by a non-dietary personnel inside the main kitchen. * The facility failed to ensure the meat thawing in the refrigerator in the main kitchen was labeled with the use-by date, and the date when the meat was pulled from the freezer. * The facility failed to ensure the proper labeling and dating of the food items in the main kitchen and satellite kitchen. * The facility failed to ensure the proper labeling and dating of the foods in refrigerator was in placed for the residents' food brought in by visitors. [...]

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to maintain the essential kitchen equipment in safe operating condition. * The facility failed to ensure the dish machine in the satellite kitchen was working. * The facility failed to ensure the sink in the main kitchen was not leaking. * The facility failed to ensure there was no ice buildup and brownish stain in the freezer of the refrigerator used to store residents' food brought in by the visitors. These failures had the potential for the equipment to not function in the way it was intended, which could cause food borne illnesses for the residents.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure one of 13 final sampled residents (Resident 330) was informed in advance of the proposed treatment regarding the use of psychotropic medications (medications affecting brain activity). * The facility failed to ensure the informed consent was obtained from Resident 330's responsible party before administering sertraline (antidepressant medication) to Resident 330. This failure had the potential to compromise the right of the resident or her responsible party (person designated to make decisions on behalf of the resident) to be fully informed regarding the medication and its potential side effects.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the reasonable accommodation to meet the needs of one of 13 final sampled residents (Resident 8). * The facility failed to ensure the call light for Residents 8 was within the resident's reach. This had the potential for the resident to not be able to call for assisstance when needed.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the residents' advance directives were part of their medical records for three of 13 final sampled residents (Residents 19, 25, and 429). This failure had the potential for the residents' wishes for provisions of health care not being followed.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the timely notification of changes for one of 13 final sampled residents (Resident 16). * The facility failed to notify the physician, RD, and resident responsible party for the resident's weight changes. This failure had the potential for a delay of the interventions to prevent further weight loss/gain.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the baseline care plans related to the fall risk was developed for one of 13 final sampled residents (Resident 379). This failure had the potential for the resident to not receive the necessary care and services in accordance with their care needs.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to develop the comprehensive care plans to reflect the individual care needs for three of 13 final sampled residents (Resident 25, 330, and 679) when: * The facility failed to develop a comprehensive care plan for Resident 25's use of Risperdal (a medication used to treat a number of mental health disorders including psychosis.) and sertraline hcl (a medication used to treat certain mood disorders such as depression.) * The facility failed to develop a care plan problem to address Resident 330's use of sertraline hcl. * The facility failed to develop a care plan problem to address the PVR monitoring for Resident 679. These failures posed the risk of not providing the appropriate, consistent, and individualized care to the residents.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to provide the services to attain or maintain the highest practicable well-being for three of 13 final sampled residents (Residents 8, 9, and 679). * Resident 9 was administered olmesartan medoxomil (medication to treat high blood pressure) and metoprolol (medication to treat high blood pressure) when Resident 9's systolic blood pressure was below the parameter prescribed by the physician. * The facility failed to continue to monitor and document assessment every shift for 72 hours after the change in condition identified for Resident 8. * The facility failed to ensure the physician's orders were followed related to monitoring of Resident 679's urinary output and PVR. These failures had the potential to negartively affect the residents' health condition and well-being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to follow the physician's order for the RD consult for one of 13 final sampled residents (Resident 16). * The RD did not review the resident's enteral feeding formula for more concentrated formula as ordered by the physician on 12/25/23, and failed to conduct the RD consultation for weight loss timely as ordered on 1/4/24, for Resident 16. This failure had the potential for a delay or dietary interventions putting the resident at risk of further undesirable outcomes.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary enteral tube care and services for two of 13 final samples residents (Residents 16 and 629). * The facility failed to ensure Resident 629's J-tube placement was verified prior to the administration of medications. * Resident 16's enteral formula bottle was left at bedside after being opened. These failures posed the risk for developing complications related to enteral feeding.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 13 final sampled residents (Residents 429) received the appropriate care for peripheral intravenous catheter. * The facility failed to ensure Residents 429's IV site was assessed and monitored as per the facility's P&P. This failure posed the risk for a delay in identify and provide necessary care if the resident developed complications such as catheter-related infections.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the respiratory services were provided as ordered for three of 13 final sampled residents (Residents 330, 429, and 629). * The facility failed to ensure Resident 330 received continuous oxygen via nasal cannula as per the physician's order. * Resident 429's physician's order for oxygen failed to show if the order was continuous or PRN. * Resident 629's nasal cannula was found in the floor and physician's order for oxygen failed to show if the order was continuous or as needed. These failures had the potential for these residents to not receive appropriate respiratory care and increase risks of infection.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to complete the entrapment assessments, obtain the physician's orders, and an informed consents prior to the use of side rails for five of 13 final sampled residents (Residents 9, 25, 330, 379, and 629). These failures had the potential to put the residents at risk for serious injuries.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the pharmaceutical services for one of 13 final sampled residents (Resident 629) and one nonsampled resident (Resident 23) to meet the needs of each resident as evidenced by: * The facility failed to ensure the medications were administered as ordered to Resident 629. * The facility failed to ensure the controlled drug, hydrocodone-acetaminophen 10 mg-325 mg tablet,signed out from the controlled drug record were documented as administered on the MAR for Resident 23 * The facility failed to ensure the disposed medications were destructed and mixed with undesirable substance or a medication destroyer chemical. These failures had the potential for poor health outcomes to the residents and controlled medications diversion.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure one of 13 final sampled residents (Resident 25) was provided the management for the use of psychotropic medications (medications that affect the mind, emotions, and behavior). * The facility failed to ensure non-pharmacological approaches to care were provided for Resident 25 while receiving risperidone (Risperdal, a medicine that helps with symptoms of some mental health conditions where someone may see, hear, or feel things that are not there or believe things that are not true or you feel unusually suspicious) and sertraline (Zoloft, a medication used to treat depression). This failure had the potential to cause harm to Resident 25.

Inspectors wroteBased on observation, interview, medical record review, and facility document review, the facility failed to ensure the medication error rate was below 5%. The facility's medication rate was 18.52%. Two of two licensed nurses (LVNs 1 and 3) observed administering the medications was found to have errors while administering the medications to four nonsampled residents (Resident 14, 17, 23, and 630). * The facility failed to ensure Resident 17 received the prescribed eye drops in accordance with the facility's P&P. * The facility failed to ensure Resident 14's inhalation medication was administered in accordance with the facility's P&P. *The facility failed to ensure Resident 25's hydroxychloroquine (a medication used to treat discoid lupus erythematosus (a chronic inflammatory condition of the skin) was given with food or meal. [...]

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the medications were properly stored and labeled. * The facility failed to ensure the discontinued medication was locked and not left unattended on top of the medication cart. * The facility failed to monitor the temperature of the resident's refrigerator in the medication room. * The facility failed to appropriately label multiple ointments with open date, dispose of the prescription ointments such as triamcinolone and mupirocin, dispose of the expired solutions, and maintain cleanliness of the treatment cart. * The facility failed to dispose opened sterile packages for IV therapy such as IV holder or lock and transparent dressing from the IV cart. * The facility failed to appropriately label the bottle of the iron tablets (supplement) and eye medication drops with open date. [...]

Inspectors wroteBased on observation, interview, facility document review, and the facility P&P review, the facility failed to ensure the kitchen staff had the appropriate skill set to safely perform the daily operation of the Food and Nutrition Services Department. * Dietary Aides 1 and 2 were unable to demonstrate the thermometer calibration procedure. * Dietary Aide 1 used the wrong strip to test the chemical concentration measured in parts per million of quaternary sanitizing solution used to sanitize food contact surfaces, and to test the chlorine concentration of the dish machine. * Dietary Aide 2 was unable to correctly describe how to manually wash dishes. These failures had the potential to lead to foodborne illnesses in a highly susceptible population of residents who received food prepared in the kitchen.

Inspectors wrote3. On 1/23/24 at 1240 hours, a concurrent meal observation and interview was conducted with Resident 632 in his room. Resident 632 complained his meal tray was missing some of the food he ordered, and he received a food he did not order. Resident 632's meal ticket showed cob salad, cucumbers, fruit x3, and ice cream x3 marked off. Resident 632's meal tray was observed with missing cobb salad, cucumbers, fruit x3, and ice cream x3 and there was a light orange pureed food in a small bowl that was not listed in the meal ticket. The Culinary Director came to the room and verified there were missing food listed in the meal ticket and there was a pureed food which was a butterscotch pudding in the tray that was not listed. Medical record review for Resident 632 was initiated on 1/23/24. Resident 632 was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility document review, the facility failed to ensure the food preferences were honored for one of 13 final sampled residents (Resident 9). * Resident 329's tray card showed the resident preferred chef salad and cranberry juice. However, this was not served to the resident. This had the potential to negatively impact the resident's well-being.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to follow their policy to ensure foods brought into the facility for residents by visitors were properly stored and safely consumed. * The facility failed to ensure the nursing staff were trained on properly labeling the food items brought in by the visitors for the residents. This failure had the potential for unsafe food handling.

Inspectors wroteBased on interview, record review and facility P&P, the facility failed to ensure the complete and accurate medical records for six of 13 final sampled residents (Residents 16, 19, 24, 25, 330, and 430) and one nonsampled resident (Resident 24). *Resident 24's insulin was documented incorrectly as being administered in their axilla for 13 instances. *Resident 16's insulin was documented incorrectly as being administered in their axilla for seven instances. In addition, Resident 16's Care Conference assessment was not completed timely. *Resident 25's insulin was documented incorrectly as being administered in their axilla for three instances. *Resident 19's insulin was documented incorrectly as being administered in their axilla for two instances. In addition, Resident 19's Care Conference assessment was not completed timely. [...]

Inspectors wroteBased on interview and facility document review, the facility failed to implement their POC dated 2/6/23. There was no documentation to show the facility was monitoring the results of audits to the QAPI committee meetings to identify if they had achieved compliance threshold of 100% for repeated deficient practice cited at F695 in accordance with their POC for recertification survey dated 2/6/23. This failure had the potential to affect the quality of care for all the residents in the facility.

Inspectors wroteBased on interview, observation, facility document review, and facility P&P, the facility failed to ensure an appropriate infection control practices for one of 13 final sampled residents (Resident 429), two nonsampled residents (Residents 630 and 633) and in the facility laundry service area. * The facility failed to follow appropriate transmission-based precautions for Resident 429. * The facility failed to ensure the staff implemented handwashing with soap and water after caring for Resident 429 who was on contact isolation for C. Difficile to care for another resident. * The facility failed to ensure equipment used for Resident 429 who was infected with C. Difficle were appropriately disinfected. * The bedpans and basins for Residents 630 and 633 in a double bed room were not labelled. * The facility failed to ensure Resident 679's urinary drainage bag was kept off the floor. [...]

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to monitor and address the use of antibiotic to identify if the resident's condition did or did not meet the McGeer's criteria (a set of specific definitions to identify true infections in long term nursing facilities) for four of 12 nonsampled residents (Residents 11, 13, 634, and 635). The facility failed to complete the criteria for indication of antibiotic use for Residents 11, 13, 634, and 635. In addtion, Resident 13's antibiotic order was not clarified with the physician regarding the stop date. These failures had the potential to negatively impact the residents' well-being.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the residents' bed were inspected, entrapment assessments were completed, and with the record of the bed inspection when identifying areas of possible entrapment with the use of bed rails for four of 13 final sampled residents (Residents 9, 25, 330, and 379). These failures had the potential to negatively impact the residents resulting in possible entrapment, serious injury, and death.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to maintain the effective pest control program to prevent the presence of gnats in the main kitchen and the satellite kitchen. This failure had the potential to lead to food-borne illnesses (illnesses caused by food contaminated with bacteria, viruses, parasites or toxins) to the residents who eat food prepared in the kitchen.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the comprehensive plans of care for one of 13 final sampled residents (Resident 25) were revised to reflect the residents' current care needs and interventions. * The facility failed to revise the comprehensive plan of care for Resident 25's diagnosis of dementia (a memory impairment and disruption of thought process that impacts a person's ability to perform daily activities). This posed the risk of not providing the resident with individualized and person-centered care.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to dispose and store trash in a sanitary manner. * The facility's two of four trash dumpsters' lids were not fully closed. One dumpster lid was fully open and another dumpster was observed overflowing with garbage, which prevented the dumpster lid to be fully closed. This failure had the potential to harbor pests.