Bel Vista Healthcare Center

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1) was safely discharged to a lower level of care by failing to:1. Ensure Resident 1 was discharged to a Board and Care (a small, residential care setting providing housing, meals, and personal care assistance for adults and seniors who cannot live alone but do not require skilled nursing care) and not discharged to a Recuperative Care facility ( provides a temporary, post-hospital care setting who are recovering from an illness and experiencing homelessness) according to physician's order and resident's preference. This failure put Resident 1 at risk for avoidable physical and psychosocial harm and resulted in an inappropriate discharge.

Inspectors wroteBased on interview and record review, the facility failed to provide the proper notice for discharge for one of two sample residents (Resident 1) by failing to:1. Provide a written discharge notice (30-day notice of proposed discharge) at least 30 days prior to the transfer or discharge of the resident from the facility. This failure had the potential to put Resident 1 at risk for inappropriate and unsafe discharge.

Inspectors wroteBased on interview and record review, the facility failed to provide the necessary care and service for one of three sampled residents (Resident 2) by failing to:1. Monitor Resident 2 for constipation (a condition in which stool becomes hard, dry, difficult to pass) daily.2. Provide necessary medications for constipation when the resident had no bowel movement for three days as ordered by the physician. These failures had the potential to put Resident 2 at risk for fecal impaction (hardened stool that's stuck in the rectum or lower colon) that could lead to a bowel obstruction (partial or complete blockage of small or large intestines which is life threatening), nausea or pain.

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1), who was assessed at risk for falls and who had a previous unwitnessed fall, did not fall again. Resident 1 following her first unwitnessed fall on 6/20/2025 had recommendations from the Rehabilitation Department to use a bed alarm (sensors placed in a bed or chair that alarm and alerts staff when a resident stands up unassisted). The bed alarm was not used, per the Rehab Department's recommendation. This deficient practice resulted in Resident 1 having a second unwitnessed fall on 6/30/2025 and sustaining a mild to moderate left parietal (refers to the sides of the head) scalp hematoma (a collection of blood outside of a blood vessel caused by a blunt trauma)/contusion (a bruise). This deficient practice had the potential for Resident 1 to sustain greater injuries.

Inspectors wroteBased on interview and record review, the facility failed to treat one of four sampled residents (Resident 1) with respect and dignity by failing to ensure Resident 1 was assisted with getting dressed prior to him leaving for his appointment. This deficient practice resulted in Resident 1 to feel embarrassed because he had to wear a hospital gown (a loose-fitting garment, typically open in the back, that patients wear in medical facilities) to his appointment. This deficient practice had the potential for Resident 1 to be exposed causing unworthiness and psychosocial harm to Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with physician orders for two of eight sampled residents (Resident 2 and 28) by: 1. Failing to follow up dermatology (branch of medicine that diagnosis and treats skin disorders) consult for Resident 2. 2. Failing to follow physician orders for dressing change for Resident 28's right above the knee amputation (AKA). These deficient practices resulted in Resident 2 not being seen by a dermatologist and had the potential for Resident 28's wound to become infected.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of ten sampled residents (Resident 21 and 28) had their admission/readmission assessments completed by Registered Nurses (RNs) This deficient practice had the potential for delay in care and services, due to missed or inaccurate identification of problems. a. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, and administering drugs and biologicals per physician orders to meet the needs of each resident for two out of five sampled residents (Resident 1 and 21) by: 1. Failing to follow up with the Medication Regimen Review (MRR: comprehensive evaluation of resident's medication performed by a pharmacist to promote positive outcomes and minimize adverse consequences) recommendations for Resident 1. 2. Failing to communicate new medication order to the pharmacy for Resident 1. 3. Failing to follow doctors orders and remove Lidoderm External Patch five (5) percent (%) (Lidocaine: medication that numbs specific area of the body by blocking pain signals to the brain) for Resident 21. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure its medication error rate was less than five (5) percents (%). Three medication errors out of 25 total opportunities yielded a medication error rate of 8%, in 1 of 4 sampled residents (Residents 1) observed during medication administration (med pass). This deficient practice of med pass error rate at 8% exceeded the 5 % threshold and had the potential of adversely affecting residents' health condition.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to administer: 1. Hydrocodone-acetaminophen with the ordered pain level parameters for Resident 1 2. Oxycodone with the ordered pain level parameters for Resident 21. This deficient practice had the potential to under or over-medicate Resident 1 and Resident 21.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement their Enhanced Barrier Precaution (EBP: infection control practices to prevent the spread of multidrug-resistant organisms (MDRO's) control measures for one of three sampled residents (Residents 21 ) by failing to wear proper Personal Protective Equipment (PPE: to protective clothing, helmets, gloves, face shields, goggles, face masks and/or respirators or other equipment designed to protect the wearer from injury or the spread of infection or illness) when coming in contact with /administering Resident 21's Lidocaine Patch (medication that numbs specific area of the body by blocking pain signals to the brain) and when handling the indwelling catheter (known as Foley catheter, a tube that allows urine to drain from the bladder into a bag that is usually attached to the thigh) drainage bag. [...]

Inspectors wroteBased on observation interview and record review the facility failed to ensure a banana was not placed on Resident 194's breakfast tray when the diet tag indicated Resident 194 was allergic to bananas. This deficient practice had the potential to subject Resident 194 to have an allergic reaction( an unpleasant or dangerous immune system reaction after a certain food is eaten.

Inspectors wroteBased on interview and record review, the facility's Quality Assessment and Assurance Committee (QAA: committee that focuses on identifying and addressing quality deficiencies in resident care) failed to implement and ensure effective oversight of the facility and implementation of their Quality Assurance and Performance Improvement (QAPI: systemic approach to improve the quality of care and services provided to residents) plan. This deficient practice had the potential to have reoccurring deficient practices that can impact the quality of care for the residents. During a concurrent interview and record review on 5/18/2025 at 6:25p.m., with the Administrator (ADM), the ADM stated they have QAPI meetings monthly and QAPIs are structured to identify potential solutions to yield positive outcomes. The ADM stated they did not have documentation of QAPI meetings prior to March 2025. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure two of 20 resident bedrooms met the requirements of 80 square feet ([sq. ft.] a unit of area measurement) per residents in multi-bed resident rooms and 100 sq. ft for each single bed resident room. This deficient practice had the potential to result in inadequate space to provide privacy, space during daily care, and access during an emergency. During a review of the facility's Client Accommodations Analysis form, provided by the facility on 5/18/2025, the facility had 2 rooms that measured less than 80 sq. ft. per resident in multi-bed rooms and two rooms that measured less than 100 sq. ft for a single bedroom. The resident rooms were as follows: room [ROOM NUMBER]: 14 inches (in: unit of length) x 10.1 in [141.4 sq. ft.] approved capacity: 2 room [ROOM NUMBER]: 14 in x 10.7 in [149.8 sq. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the status of one of three sample residents (Resident 1)'s alleged abuse allegation was assessed and monitored. These deficient practices had the potential to negatively affect the residents' physical comfort and psychosocial well-being by not receiving the needed and necessary services timely.

Inspectors wroteBased on interview and record review, the facility failed to complete and to provide a written notice of seven-day bed hold (a guaranteed reservation for residents that are transferred out emergently) document when the resident was transferred to the General Acute Care Hospital (GACH) for one of three sampled residents (Resident 1). This failure resulted in Resident 1 and Resident 1's Responsible Party not knowing their rights to a seven-day bed hold.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) clothing was inventoried prior to being sent out to be laundered by an outside vendor. This deficient practice resulted in the facility not knowing which clothing was being laundered by the outside vendor and resulted in the loss of Resident 1 ' s clothing.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) Interdisciplinary Team (IDT- a group of professional and direct care staff that have primary responsibility for the development of a plan of care for the patient) Conference Notes accurately reflected the list of concerns and topics discussed during the IDT meeting. This deficient practice has the potential to result in a lack of communication and implementation of Resident 1 ' s plan of care.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure one of one sampled resident (Resident 38) who with diagnosis type 2 diabetes mellitus (abnormal blood sugar) and receiving Sitagliptin phosphate ( medication to lower blood sugar) received a weekly complete blood count ([CBC] a laboratory test which gives information about the production of all blood cells in the body) and comprehensive metabolic panel ([CMP] a group of blood tests which provide information about the body's metabolism [chemical reaction in the body's cells which change food into energy]) per physician order. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure medication carts (a moveable (a movable piece of equipment used in healthcare facilities to store, transport, and dispense medicines, medical supplies, and emergency equipment) 1, 2, and the facility's intravenous ([IV] giving medicines or fluids through a needle or tube inserted into a vein) medication carts were locked when unattended. This deficient practice resulted in resident's, visitors, and other staff having immediate access to medications and had the potential for theft, loss, and unauthorized consumption of medications. 2. Ensure the medication cart 2 keys were left unattended on top of medication cart 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess, care plan, and obtain a physician's order to have the bed against the wall for three of 31 sampled residents (Residents 15, 24 and 28). This deficient practice had the potential to result in unnecessary use of a physical restraint (purposely limiting or obstructing freedom of a person's bodily movement).

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure Licensed Vocational Nurse (LVN) 11 immediately enters the date and time of a controlled medication [a drug or other substance that is tightly controlled by the government because it may be abused or cause addiction and may cause significant risk to patient safety]) administration, and her initials to Medication Administration Record ( MAR) and the Controlled Medication Sheet (a form used to document and track the administration of controlled substances for one of two sampled residents (Resident 16) per facility's policy and procedure ( P&P). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Medication Administration Record ([MAR] a record of all medications administered to a resident) were accurately documented for the month of 5/2024 for two of two sampled residents (Resident 18 and 139). Licensed nurses documented: 1. For Resident 18, Licensed Vocational Nurse (LVN) 10 documented on Resident 18's MAR as administered for Ipratropium-Albuterol Solution (a medication used to open bronchial tubes [air passages]) every six hours for shortness of breath (unable to breathe normally), on 5/17/2024 at 9 p.m., and on 5/18/2024 at 3 a.m., when the medication was not delivered in the facility. This deficient practice placed Resident 18 at risk for further respiratory complications, change of condition, and unnecessary hospitalization from lack of treatment. 2. [...]

Inspectors wroteBased on interview, and record review, the facility failed to report an allegation of staff to resident physical abuse to the California Department of Public Health (CDPH), Local Law Enforcement, and the State Long Term Care Ombudsman ([LTC] public advocate) within the regulated time frame of two hours for one of one sampled resident (Resident 30). This deficient practice resulted in CDPH not being aware of the abuse allegation that occurred in 4/2024 until 5/18/2024 and the inability to investigate the allegation on time. This deficient practice had the potential for pertinent information to be lost and/or forgotten, more allegations of abuse to go unreported and continued abuse to occur.

Inspectors wroteBased on interview, and record review, the facility failed to develop and implement an individualized care plan with measurable objectives, timeframes, and interventions t for two of two sampled residents (Resident 24 and Resident 9) when: a. Resident 24's non- compliance on turning and repositioning as part of wound management interventions; and b. Resident 9's prescribed anti-anxiety medication (used to treat anxiety [(a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness) disorders) with subsequent monitoring for episodes of anxiety and the response to medications such as side effects and/ or adverse reactions (harmful or unpleasant reaction to medication). These deficient practices had the potential to negatively affect the delivery of necessary care and services for Resident 24 and 9).

Inspectors wroteBased on observation, interview, and record review, the licensed nursing staff failed to follow professional standards of practice for one of one sampled resident (Resident 29) by: 1. Not flushing (introducing water to the tube) the medication pre and post administration of medication with 30 milliliters ([mL] a unit of measurement) though a gastrostomy ([G-Tube] a surgical opening made into the stomach to provide nutritional support and administer medications to a resident) of water. 2. Not checking gastric residual (the volume of fluid remaining in the stomach) prior to medication administration. 3. Not mixing medication with five to 15 mL of water prior to administration per facility's policy and procedure. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 31 sampled resident's (Resident 30) got out of bed as ordered and was offered to get out of bed when he requested to attend the facility's Cinco De Mayo Festivities. This deficient practice resulted in Resident 30's not getting out of bed since his admission to the facility on 3/4/024, feeling of sadness, and inability to participate in the Cinco de Mayo Festivities.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two of two sampled residents (Resident 9 and Resident 18) were: a. provided assistance in recharging Resident 9's hearing aid; and b. provided assistance for Resident 18 to be scheduled for ancillary services such as Eyes, Ears, Nose and Throat consultation and assessed/ determined for a hearing aid. These failures has caused Resident 9 and Resident 18 to feel frustrated during their care and treatment which could potentially delay the delivery of their care and services that can inadvertently affect their quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one of one sampled resident (Resident 11) was provided floor mats to both side of her bed, who have a history of falling. This failure has the potential for Resident 11 to incur injury and suffer complications associated with a fall.

Inspectors wroteBased on interview, and record review, the facility failed to ensure a resident (Resident 140), who received hemodialysis (process of purifying the blood of a person whose kidneys [one of a pair of organs in the abdomen which remove waste and extra water (as urine) and help keep chemicals balanced in the body] are not working normally) intake and output status was monitored per the physician's orders for one of one sampled resident. This deficient practice had the potential to over and/or underload Resident 140 with fluid.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure resident who has a history of Post traumatic stress disorder (PTSD- a mental health condition that's triggered by a terrifying event either experiencing it or witnessing it) was screen and was assessed for re-traumatization of traumatic experience for one of one sampled resident (Resident 23). This deficient practice has the potential for staff unable to identify fears that can bring back trauma.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper use of bed rails (are adjustable metal or rigid plastic bars that attach to the bed) for two of three sampled residents (Resident 15, 24, and 28), as indicated in the facility's policy and procedure by failing to: assess, monitor, evaluate, and provide care plan for residents with side rails. These deficient practices had the potential to result in inappropriate use of bed rails for (Resident 15,24 and 28) that can lead to entrapment and/or injuries.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident who has a history of Post traumatic stress disorder (PTSD- a mental health condition that's triggered by a terrifying event either experiencing it or witnessing it), and depression (a depressed mood or loss of pleasure or interest in activities for long periods of time) was provided with individualized approach to care and understand resident's distress for one of one sampled resident(Resident 23). This deficient practice has the potential not to provide behavioral health care services needed for Resident 23.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 9), who was prescribed an anxiolytic (also known as anti-anxiety, a drug used to treat symptoms of anxiety such as feelings of fear, dread, uneasiness that may occur as a reaction to stress) for anxiety disorder was monitored for behavior of anxiety prior to administration of the medication and monitored for side effects and/or adverse reactions to the medication every shift. This failure has the potential for Resident 9 to be unnecessarily medicated with anxiolytic (anti-anxiety medication) which could place Resident 9 high risk for adverse and/ or side effects that could negatively affect her overall health and well-being.

Inspectors wroteBased on interview and record review the facility failed to ensure laboratory findings was relayed to medical doctor (MD) when available for one of one sampled residents ( Resident 6). This deficient practice has the potential to miss abnormal laboratory to be relayed to MD and informed for any abnormal findings.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the walk-in freezer in the facility's kitchen did not have an ice buildup. This failure has the potential for the residents' food supply to be tampered and/or contaminated that could put the residents at risk for food-borne illnesses.

Inspectors wroteBased on interview and record review, the facility failed to address/ implement facility assessment elements when: a. The facility failed to include the Infection Prevention Nurse (IPN) during the resident's assessment in the facility's assessment dated 01/30/ 2024 for the population of 39 census. b. The facility failed to assess needs for Resident that will be admitted to the facility with trauma experience to be able to provide needs and necessary care needed. These deficient practices had a potential to result in the provision of inadequate care and services to the facility's resident population.

Inspectors wroteBased on interview and record review, the facility's Quality Assessment and Assurance ([QAA] to develop and implement appropriate plans of action to correct identified quality deficiencies) and Quality Assurance Performance Improvement ([QAPI] designated to bring about constant and measurable improvement in the services provided at the facility for continual improvement of quality care) committee failed to: 1. Maintain effective systems in place to obtain and use feedback for facility issues submitted by direct care staff, residents, and resident representatives with regards to trauma informed care. 2. Monitor, review and analyze data for performance improvement of facility issues such as Abuse, use of side rails or bed against the wall, and change of condition. These deficient practices have the potential to not identify systematic approach to improve services to the residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident that is taking antibiotic vancomycin (can treat infections) 125 mg oral suspension for Clostridioides difficile (c-diff- is a bacterium that causes an infection of the colon, the longest part of the large intestine) was discontinued from contact isolation and was not placed in enhanced precaution for one of one sample Resident (Resident 38) This deficient practice had the potential for other Residents to get infected while Resident 38 is still on antibiotic without precaution.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of 20 residents bedrooms measured at least 80 feet square feet (sq. ft) per resident in rooms [ROOM NUMBERS]. The deficient practice resulted in reduced, required bed space per resident in rooms [ROOM NUMBERS], and had the potential for inadequate space during resident's care, or the inability for residents' access and use of personal assistive devices, furniture and providing enough space for visitors.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the caregivers of one of one sampled resident (Resident 32) were properly identified through background check, competencies verified and provided orientation of the facility's rules and regulations before allowed to render care for one of one sampled resident (Resident 32). This failure had the potential for Resident 32 to be provided assistance and care not in line with the professional standard of care that could negatively affect her safety and well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure advance directives (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) for three of eight sampled residents (Residents 13, 33 and 16) was offered and/or initiated. This deficient practice had the potential to cause conflict with Resident 13, 33, and 16's wishes regarding health care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess, care plan, and obtain a physician's order for having the bed against the wall for ten of 31 sampled residents (Residents 7, 14, 137, 138, 27, 25, 22, 12, 26, and 34). This deficient practice had the potential to result in unnecessary use of a physical restraint (purposely limiting or obstructing freedom of a person's bodily movement).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an accurate assessment was conducted for three of eight sampled residents (Residents 23, 31, and 35). 1. Resident 23's limited range of motion was coded incorrectly. 2. Resident 35's skin condition during the assessment reference date (ARD) was not coded. 3. Resident's 31's assessment was coded incorrectly for therapeutic diet (meal plan that controls the intake of certain foods or nutrients). This deficient practice had the potential to result in an inaccurate reflection of Residents 23, 31, and 35's medical status and functional abilities.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a comprehensive and resident centered care plan for three of eight sampled residents (Residents 20, 33, and 34). This deficient practice had the potential to result in a delay in delivery of care and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure there was sufficient nursing staff to provide care for two of 31 sampled residents (Residents 16 and 22). Resident's 16 and 22's call lights (device used by residents to signal his or her need for assistance from healthcare staff) were not answered in a timely manner. This deficient practice resulted in Residents 16 and 22's needs not being met, and resulted in Resident 16's accidental defecation (the act of pooping) on the floor which impacted Resident 16's dignity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store food in a sanitary manner to prevent growth of microorganisms that could cause food borne illness (any illness resulting from the food spoilage of contaminated food) for 33 out of the 55 residents in the facility by: a. Storing staff food together with resident food. b. Discarding frozen fruit and ground meat on the labeled discarded date. These deficient practices had the potential to cause food borne illness for 33 out of the 55 residents in the facility. c. Facility failed to maintain dish washer temperature of 120 degrees Fahrenheit (F) as outlined in the facility policy and failed to ensure the chemical in the dishwasher used for sanitizing was at the proper level of 100 parts per million (PPM) to ensure dishes were cleaned. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection control program which prevented the spread of infection and COVID-19 (a respiratory disease caused by a coronavirus called SARS-CoV-2) when: a. Staff failed to complete a self-screen for temperature and symptoms of COVID-19 prior to starting their shift. b. Staff failed to properly doff (remove) personal protective equipment ([PPE] protective clothing to prevent the spread of infections). c. Staff wearing appropriate PPE. These deficient practices could potentially spread and expose residents and staff to COVID-19.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure facility staff wore name badges to identify themselves to residents and families. This deficient practice had the potential to negatively affect Resident 16's sense of self-esteem, self-worth and felt his rights was violated.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain two of 31 sampled residents (Residents 25 and 16) dignity by failing to: a. Ensure Resident 25 was provided with a dignified dining experience. b. Ensure Resident 16 did not accidentally defecate (pooping) on the floor. These deficient practices did not preserve Resident 25 and Resident 16's dignity thus impeding on the realization of the resident's highest attainable practicable well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of eight sampled resident's (Resident 33) pre-admission screening and resident review (PASARR) assessment screening was followed up to determine the facility's ability to provide for the special needs of the resident. This deficient practice placed Resident 33 at risk for not receiving the necessary care and services required and needed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nursing staff met professional standards of quality and competency, for proper medication administration technique of one of two licensed nurses observed administering medications, as evidenced by the facility's failure to ensure that two (2) medications were administered to Resident 6 during medication administration (med pass) and licensed staff did not sign the Medication Administration Record (MAR) without giving the medication for Resident 6. This deficient practice resulted in Resident 6 complaining of pain and the potential for harm to Resident 6 due to not receiving medications indicated for nutritional supplement and pain caused by their individual medical conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide feeding assistance for one of 31 sampled residents (Resident 25). This deficient practice resulted in Resident 25's inadequate nutritional intake thus putting the resident at high risk for malnutrition.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident, who was at risk for aspiration (when food, drink, or foreign objects are breathed into the lungs) and was noncompliant with her nothing per mouth ([NPO] to withhold food and fluids)) order, did not have a pitcher of water and enteral formula at the bedside (Resident 31). This deficient practice placed Resident 31 at risk for aspiration and choking.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide routine foot care for one of one sampled residents (Resident 11). Resident 11 was observed with long, curved toenails, and was last seen by the podiatrist on 10/8/2021. This deficient practice resulted in complaints of pain and discomfort, and had the potential to cause complications with mobility and foot health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to conduct an interdisciplinary team ([IDT] group of different disciplines working together towards a common goal for the resident) meeting, update interventions, perform neurological assessments and rehabilitation assessment status post fall for Resident 13. These deficient practices resulted in Resident 13 suffering multiple falls in three consecutive days.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Resident 137's tube feeding (a way of delivering nutrition directly to the stomach through a surgically inserted tube) formula was running at the prescribed rate ordered. This deficient practice had the potential for decreased nutritional intake.

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor the intake and output status for one of one sampled residents (Resident 33) receiving hemodialysis (process of purifying the blood of a person whose kidneys are not working normally). This deficient practice had the potential to over or underload Resident 33 with fluid, which can affect the kidneys.

Inspectors wroteBased on observation, interview, and record review, the facility failed to comprehensively assess the root cause of behavioral symptoms and develop measurable goals and interventions to address care and treatment of residents with dementia (a disorder of mental processes caused by brain disease or injury and marked by memory disorder, personality changes, and impaired reasoning) for one of 8 sampled residents (Resident 20). This deficient practice had the potential to negatively affect the delivery of services to Resident 20.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate amount of emergency drugs to residents by failing to replace oral (PO) medication in the emergency kit ([E-kit] storage receptacle that contains a drug supply that can be used for residents during emergencies) within 72 hours of usage for one of one medication storage rooms in the facility. This deficient practice had the potential to result in the unavailability of medication for the residents during an emergent situation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that it was free of a medication error rate of less than five percent as evidenced by the identification of three (3) medication errors based on 27 medication opportunities, that yield a facility medication error rate of 11.11 percent during medication administration. The following three medication errors occurred for: a. The facility failed to remove a lidocaine patch (used to relieve pain and numb the skin) for Resident 6 at 9 p.m. per physician order. b. The facility failed to administer a dose of Ascorbic Acid (Vitamin C) for Resident 6 as ordered. c. The facility failed to administer Aspercream lidocaine cream 4 percent (%) to Resident 6's left hand and left hip as ordered. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drugs and biologicals (substance from biological sources) used in the facility was labeled in accordance with professional principles by: a. Failing to indicate the date when the Aplisol (brand name of a solution for Tuberculin Purified Protein Derivative, PPD - used to aid in the detection of infection with mycobacterium tuberculosis, TB - a highly contagious infection of the lungs) vial was opened to readily identify when the vial should be discarded. This deficient practice had the potential to cause inaccurate test results in the detection of TB and can lead to untreated mycobacterium tuberculosis and spread of infection. b. Failing to ensure medications for a discharged resident (Resident 140) and a used normal saline vial were not stored in one (1) of two (2) medication carts in the facility. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staffing information was posted and updated on a daily basis. This deficient practice resulted in the total number of staff and the actual hours worked by the staff being not readily accessible to residents and visitors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of 20 residents bedrooms measured at least 80 feet square feet (sq. ft) per resident in rooms [ROOM NUMBERS]. The deficient practice resulted in reduced, required bed space per resident in rooms [ROOM NUMBERS], and had the potential for inadequate space during resident's care, or the inability for residents' access and use of personal assistive devices, furniture and providing enough space for visitors.